NLn oosbi^ NATIONAL LIBRARY OF MelUIwIIHe. Washington,D.C. NLM005619811 MANUAL OF OPEKATIYE SUKGEKY BY JOSEPH D. BRYANT, M. D. PROFESSOR OF ANATOMY AND CLINICAL SURGERY, AND ASSOCIATE PROFESSOR OF ORTHOPEDIC SURGERY, BELLEVUE HOSPITAL MEDICAL COLLEGE ; VISITING SURGEON TO BELLEVUE HOSPI- TAL ; CONSULTING SURGEON TO THE BUREAU OF MEDICAL AND SURGICAL RELIEF, OF BELLEVUE HOSPITAL J CONSULTING SURGEON TO THE NEW YORK LUNATIC ASYLUM, AND TO THE NORTHWESTERN DISPENSARY. WITH ABOUT EIGHT HVNDEED ILLUSTRATIONS NEW YORK D. APPLETOK AND COMPANY 1887 Wo Copyright, 1886, By D. APPLETON AND COMPANY. All rights reserved. s^7^' >_ TO STEPHEN SMITH, M.D. AND TO MY PRECEPTOR GEORGE W. AVEEY, M.D. £i)is Volume IS EESPECTFULLY INSCBIBED THOUGH BUT A MEAGER RECOGNITION OF THE MANY KINDNESSES SHOWN BY THEM TO THE AUTHOR PREFACE. The frequent request on the part of those whom it has been my pleasure to instruct in operative surgery during the past few years, to make a book based somewhat on the plan I have employed in teaching this subject, is the principal incentive to my action. The field of operative surgery is too well cultivated already for one to do more in this brief space than aid the student of surgery to acquire established facts. The works of Ashlmrst, Agnew, Gross, Erichsen, Holmes, Smith, Esmarch, Packard, Stimson, and many others, to- gether with the current medical literature, have been consulted. The illustrations, which are numerous, have been selected in most instances from standard works, although a considerable number of original and modified illustrations have been introduced. Mr. W. F. Ford, of the reputable firm of Caswell, Hazard & Co., of this city, kindly provided the instrumental cuts, as is to be seen by the " Index of Illustrations." The author desires to acknowledge the aid derived from the above-mentioned sources, and trusts the reader will find something to commend in the pages that are to follow. The author regrets that sufficient data are not at hand to permit the " results " to be given in all instances as modified by the antiseptic method of treatment. The operations peculiar to the female sex, and the eye and ear, have not been considered, since they are en- titled, in the opinion of the author, to a more extended considera- tion than the intentional scope of this work will admit. The au- thor desires to acknowledge the valuable services of Drs. Glover, C. Arnold, and Herman M. Biggs, in connection with the proof- reading, and of Dr. Arnold also for the complete indices of the book. The assistance of Dr. A. H. Doty in preparing many of the original illustrations is likewise gratefully acknowledged. Joseph D. Bryant, M. D. 66 W. Thirty-fifth Street, New York, October 28, 1886. CONTENTS. CHAPTER I. GENERAL CONSIDERATIONS. PAGE Definition of operative surgery—Facts to be ascertained before operating—Season of the year for operating—Time of day—Surroundings of the patient—Tem- perature of the room—Place for an operation—Nursing—Preparatory treatment —Diet—Essential and preparatory requirements—Anaesthetics—Inflammability of ether—Chloroform more dangerous than ether—Varieties of inhalers— Amount of ether required—Purity of the anaesthetic—Dangers of—How to pre- pare a patient for anaesthesia—Method of administering ether—Treatment for an overdose of ether—Intestinal etherization—Local anaesthesia—Instruments necessary for operating—Methods of holding the scalpel—Forms of incisions—- Instruments should be plain—Receptacle for instruments—Operating table— Empty vessels—Clean towels and old linen—Antiseptic solutions—Sponges . 1 CHAPTER II. AGENTS FOB CONTROLLING HEMORRHAGE. Styptics—Position—Elastic bandage—Compresses—Digital pressure—Davy's lever —Petit's tourniquet—Trendelenburg's rod—Acupressure—Torsion—Forceps— Tenacula—Cautery—Ligatures—Assistants—Patient prepared . . . . 21- CHAPTER III. TREATMENT OF OPERATION WOUNDS. Sutures—Needles—Needle-holders —Various forms of sutures—Drainage-tubes- Canalization—Antiseptic spray—Antiseptic douche—Antiseptic dressings—Anti- septic solutions—Quietude of patient—Common preparations for an antiseptic operation—Open dressings—Precautionary requirements of operations—Special emergencies of operations...........41 CHAPTER IV. LIGATURE OF ARTERIES. Guides to ligaturing—Making primary incision—Opening the sheath of a vessel- Passing the ligature—Instruments required for ligaturing—Ligature of abdomi- nal aorta—Of common iliac arteries—Of internal iliac artery—Of gluteal artery —Of sciatic artery—Of internal pudic artery—Of dorsalis pedis artery—Of ex- ternal iliac artery—Of epigastric artery—Of deep circumflex artery—Of femoral artery—Of innominate artery—Of subclavian artery—Of vertebral artery—Of viii CONTENTS. internal mammary artery—Of axillary artery—Of brachial artery—Of radial artery—Of ulnar artery—Of superficial palmar arch—Of common carotid artery —Of the common carotids—Of the external carotid artery—Of the internal carotid artery—Of the superior thyroid artery—Of the lingual artery—Of the facial artery—Of the temporal artery—Of the occipital artery . . . .56 CHAPTER V. OPERATIONS ON VEINS, CAPILLARIES, ETC. Ligature of veins—Operations for varicose veins—Injection—Acupressure—Subcu- taneous ligaturing—Hemorrhoids—Operation for internal hemorrhoids—Ex- cision—Crushing—Ligaturing—Ligature with incision—Injection—Varicocele, treatment of—By excision of the scrotum—By compression with wires or pins —By subcutaneous ligaturing—Venesection—Transfusion—With blood—With saline solutions—With milk—Mother's mark—Treatment of—Naevi—Treatment of—Cirsoid growths—Treatment of.........117 CHAPTER VI. OPERATIONS ON THE NERVOUS SYSTEM. Operations for hydrocephalus—For meningocele—For hydrorachis—Trephini:g the cranium—Instruments for—Precautions in—Location of special functions of brain—Operations on supra-orbital nerves—On infra-orbital nerves—On supe- rior maxillary nerves—On inferior dental nerve—On lingual nerve—On facial nerve—On great occipital nerve—On auricularis magnus nerve—On spinal accessory nerve—On musculocutaneous nerve—On musculo-spiral nerve—On median nerve—On radial and ulnar nerves—On great sciatic nerve—On internal popliteal nerves—On external popliteal nerves—On small sciatic nerves—On anterior and posterior tibial nerves—On plantar nerves—On perineal nerves— On anterior crural nerve—On long saphenous nerve—On short saphenous nerve —Nerve suturing—Nerve transplantation........134 CHAPTER VII. OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. Instruments for tenotomy—Rules for tenotomy—Tenotomy of flexor sublimis and profundus digitorum muscles—Of extensor communis digitorum—Of extensor primi internodii, secundi internodii, and ossis mctacarpi pollicis—Of flexor carpi radialis—Of flexor carpi ulnaris—Of biceps of forearm—Of tibialis posticus— Of flexor longus digitorum of leg—Of flexor longus pollicis of leg—Of tendo Achillis—Of peroneus longus and brevis—Of tibialis amicus—Of extensor pro- prius pollicis—Of extensor longus digitorum—Of peroneus tertius—Of biceps of leg—Of inner hamstring tendons of leg—Of the quadriceps extensor tendon —Of pectineus—Of adductor longus—Of tensor vaginae femoris—Of sartorius— Of multifidus spina;—Of latissimus dorsi—Of erector spina?—Of sterno-cleido- mastoid—Of the plantar fascia—Of the palmar fascia—Dupuytren's contraction —Tendon suturing........."... 151 CHAPTER VIII. OPERATIONS ON BONES. Gouging—Instruments necessary for—Sequestrotomy—Instruments necessaiy for__ Direct method of—Indirect method of—Excision—Time of operating—Instru- CONTENTS. ix ments necessary for—Treatment of excision wounds—Excision of the upper jaw—Special instruments for—Complete removal of—Operation by median in- cision—Excision below floor of orbit—Subperiosteal excision of—The superior maxillae may be removed simultaneously—Excision of the inferior maxilla— Excision of central portion of—Of lateral portion of—Of half of—Of entire bone—Of the alveolar process of—Operations for anchylosis of—Excision of the sternum—Excision of a portion of a rib—Excision of the clavicle—Ex- cisions of the scapula—Excisions of the humerus—Excision of glenoid angle of scapula—Excisions of the el bow-joint—Excision of the ulna—Excision of the radius—Excisions of the wrist-joint—Excision of the lower extremities—Of the bones of the forearm—Of the metacarpophalangeal joints—Of the phalan- geal joints—Of the metatarsophalangeal joints—Of the metatarso-tarsal joints —Of the tarsal joints—Excision of the calcaneum—Of the astragalus—Excis- ions of the ankle-joint—Excision of the bones of the leg—Excisions of the knee-joint—Excision of the patella—Of the great trochanter—Excisions of the hip - joint—Excision of the coccyx — Osteotomy—Instruments employed for—Neck of femur, sections of—Supra-condyloid osteotomy—Osteoarthrot- omy—Osteotomy for genu varum—For " bow-legs "—For hallux valgus—Os- teoplasty..............161 CHAPTER IX. AMPUTATIONS. General considerations—Care in making flaps—Classification of flaps—Comparative merits of different forms of flaps—Agents required for an amputation—Proper manner of holding amputating knife—Proper manner of carrying it around the limb—Proper manner of using the saw—How to operate—Use of retractors— Amputations at the phalangeal articulations—Amputations at the metacarpo- phalangeal articulations—Amputations at the carpo-metacarpal articulations— Amputations through the metacarpal bones—Amputations at the wrist-joint— Amputations at the elbow-joint—Amputations of the forearm—Amputations of the arm—Amputations at the shoulder-joint—Amputations above the shoulder- joint ..............222 CHAPTER X. AMPUTATIONS OF THE LOWER EXTREMITIES. Amputations of the phalanges in their continuity—Amputations of single toes—Am- putations of adjoining toes—Amputation of toes at metatarso-phalangeal joints —Amputation through metatarsal bones—Amputation of great toe, with its metatarsal bone—Amputation of the fifth toe, with its metatarsal bone—Lis- franc's amputation—Chopart's amputation—Forbes' modification of Chopart's amputation—Sub-astragaloid disarticulation—Hancock's amputation—Tripier's method—Molliere's method—Syme's amputation—Modification of Syme's opera- tion—Roux's operation—Pirogoff's amputation—Modifications of Pirogoff s am- putation—Le Fort's modification of Pirogoff's amputation—Esmarch's modifica- tion of Le Fort's operation—Mikulicz's amputation—Supra-malleolar amputa- tion—Amputations at the lower third of the leg—Amputations at the middle third of the leg—Amputations at the knee-joint—Amputations through the con- dyles of the femur—Carden's method—Gritti's method—Stokes' method—Ampu- tations of the thigh—Amputations at the hip-joint......255 X CONTENTS. CHAPTER XI. DEFORMITIES. Drisement force—Barton's operation for anchylosis—Curvature of the spine—Plaster- of-Paris jacket for—Webbed fingers, treatment for—Ingrown nail—Ogston's treatment of flat-foot—Stokes' treatment of—Tarscctomy.....297 CHAPTER XII. y PLASTIC SURGERY. Preparation of patient for -^Formation of flaps—Methods of transfer of flaps—Skin- grafting—Rhinoplasty—Mechanical appliances for deformed nose—Hare-lip— Cheiloplasty—Stomatoplasty—Staphyloplasty—Staphyloraphy—Uranoplasty— Elongated uvula, treatment of..........304 CHAPTER XIII. OPERATIONS ON THE MOUTH, PHARYNX, AND CESOPHAGUS. Salivary fistula, treatment of—Excision of tonsils—Treatment for tongue-tie—For ranula—Excision of the tongue—G^sophagotomy—Dilatation of the oesophagus —esophagectomy—ffisophagostomy........335 CHAPTER XIV. OPERATIONS ON HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. Indications to be met—Forms of sutures employed for sewing serous surfaces— Gastrostomy—Gastrotomy—Gastroenterostomy—Duodenostomy—Jejunostomy —Resection of the pylorus—Cholecystotomy—Cholecystectomy—Laparotomy— Enterotomy—Enterectomy—Colotomy—Iliac abscess, operation for—Artificial anus, treatment for—Nephrotomy—Nephrectomy—Nephrolithotomy—Nephror- raphy—Splenectomy—Paracentesis abdominis — Hernia — Radical cure of— Kclotomy .............. 348 CHAPTER XV. OPERATIONS ON THE ANUS AND RECTUM. Examination of anus—Operation for imperforate anus—For absence of anus—For fistula in ano—Surgical anatomy of rectum—Operations for prolapsus ani—For cancer of rectum—For stricture of rectum—For imperforate rectum . . . 401 CHAPTER XVI. OPERATIONS ON TnE URINARY BLADDER. Introduction of a catheter or sound into the bladder—Introduction of whalebone guides—Aspiration of bladder—Cystotomy—Digital exploration of bladder— Treatment of extroversion of bladder—Puncturing bladder—Lithotrity—Litho- lapaxy—Lithotomy . . . . . . . . . . .416 CHAPTER XVII. OPERATIONS ON THE PENIS AND SCROTUM. Operations for hydrocele—Castration—Circumcision—Treatment of paraphymosis__ Methods of amputation of penis—Extirpation of penis—Operations for hypo- CONTENTS. xi PAGE spadias—Operations for epispadias— Urethroraphy—Urethroplasty—External perineal urethrotomy—Internal urethrotomy—Tapping the urethra . . . 455 CHAPTER XVIII. MISCELLANEOUS OPERATIONS. Tapping the pericardium—Extirpation of the breast—Extirpation of the axillary glands—Extirpation of the parotid gland—Paracentesis thoracis—Perforation of the antrum—Plugging posterior nares—Removal of nasal polypi—Removal of naso-pharyngeal polypi—Deviation of the septum nasi, operations for—Laryn- gotomy—Tracheotomy—Laryngo-tracheotomy—Intubation of the larynx—Phar- yngotomy—Laryngectomy—Removal of goitre—Arthrectomy—Wiring patella —Movable bodies in joints, operation for—Ganglion, operations for—Wiring of bones for compound fractures..........479 B ILLUSTRATIONS. Abdominal sections, location of incisions for. Fig. 563. Original. 352 Acupressure. Figs. 45-i7. Thomas Bryant. 32 Allingham's screw crushing instrument for hemorrhoids. Fig. 170. Cam-ell, Hazard <& Co., W. F. Ford, N. Y. 120 Amputating knife, how to grasp. Fig. 315. Original. 231 Amputating knife, how to carry around limb. Fig. 316. Original. 232 Amputating knife, how to carry around limb, another method. Fiar. 317. S. Smith. 232 Amputating knife, how earned around limb, a common method. Fig. 318. Esmarch. 232 Amputation, catching bleeding points. Fig. 327. Packard. 234 Amputation by circular method. Fig. 303. Esmarch. 224 Amputation by circular method, dissecting up flap. Fig. 304. Esmarch. 225 Amputation by circular method, dissecting up flap, how not to do it. Fig. 305. Esmarch. 225 Amputation by circular method, circular division of muscles. Fig. 306. Esmarch. 226 Amputation, circular method, sawing the bon5. Fig. 324. Ashhurst, modified. 234 Amputation, circular, stump after. Fig. 307. Esmarch. 226 Amputation, circular, modified. Fig. 308. Ashhurst. 227 Amputation, equilateral flaps. Fig. 313. Esmarch. 220 Amputation, Hancock's. Figs. 402, 403. Esmarch. 266 Amputation, periosteal flap. Figs. 425, 427. Amputation, rectangular flap. Figs. 311, 312. Amputation, sawing the bone. Fig. 324. Amputation, Teale's method. Figs. 311, 312. Amputation, flap by transfixion. Figs. 300, 310. Amputation, De Lignerolles'. Figs. 308-403. Amputation at medio-tarsal articulation, Chopart's. Fi*. 386. Amputation at medio-tarsal articulation, Chopart's. Figs. 392-307. Amputation at metatarso-phalangeal articulation, square-flap method, of all the toes Figs. 380-383. Esmarch. Amputation, sub-astragaloid. Figs. 398-403. Esmarch. Amputation, sub-astragaloid, De Lignerollcs'. Figs. 398-401,403. Esmarch. Anaesthetics, administering, drawing the tongue forward. Fig. 9. Esmarch Anaesthetics, administering, pressing the jaw forward. Fig. 10. Esmarch. 14 Anchylosis, bony, Barton's operation for. Fig. 461. Gross. 298 Aneurism needle and director combined. Fig. 97. C, H. & Co., Ford. 59 Aneurism needle, Fletcher's. Fig. 100. €., H. & Co., Ford. 60 Aneurism needle, Mott's. Fig. 09. C, H. & Co., Ford. 60 Aneurism needle, Syme's. Fig. 98. C, H. & Co., Ford. 60 Aneurism needle, " Student's." Fig. 100. C, H. & Co., Ford. 60 Ankle-joint, disarticulation at the. Figs. 404-409, 413-415, 417-424. Esmarch. 267, 268, 270, 271-273 Ankle-joint, disarticulation at the. Fig. 410. Original. 269 Ankle-joint, amputation at, modification of Syme's. Fig. 410. Original. 269 Ankle-joint, amputation at, removal of the entire foot, Syme's. Figs. 404-409. Esmarch. 267,268 Esmarch. Ashhurst. Esmarch. Esmarch. Original. 274, 275 Gross. 229 Ashhurst, modified. 234 Gross. 229 Gross. 228 Esmarch. 264-266 New. 260 Esmarch. 262-264 258, 250 264-266 264-266 13 xiv ILLUSTRATIONS. Ankle-joint, amputation at, Roux's. Figs. 411, 412. Ankle-joint, amputation at, Esmarch's. Figs. 421-424. Ankle-joint, amputation at, Bruns'. Fig. 420. Ankle-joint, excision of, internal incisions. Fig. 275. Ankle-joint, excision of, removal of lower end of fibula. Fig. 274. Ankle-joint, excision of. Fig. 272. Ankle-joint, anatomy of. Fig. 273. Ankle-joint, anatomy of, inner side. Fig. 276. Ankle-joint, amputation at, Pirogoff's. Figs. 413-415 Ankle-joint, amputation at, Pirogoff's. Fig. 416. Ankle-joint, amputation at, Pirogoff's. Fig. 417. Ankle-joint, amputation at, Le Fort's. Figs. 418-419. Anklets and wristlets, Pritchard's. Fig. 695. Antiseptic adhesive plaster between sutures, big. 77. Antiseptic dressing in position. Fig. 90. Antiseptic spray apparatus, Weir's. Fig. 89. Anus, absence of. Fig. 619. Anus, artificial, cnterotome applied. Fig. 577. Aorta, abdominal, and inferior vena cava. Fig. 101. Aponeurotome. Fig. 711. Arch, palmar, superficial linear guide to. Fig. 161. Arm, amputation of, Langenbcck. Fig. 364. Arm, amputation of, by long anterior flap. Fig. 366. Arm, amputation of, by unequal skin-flaps.' Fig. 365. Arteries, femoral, deep and superficial, relations of. Fig. 122. Arteries, iliac, linear guides to. Fig. 102. Arteries, iliac, venous relations of. Fig. 103. Arteries, iliac, venous relations of. Fig. 103. Arteries, ligature of, opening sheath of vessel. Fig. 92. Arteries, ligature of, passing aneurism needle. Fig. 93. Arteries, ligature of, passing probe. Fig. 04. Arteries, ligature of, primary incision. Fig. 01. Arteries of neck, linear guide. Fig. 136. Arteries of neck and face, linear guide. Fig. 137. Artery, abdominal aorta and in (trior vena cava. Fig. 101. Artery, axillary, ligature of first portion. Fig. 141. Artery, axillary, ligature of first portion. Fig. 142. Artery, axillary, ligature of third portion. Fig. 144. Artery, axillary, linear guide to third portion. Fig. 143. Artery, brachial, digital compression of. Fig. 38. Artery, brachial, ligature of, in middle third. Fig. 146. Artery, brachial, ligature of, in middle third. Fig. 147. Artery, brachial, tourniquet applied. Fig. 41. Artery, brachial, ligature of, in lower third. Fig. 148. Artery, brachial, ligature of, in lower third. Fig. 140. Artery, brachial, linear guide to. Fig. 145. Artery, carotid, common, ligature of. Fig. 164. Artery, carotid, common, ligature of, below omo-hyoid muscle. I Artery, carotid, common, surgical anatomy of. Fig. 162. Artery, carotid, external, surgical anatomy of. Fig. 165. Artery compressor, Gross'. Fig. 57. Artery compressor, Milne's. Fig. 58. Artery compressor, Speir's. Fig. 61. Artery, dorsalis pedis. Fig. 130. Artery, dorsalis pedi-s ligature of. Fig. 131. Artery, dorsalis pedis, linear guide to. Fisj. 126. Artery, epigastric, linear guide to. Fig. 111. Artery, epigastric, course of. Fig. 610. PAGE Gross. 270 Esmarch. 273 Esmarch. 272 Esmarch. 201 Esmarch. 200 Esmarch. 109 Esmarch. 200 Esmarch. 201 Esmarch. 270 ,271 S. Smith. 271 Esmarch. 271 Esmarch. 272 C., H. & Co., Ford. 443 Esmarch. 43 B. A. Watson. 50 C.,H.& Co., Ford. 48 Gross. 403 Packard. 373 Sedillot. 61 C.,H.& Co., Ford. 453 Gross. 106 Esmarch. 249 Esmarch. 250 Esmarch. 240 Gray. 77 Stimscn, modified. 61 Sedillot. 62 Sedillot. 62 Gross. 58 Esmarch. 58 Esmarch. 58 Packard. 57 Stimson, modified. S6 Original. 89 Sedillot. 61 Sedillot. 96 Molt. 97 Sedillot. 98 New. 97 Esmarch. 28 Sedillot. 99 Mott. 100 Esmarch. 29 Sedillot. 100 Mott. 100 Neiv. 98 Mott. 108 'ig. 163. Sedillot. 108 Sedillot. 106 Sedillot. 10S C, H. d Co., Ford. 34 C., If. d Co., Ford. 35 C., H. & Co., Ford. 35 Packard. 8i Sedillot. 82 Stimson, modified. 79 Stimson, modified. 70 Gray. 396 ILLUSTRATIONS. XV Artery, facial, ligature of. Fig. 168. Artery, femoral, compression of, digital. Fig. 37. Artery, femoral, ligature of, at apex of Scarpa's triangle. Fig. 118 Artery, femoral, ligature of, at apex of Scarpa's triangle. Fig. 119 Artery, femoral, ligature of, in Hunter's canal. Fig. 120. Artery, femoral, ligature of, in Hunter's canal. Fig. 121. Artery, femoral, ligature of, in upper third. Fig. 116. Artery, femoral, linear guide to. Figs. 111-114. Artery, femoral, relations of. Fig. 115. Artery, femoral, relations of. Fig. 117. Artery, femoral, tourniquet applied to. Fig. 40. Artery, gluteal, ligature of. Fig. 107. Artery, gluteal, linear guide to. Fig. 106. Artery, iliac, common, incision for ligaturing. Fig. 104. Artery, iliac, external, ligature of. Fig. 112. Artery, iliac, external, ligature of. Fig. 113. Artery, iliac, external, linear, guide to. Fig. 111. Artery, iliac, primitive, ligature of. Fig. 105. Artery, lingual, ligature of. Fig. 166. Artery, lingual, surgical anatomy of. Fig. 167. Artery, obturator, course of. Fig. 614. Artery, occipital, ligature of. Fig. 169. Artery, popliteal, ligature of, at lower third. Fig. 125. Artery, popliteal, ligature of, at upper third. Fig. 124. Artery, popliteal, linear guide to. Fig. 123. Artery, pudic, linear guide to. Fig. 109. Artery, pudic, passing needle around. Fig. 110. Artery, radial, ligature of, at apex of styloid process Fig. 155. Artery, radial, ligature of, at lower third. Fig. 153. Artery /radial, ligature of, at lower third Artery, radial, ligature of, at upper third Artery, radial, ligature of, at upper third Artery, radial, linear guide to. Fig. 150. Artery, sciatic, ligature of. Fig. 108. Artery, sciatic, linear guide to. Fig. 106. Artery, subclavian, ligature of third portion. Fig. 139. Artery, subclavian, ligature of third portion. Fig. 140. Artery, subclavian, surgical anatomy of. Fig. 138. Artery, temporal, ligature of. Fig. 168. Artery, torsion of an. Fig. 49. Artery, tibial, anterior, ligature of, at middle third. Fig. 129. Artery, tibial, anterior, linear guide to. Fig. .126. Artery, tibial, posterior, ligature of, at lower third. Fig. 135. Artery, tibial, posterior, ligature of, at middle third. Fig. 133. Artery, tibial, posterior, ligature of. at middle third. Fig. 134. Artery, tibial, posterior, linear guide to. Fig. 132. Artery, ulnar, ligature of, at junction of middle and upper thirds. Artery, ulnar, ligature of, at junction of middle and upper thirds Artery, ulnar, ligature of, at lower third. Fig. 158. Artery, ulnar, ligature of, at lower third. Fig. 159. Artery, ulnar, ligature of, at wrist. Fig. 160. Artery, ulnar, linear guide to. Fig. 150. Aspirator, Fitch's. Fig. 581. Aspirator, trachea. Fig. 786. Aspirator, Potain's. Fig. 580. Atomizer, Richardson's. Fig. 14. PAOR 116 Fig. 154. Fig. 151. Fig. 152. Sedillot. Esmarch. Sedillot. Mott. Sedillot. Mott, modified. S. Smith. Stimson, modified. 70-72 Sedillot. 73 Gray. Esmarch. S. Smith. Stimson, modified. Otis, modified. S. Smith. Mott. Stimson, modified. Otis, modified. Sedillot. Esmarch, modified. Gray. Sedillot. S. Smith. Sedillot. Xeiv. S. Smith. S. Smith. Sedillot. Sedillot. Molt. Sedillot. Mott. Stimson, modified. S. Smith, Stimson, modified. Sedillot. Mott. Sedillot. Sedillot. Esmarch. Sedillot. Stimson, modified. Sedillot. Sedillot. Mott. Stimson, modified. Fia-. 156. Sedillot. Fig. 157. Mott. Sedillot. Mott. Sedillot. Stimson, modified. C.,H.dk Co., Ford. C.,H.& Co., Ford. C.,H.& Co., Ford. C, H. & Co., Ford. 74 29 67 66 63 70 70 70 64 114 114 400 117 79 78 78 68 68 103 103 103 102 102 101 67 66 91 91 90 116 33 81 79 84 84 84 83 104 104 105 105 105 101 378 497 378 17 Band, compression, Nicaise's. Fig. 29. Esmarch. 25 xvi ILLUSTRATIONS. Bandage, clastic. Fig. 27. Bandage, elastic, applied. Fig. 23. Bandage, rubber, Martin's. Fig. 33. Bistouri cache, Civiale's. Fig. 747. Bistouries and scalpels. Fig. 15. Bistoury, beaked, Gouley's. Fig. 741. Bladder, evacuating apparatus or washer, Bigclow's. Fig. 670. Bladder, evacuating apparatus or washer, Otis'. Figs. 671, 672. Bladder, evacuating apparatus or washer, Thompson's. Fig. 669. Bladder, extroversion of the, Bigelow's operation. Fig. 651. Bladder, extroversion of the, Bigelow's operation. Fig. 652. Bladder, extroversion of the, Maury's operation. Fig. 650. Bladder, extroversion of the, Wood's operation. Figs. 653, 654. Bladder, puncturing the. Fig. 657. Blow-pipe. Fig. 64. Fig. 487. Fig. 745. 646. Fig. 746. Fig. 753, 754. Fig. 755. Bone pliers, Butcher's. Bougies a boule, Otis'. Bougies, filiform. Fig Bougies, non-metallic. Breast, removal of the. Breast, removal of the, incisions for. Buck's needle conductor. Fig. 48. Bunion, with hallux valgus. Fig. 468. Esmarch. Esmarch. C, II. & Co., Ford. C.,H.& Co., Ford. C.,H.& Co., Ford. G, H. & Co., Ford. C, H. & Co., Ford. C, II. & Co., Ford. C.,H.& Co., Ford. S. Smith. Agnew. S. Smith, modified. Gross. Bumstead & Taylor. C, H. & Co., Ford. C, II. & Co., Ford. C.,H.& Co., Ford. C, II. & Co., Ford. C.,H.& Co., Ford. S. Smith. Gross, modified. G, H.& Co., Ford. Gross. PAGB 24 25 27 475 18 471 432 433 432 424 424 423 425 426 36 316 475 420 475 479 480 32 302 Canal, femoral, location of. Fig. 612. Canula, Bellocq's. Fig. 757. Canuia, polypus, nasal. Fig. 760. Capillaries, subcutaneous ligaturing of. Figs. 189-194. Carpo-metacarpal articulation, amputations at. Figs. 341- Carpus, ligaments of dorsal surface of. Fig. 266. Carpus, ligaments of palmar surface of. Fig. 267. Carpus, synovial membranes of. Fig. 265. Catheter, chemise. Fig. 694. Catheter, double-elbowed, Mercier's. Fig. 636. Catheter, elbowed, Mercier's. Fig. 637. Catheter, evacuating, Bigelow's. Fig. 673. Catheter, evacuating, spiral-tipped, Warren's. Fig. 674. Catheter, evacuating and lithotiite combined, author's. I Catheter-guide, Keyes'. Fig. 640. Catheter-guide, Otis'. Fig. 641. Catheter, olivary gum. Fig. 642. Catheter, passing a. Fig. 644. Catheter entering bladder. Fig. 645. Catheter, self-retaining. Fig. 638. Catheter, self-retaining, Holt's. Fig. 639. Catheter, velvet-eye. Fig. 643. Catheter, tunneled, and guide, Gouley's. Fig. 649, 742. Catlin. Fig. 321. Cautery-irons. Fig. 63. Cautery, thermo, Paquelin's. Fig. 65. Cheek-compressor for hare-lip, Hainsley's. Fig. 406. Chisel. Fig. 225. Chisels. Fig. 202. Chciloplasty, lower lip, Celsus' method. Fig. 408. Cheiloplasty, lower lip, Celsus' method. Fig. 409. Cheiloplasty, lower lip, contracted. Buck's method. Figs Cheiloplasty, lower lip, horizontal incision. Fig. 500. Cheiloplasty, lower lip, Malgaignc's method. Fig. 504. Gray. 398 C, H.& Co., Ford. 484 G, H. & Co., Ford. 485 S. Smith, 133 345. Esmarch. 240, 241 Esmarch. 194 Esmarch. 194 Esmorch. 193 C.,H. & Co., Ford. 443 G, H. d Co., Ford. 416 G, H. & Co., Ford. 416 C.,H.& Co., Ford. 433 C.,H.& Co., Ford. 434 'ig. 677. G, H. & Co., Ford. 436 C.,H.& Co., Ford. 417 C, H. d Co., Ford. 417 G, H. & Co., Ford. 417 Bumstead d Taylor. 417 Bumstead & Taylor. 419 C.,H.& Co., Ford. 416 G, H. d Co., Ford. 416 C, II. & Co., Ford. 417 C. H. & Co., Ford. 421 C..H.& Co., Ford. 233 C.,H.& Co., Ford. 36 G, H. d Co., Ford. 36 Gross. 320 C, II. & Co., Ford. 162 C, H. d Co., Ford. 215 Few. 320 Stimson, modified. 321 . 502, 503. Buck. 322, 323 Stimson. 321 Stimson. 324 ILLUSTRATIONS. xvii Cheiloplasty, lower lip, operation by V-shaped incision. Fig. 497. Cheiloplasty, lower lip, Sedillot's method. Fig. 505. Cheiloplasty, Syme's method. Fig. 501. Cheiloplasty, upper lip, Dieffenbach's method. Figs. 508, 509. Cheiloplasty, upper lip, Buck's method. Figs. 506, 507. Cheiloplasty, upper lip, ISedillot's vertical-flap method. Figs. 510, Chloroform inhaler, Esmarch's. Fig. 1. Clamp, bandage, Langenbeck's. Fig. 32. Clamp, Bodenhamer's. Fig. 729. Clamp, scrotal, Henry's. Fig. 173. Clamps, nasal septum, Adams'. Fig. 771. Collins' transfusion instrument. Fig. 185. Colon, ascending, surgical relations of. Fig. 572. Colon, descending, surgical relations of. Fig. 571. Colotomy, left lumbar. Figs. 573-575. Colotomy, left lumbar. Fig. 576. Colotomy, left lumbar (Amussat), linear guide to colon. Fig. 570. Compress, conical. Fig. 36. Compress, oblong. Fig. 35. Compress, pyramidal. Fig. 34. Crutch, Clover's, applied. Fig. 606. Dilator, Dolbeau's. Figs. 632, 633. Dilators, oesophageal. Fig. 547. Dilator, trachea, Chassaignac's. Fig. 780. Dilator, trachea, Trousseau's. Fig. 779. Dilator, urethral, Gross'. Fig. 714. Director, Allingham's. Fig. 629. Director, grooved. Fig. 24. Director, grooved, and aneurism needle combined. Fig. 97. Director, hernial, Levis'. Fig. 603. Double hook, Langenbeck's. Fig. 778. Drainage, spiral, Ellis'. Fig. 87. Drainage-tube, rubber. Fig. 88. Drill, bone, French. Fig. 791. Elbow-joint, amputation at. Fig. 360. Elbow-joint, amputation at, circular. Fig. 361. Elbow-joint, amputation at, single-flap. Fig. 362. Elbow-joint, disarticulation at. Figs. 360, 361. Elbow-joint, disarticulation at. Figs. 362, 363. Elbow-joint, excision of, Hiiter. Fig. 259. Elbow-joint, excision of, exposing internal condyle. Fig. 263. Elbow-joint, excision of, Langenbeck. Fig. 261. Elbow-joint, excision of, Liston. Fig. 262. Elbow-joint, ligaments of. Fig. 260. Elbow-joint, relations of ulnar nerve to. Fig. 258. Elevator. Figs. 198-200. Enterectomy, Treves' apparatus for. Fig. 569. Epispadias, Nelaton's operation for. Figs. 734, 735. Epispadias, Thiersch's operation for. Fig. 736, 737. Ether inhaler, Allis'. Figs. 3, 4. Ether inhaler, cloth and paper. Fig. 2. Ether inhaler, Clover's. Fig. 6. Ether inhaler, Lente's modified. Fig. 5. Ether inhaler, Noycs'. Fig. 8. Ether inhaler, Squibb's. Fig. 7. Etherization, intestinal, apparatus for. Fig. 13. PAGE Stimson. 320 Stimson. 324 New. 322 Agnew. 326 Buck. 324 , 325 511. Stimson, modified. 326 Esmarch. 6 G, H. d Co., Ford. 26 G, H. d Co., Ford. 462 c. H. d Co., Ford. 122 a, H. d Co., Ford. 492 Esmarch. 129 Treve.s. 370 Treves. 369 Original. 371 Packard. 372 s. Smith, modified. 367 Esmarch. 27 Esmarch. 27 Esmarch. 27 Original. 444 c. If. d Co., Ford. 440 C, , H. d Co., Ford. 345 G, H. d Co., Ford. 495 G. , H. & Co., Ford. 495 G. , H. d Co., Ford. 454 C, H. & Co., Ford. 407 c. , II. d Co., Ford. 20 c, II. d Co., Ford. 59 G, H. d Co., Ford. 302 c. , H. d Co., Ford. 495 G, H. d Co., Ford. 4G G. H. d Co., Ford. 40 a, H. d Co., Ford. 509 Esmarch. 247 Esmarch. 247 S. Smith. 24S Esmarch. 247 S. Smith. 24 S Esmarch. 189 Esmarch. 180 Esmarch. 189 Esmarch. 189 Esmarch. 189 Esmarch. 188 c, H. d Co., Ford. 136 Treves. 366 New. 467 Stimson. 468 Heath, 7 Original. 7 a. H. d Co., Ford. 9 Extensor proprius pollicis ) Anterior tibial nerve. (Gray.) Inner side. Tibialis anticus. Extensor proprius pollicis (crosses it at its lower part). ( Anterior (tibial artery. Behind. Interosseous membrane. Tibia. Anterior ligament of ankle-joint. Outer side. Anterior tibial nerve. Extensor longus digitorum. Extensor proprius pollicis. Fig. 127.—Transverse section, upper third. Fig. 128.—Transverse section, middle third 1. Popliteus. 2, 3. Gastrocnemius. 4L Soleus. 6. Peroneus longus. 6. Exten- sor longus digitorum. 7. Tibialis anti- cus. 8. Tibialis posticus. 9. Posterior tibial artery and venae comites. 10. Posterior tibial nerve. 11. Anterior tib- ial artery and venae comites. 12. An- terior tibial nerve. 1. Soleus. 2, 3. Gastrocnemius. 4. Flexor longus pollicis. 5. Peroneus longus and bre- vis. 6. Extensor longus pollicis. 1. Exten- sor com. digitorum. 8. Tibialis anticus. 9. Tibialis posticus. 10. Flexor longus digi- torum. 11. Anterior tibial artery and ve- nae comites. 12. Anterior tibial nerve. 13. Posterior tibial artery and venae comites. 14. Posterior tibial nerve. 15. Peroneal artery and venae comites. Operation. — Upper Third (Fig. 126).—The great depth of the vessel in this situation renders the tying of it one of the most tedious of operations. Unless circumstances demand it, the ligaturing in this situation should not be attempted. Fig. 127 shows the deep relations of the vessel. The linear and muscular guides are similar to those of the middle third. Middle Third (Fig. 126, a).—The artery in this situation lies quite deep, and a good light must be had to see the bottom of the operation LIGATURE OF ARTERIES. 81 wound. Place the patient on the back with the thighs extended, the leg turned inward, and the foot forcibly extended to mark the outlines of the tibialis anticus muscle. Make an incision four or five inches in length on the line indicating the course of the artery, down to the fascia, which is then divided on a director. The aponeurosis is then divided along the line of apposition between the tibialis anticus and the extensor longus digitorum; it should likewise be divided transversely to admit of the wider separation of these muscles. The foot is now flexed, and, with the finger, or handle of the scalpel, the line of separation is extended directly down to the vessel; separate the surfaces of the wound with spatulae, when the artery, with its nerve and veins, will be seen, the nerve being in front and to the outer side ; sepa- rate the veins from the artery, draw the nerve aside, and pass the ligature from without in- ward (Fig. 129). Operation at the Lower Third (Fig. 126, l).—With the limb as in the preceding in- stance, extend the foot to mark the course of the tendon of the tibialis anticus ; make an incision along the external border of the ten- don on the linear guide about three inches in length. Divide the fascia on a director, and seek with the finger for the space between the tibialis anticus and the extensor proprius pollicis which has crossed to the inner side of the vessel; flex the foot, separate these muscles, and the artery will be seen accompanied by its veins and nerve, the latter lying in front and a little to the outer side ; iso- late the artery, and place the ligature by passing it from without inward. Fallacies.—The outer surface of the head of the tibia may be mistaken for the head of the fibula, which will bring the linear guide too far to the in- ner side of the leg, and cause the incision to be made over the belly of the tibialis anticus muscle. To avoid this it must be remembered that the head of the fibula is more posteriorly, and constitutes the most external bony prominence at this point. The septum between the tibialis anticus and the Fig. 129.—Ligature of anterior tibial, middle third. Fig. 130. — Dorsalis pedis artery. 82 OPERATIVE SURGERY. extensor longus digitorum may be indistinct or absent; then the outer border of the tibialis anticus can be determined, 1, by forcible exten- sion of the tarsus; 2, by .determining its limits by the resistance to lateral pressure ; 3, the line indicating the interspace may be seen at the lower extremity of the incision when not visible above. The vessel may be rudimentary or absent; it may run more super- ficially than common. So long, however, as it keeps in the proper line its pulsations will lead to its detection. Ligature of the.Dorsalis Pedis Artery.—This vessel is a continu- ation of the anterior tibial (Fig. 126, c), beginning at the ankle-joint and passing downward between the metatarsal bones of the great and second toes. It is tied in one situation, and on a line which is a direct continuation of the linear guide to the anterior tibial. The muscular guide is the outer border of the tendon of the ex- tensor proprius pollicis (Fig. 130). Contiguous Anatomy. Plan of the Relations of the Dorsalis Pedis Artery. In front. Integument and fascia. Innermost tendon of extensor brevis digitorum Tibial side. Extensor proprius pollicis (Gray.) Fibular side. Extensor longus digitorum. Anterior tibial nerve. Fig. 131.—Ligature of dor- salis pedis. j Dorsalis ) ( pedis artery. £ Behind. Astragalus. Scaphoid. Internal cuneiform, and their ligaments. Operation.—Extend the tarsus and forcibly flex the great toe to make prominent the ten- don of the extensor proprius pollicis ; make an incision about three inches in length along its outer border, commencing from the bend of the ankle ; divide the fascia on a director, when the fleshy inner portion of the extensor brevis digitorum will be seen ; this should be drawn outward, when the artery and its satellite veins will appear; separate the artery from them, and pass the needle as best suits the conven- ience of the operator (Fig. 131). Fallacy.—It may pass outside of the line indicating its proper course. Ligature of the Posterior Tibial Artery.— This is an artery of considerable size which LIGATURE OF ARTERIES. 83 comes from the popliteal at the lower border of the popliteus muscle ; it passes obliquely to the tibial side of the leg, goes down between the superficial and deep layers of muscles to a point midway between the Fig. 132.—Linear guide to posterior tibial. internal malleolus and inner tuberosity of the os calcis, where it terminates a little further on in the external and internal plantar ar- teries. It may be ligatured in three situations : at its, middle third, at its lower third, and as it passes behind the inner malleolus. The linear guide of this vessel is drawn from the middle of the popliteal space to midway between the inner malleolus and tuberosity of the os calcis. This guide is not a feasible one, since to reach the artery by cutting upon it necessitates the division of the fibers of the muscles of the calf of the leg. The linear guide to the operation is made by drawing a line three fourths of an inch behind the posterior border of the tibia in the upper and lower thirds, and from its upper to its lower extremity (Fig. 132). The Muscular Guide.—At its middle third it lies beneath the so- leus ; at its lower third to the outer border of the flexor longus digi- torum. Contiguous Anatomy. Plan of the Relations of the Posterior Tibial Artery. (Gray.) In front. Tibialis posticus. Flexor longus digitorum. Tibia. Ankle-joint. Inner side. Outer side. Posterior tibial nerve, ( Posterior ) Posterior tibial nerve, upper third. ( tibial artery. ) lower two thirds. Behind. Gastrocnemius. Soleus. Deep fascia and integument. 84 OPERATIVE SURGERY. Operation at its Middle Third (Fig. 132, c).— Place the patient on the back, flex the leg on the thigh and the thigh on the pelvis, so that Fig. 134.—Ligature of posterior tibial, middle third, a. Fascia and fat. b. Gastrocnemius muscle, c. Cellular tissue, d. Soleus muscle and its aponeurosis, e. Sheath of vessels. /. Posterior tibial artery, g. Venae comites. h. Posterior j| tibial nerve. i the leg will lie on the outer side. Make an incis- y ion on the linear guide to the operation, about Fig. 133.—Ligature ofpos- „ ., ., ° -,••-,.,■,-, £ terior tibial, middle third, four inches in length ; divide the deep fascia, rec- ognize the inner border of the gastrocnemius, be- neath which will be seen the fibers of the soleus, which should be di- vided on a director, down to the pale yellow aponeurosis on its under surface ; separate the fibers of the soleus | I U and make an opening through its apo- neurosis, about one inch from the inner | border of the tibia, of sufficient size to expose the artery, which is found be- neath, attended by its veins and the pos- terior tibial nerve (Fig. 133) ; draw the nerve to the outer side, separate the ves- sel from the veins, and pass the needle from without inward (Fig. 134). Operation at the Lower Third (Fig. 132, J).—Place the limb as before; make an incision in the course of the linear guide about three inches in length ; di- vide the integument and fascia in the usual manner ; separate the borders of the wound, then divide the aponeurosis (which binds down the deep layer of muscles) at about one inch from the pos- terior border of the tibia, push aside the fat, and the vessel, with its -o .4 Fig. 135.—Ligature of posterior tib- ial, lower third. LIGATURE OF ARTERIES. 85 nerve and veins, will be found at the outer border of the flexor longus digitorum. Separate the vessel, push the nerve to the outer side, and pass the needle from without inward (Fig. 135). Operation between the Os Calcis and Internal Malleolus.—Place the foot on the outer surface and make a curved incision about three inches in length, with the concavity uppermost, and its center at a point midway between the malleolus and the inner tuberosity of the os calcis (Fig. 132, a). Divide the fascia and the internal annular ligament on a director, using caution with the director, since the ar- tery lies beneath the ligament; isolate the vessel from the veins and pass the needle from without inward. In passing through the super- ficial tissues, some small branches of the long saphenous vein may be divided, unless caution be used. In old people both these and the venas comites often become varicose, which increases the difficulty of finding and isolating the artery. It is better not to attempt to liga- ture it in this situation if evidences of varicosities exist. Fallacies.—The posterior tibial maybe rudimentary or absent. In either instance the peroneal is usually increased in size. Ligature of the Peroneal Artery.—It arises from the posterior tibial about an inch below the popliteus muscle, passes obliquely outward to the inner border of the fibula (Fig. 128), along which it descends to the lower third of the leg, and is finally distributed to the outer side of the ankle. It may be ligatured at the middle third of the leg. The linear guide is a line drawn from the posterior border of the head of the fibula to the external border of the tendo Achillis at its insertion. Contiguous Anatomy. Plan of the Relations of the Peroneal Artery. (Gray.) In front. Tibialis posticus. Flexor longus pollicis. ( Peroneal) \ artery. ) Behind. Soleus. • Deep fascia. Flexor longus pollicis. Operation.—Extend the foot and make an incision about four inches in length along the line indicated, parallel with the external border of the fibula. Separate the attachments of the soleus and the flexor longus pollicis from each other, when the artery will be found at the inner side of the flexor longus pollicis close to the fibula. Outer side. Fibula. 86 OPERATIVE SURGERY. Fallacies.—-It may be absent; this is, however, very rare. It may be overlooked, and the posterior tibial found instead. If its close re- lation to the fibula be remembered, this mistake will not occur. Ligature of the Innominate Artery.—The innominate artery arises from the beginning of the transverse arch of the aorta in front of the left common carotid, passes obliquely upward and outward to the up- per border of the right sterno-clavicular articulation, where it divides into the right common carotid and right subclavian. It has no prac- tical linear or muscular guides. Contiguous Anatomy. Plan of the Relations of the Innominate Artery. (Gray.) In front. Sternum. Sterno-hyoid and sterno-thyroid muscles. Remains of thymus gland. Left innominate and right inferior thyroid veins. Inferior cervical cardiac branch from right pneumogastric nerve. Right side. Right vena innominata. Right pneumogastric nerve. Pleura. Innominate artery. Behind. Trachea. Left side. Remains of thymus. Left carotid. /^ Operation.—Numerous incisions have been given for gaining ac- cess to the vessel. The one which is best calculated to afford the requisite amount of room was employed by the late Valentine Mott (Fig. 136, d). Place the patient on the back, with the shoulders somewhat raised, and the head turned to the, oppo- site side. An incis- ion is then made three inches in length, extending along the upper bor- der of the clavicle to opposite the cen- ter of the episternal notch. This is joined by another of a sim- lar length directed along the anterior portion of the sterno-mastoid muscle. This trian- gular flap, consisting of the integument, superficial fascia, and pla- Fig. 136.—Linear guides to arteries of neck. LIGATURE OF ARTERIES. 87 tysma, is turned upward and outward. The portions of the sterno- cleido-mastoid, corresponding to the horizontal incision, and the ster- no-hyoid and sterno-thyroid muscles, are divided on a director and turned aside. The inferior thyroid veins, if they now come into view, must be carefully drawn aside, the deep cervical fascia must be carefully torn or cut through, when the sheath containing the com- mon carotid artery, pneumogastric nerve, and internal jugular vein is brought into view. Open the sheath, draw the vein and nerve to the outer side, and follow the carotid down to the subclavian, the origin of which should be exposed. The upper portion of the innom- inata is then to be separated from its important connections by the finger or a blunt director ; the left vena innominata is depressed, and the right vena innominata, right internal jugular, and pneumogas- tric nerve are carried to the right, and then the aneurism needle is passed from below upward, and from behind, forward and inward, in close contact with the vessel. It is suggested to remove a sufficient portion of the upper end of the sternum to admit of the direct open- ing into the sheath of the innominata. It is thought that this mea- sure will the better preserve the nutritive integrity of the coats of the vessel by leaving its vascular connections with the sheath undisturbed above. Fallacies.—If the innominata be shorter than usual, the lower extremity of the common carotid may be tied instead. If the aorta arches to the right side, the innominata will be on the left side, in- stead of the right. The necessity of treating all the veins and the pleura with most judicious care is emphasized by the knowledge of the fact, that, nearly all the fatal cases thus far have died from pleuritis or secondary hemorrhage. Results.—This vessel has been ligatured seventeen times, with two recoveries. Ligature of the Subclavian Artery.—The subclavian artery, on the right side, arises from the arteria innominata, opposite the junction of the right clavicle with the sternum ; on the left side it arises from the arch of the aorta. These vessels must, therefore, differ in the first part of their course in length, direction, and with relation to their contiguous anatomical structures. This vessel can be ligatured in three situations : between the inner border of the scalenus anticus and its origin ; behind the scalenus ; between its termination at the lower border of the first rib and the outer border of the scalenus anticus. Ligature of the First Portion, Left Side.—This portion has no definite linear or muscular guide. The inner border of the scalenus anticus is important as leading to and limiting its extent. Owing to its origin from the arch of the aorta, it is of great depth, almost beyond the reach of a ligature ; while its close relation to very 88 OPERATIVE SURGERY. important structures—injury to which, of itself, may be more grave than the condition for which the vessel is to be tied—ren- der it exceedingly difficult to perform, and of questionable expedi- ency. Contiguous Anatomy. Plan of Relations of First Portion of Left Subclavian Artery. (Gray.) In front. Pleura and left lung. Pneumogastric, cardiac, and phrenic nerves. Left carotid artery. Left internal jugular and innominate veins. Sterno-thyroid, sterno-hyoid, and sterno-mastoid muscles. Inner side. Outer side. (Esophagus. S Left subclavian artery, ) Pleura. Trachea. \ first portion. ) Thoracic duct. Behind. Oesophagus and thoracic duct. Inferior cervical ganglion of sympathetic. Longus colli muscle and vertebral column. Operation.—Place the patient on the back with the head extended and turned to the opposite side ; the left shoulder should be well de- pressed ; make an incision three inches and a half in length along the inner border of the sterno-cleido-mastoid down to the sternum; another, two inches and a half in length along the inner extremity of the clavi- cle, meeting the former near the trachea. It is seen that this incision is substantially the same as that for the ligaturing of the innomi- nate artery (Fig. 136, d). The flap, consisting of the integument, superficial fascia, and platysma, is turned aside ; one half of the cla- vicular portion of the sterno-mastoid and its whole sternal portion are then divided on a director, bringing into view the sterno-hyoid, sterno- thyroid muscles, and, to the outer side, the omo-hyoid. The sterno- thyroid and sterno-hyoid should be divided with great care, after be- ing liberated from the fascia which covers them. The inner edge of the scalenus anticus muscle is now sought for; when found, it will guide the finger directly to the vessel. The important contiguous structures are now drawn inward and pressed away from the artery, using great caution to avoid the thoracic duct, which will be in the line of search, as it passes behind the jugular vein at its junction with the left innominate vein. The needle is carefully passed from before backward. The great depth of the vessel will make it exceedingly difficult to pass the needle, which should be the one with the adjust- able extremity. Results.— Tied by Dr. J. Kearney Rogers, 1845 ; patient died from secondary hemorrhage on the fifteenth day. LIGATURE OF ARTERIES. 89 Ligature of First Portion, Right Side.—The inner border of the anterior scalenus leads to it upon this, as upon the left side. Contiguous Anatomy. Relations of First Portion of Right Subclavian Artery. (Gray.) In front. Clavicular origin of sterno-mastoid muscle. Sterno-hyoid and sterno-thyroid muscles. Internal jugular and vertebral veins. Pneumogastric, cardiac, and phrenic nerves. j Right subclavian artery, ) ( first portion. ) Beneath. Pleura. Behind. Recurrent laryngeal nerve. Sympathetic nerve. Longus colli muscle. Transverse process of seventh cervical or first dorsal ivertebra. Operation.—The position of the patient, primary incisions, and dissection are substantially the same as the preceding. The internal jugular should be pressed aside and the needle passed from below up- ward and from before back- ward, carefully avoiding the pleura, recurrent laryngeal and phrenic nerves. The lig- ature of the vertebral and in- ternal mammary arteries at the same time will lessen the danger of secondary hemor- rhage. Fallacies. —This vessel may arise from the arch of the aorta, when it will be more deeply situated, often passing behind the oesopha- gus or between it and the trachea. Results.— It has been lig- atured thirteen times; all the cases proved fatal, of which eight died of hemorrhage. Ligature Of the Second FlG- 13?--Linear g^des to arteries of neck and face. and Third Portions.—The linear guide to the operation is drawn just above the upper border of the clavicle, extending between the poste- rior border of the sterno-cleido-mastoid and the anterior border of the trapezius, and should be about four inches in length (Fig. 137, a). 90 OPERATIVE SURGERY. Fig. 138.—Surgical anatomy of subclavian. Muscular Guides to the Artery.—This vessel has no superficial muscular guide. The deep muscular guide is the outer border of the scalenus anticus. The posterior belly of the omo-hyoid, while not in close contact with it, serves an important purpose in directing the attention of the surgeon toward it. The situation of the outer border of the scalenus anticus is well indicated by the posterior border of the sterno-cleido-mastoid, provided the latter muscle be not uncom- monly developed. The junction of the inner two inches of the clavicle with its outer portion is a far more unvarying indication of the approximate deep location of the outer border of the scalenus anticus than is the former. The tubercle on the first rib, into which the scalenus anticus is inserted, is the guide to the vessel, the artery being directly behind it (Fig. 138). Contiguous Anatomy. Relations of Third Portion of Subclavian Artery. (Gray.) In front. Cervical fascia. External jugular, supra-scapular, and transverse cervical veins. Descending branches of cervical plexus. Subclavius muscle and supra-scapular artery and clavicle. Above. Below. Brachial plexus. Omo-hyoid. Behind. Scalenus medius j Subclavian artery, ) ( third portion. ) First rib. Operation—Third Portion.—Place the patient on the back with the shoulders elevated from the table, head bent backward and turned to the opposite side. Draw the shoulder of the corresponding side firmly downward to the side of the patient, and retain it in that posi- tion. Compress the external jugular vein above the clavicle, long enough to cause its distention, thereby indicating its exact situation. The integument is then drawn evenly downward and incised upon the LIGATURE OF ARTERIES. 91 Fig. 139.—Ligature at third portion of subclavian. clavicle, and will, when allowed to retract, carry the incision upward to its proper situation—orfe-half inch above the clavicle. The super- ficial fascia and platysma are then divided upon a director, being care- ful not to sever the external jugular, which can be either pulled aside or divided between two ligatures. The supra-scapular and transverse cervical veins should be treated in the same manner. The omo-hyoid is now sought for and drawn upward, if necessary, and the supra- scapular artery avoided. The deep cervical fascia is torn asunder by the finger-nail or a director, and the outer border of the' scalenus anticus felt for on a line with the outer margin of the ster- no-cleido-mastoid, if the latter have not been di- vided ; if so, it should be located as described un- der the head of " Mus- cular Guides to the Ar- tery." If the head be turned forcibly to the opposite side, the scale- nus anticus will be made tense and more prominent. When found, it should be followed downward to its insertion, when the finger will rest upon the tubercle of the first rib, immediately behind which the pulsa- tion of the artery will be felt. The vessel is now carefully exposed and the needle passed from be- fore backward (Fig. 139). Great caution should be taken not to interfere with the subclavian vein, which lies in front of, and on a lower plane than the artery (Fig. 140). Fallacies. —The ster- no-cleido-mastoid may have an unusual breadth of origin from the clavicle, thereby causing the incision to be made too far posteriorly. The clavicular measure- ment will prevent this error. The tubercle on the anterior surface of a transverse process of one of the lower cervical vertebrae may be mis- taken for the tubercle of the first rib. This, however, is easily recti- Fig. 140.—Ligature of subclavian artery, third portion. a. Anterior border of trapezius muscle, b. Sterno- mastoid muscle, c. Omo-hyoid muscle, d. Scalenus anticus muscle, e. Aponeurotic tissue. /. Subcla- vian vein, partly behind clavicle, g. Occasional ori- gin of the supra-scapular artery, h. External jugu- lar vein. i. Inner cords of the brachial plexus. j. Superficial descending branches of brachial ple'xus. k. Subclavian artery. I. Connective tissue. 92 OPERATIVE SURGERY. fied by remembering that the rib is located downward and backward, that no contiguous pulsation is found, and that the outline of the scalenus anticus is absent. The tubercle may be absent, and the muscular insertion into the rib must then be relied upon. The artery may be in front of the tubercle and the vein behind it. The pulsation as well as the anatomical appearances will determine the interchange of situations. The inner cord of the brachial plexus may be mistaken for the artery. A little attention to the distinctive physical characteristics between nerves and arteries will quickly settle this doubt. Results.—Two hundred and fifty-one cases are tabulated, of which one hundred and thirty-four, or fifty-three per cent, died. Ligature of the Second Portion.—AM the muscular and linear guides are practically similar to those of the preceding. Contiguous Anatomy. Plan of Relations of Second Portion of Subclavian Artery. (Gray.) In front. Scalenus anticus. Phrenic nerve. Subclavian vein. j Subclavian artery, ) Below- \ second portion. ) Pleura. Behind. Pleura and middle scalenus. Operation.—The steps essential to arrive at the proper site in this instance, are not varied from those given for the third portion, until the outer border of the scalenus anticus is well determined ; the phre- nic nerve and subclavian vein should then be pushed aside and the muscle divided (Fig. 140, d), when the retraction of its fibers will ex- pose the artery to view. The needle is then passed as before, closely hugging the artery, to avoid the pleura below and posteriorly. Fallacies.—The vein and artery may be transposed. Results.—Thirteen cases are reported, of which nine, or sixty-nine per cent, were fatal. The subclavian should always be tied in the third portion when possible ; if impossible, then the second should be selected. The liga- ture of the first portion is unwarranted in view of the results here- tofore obtained. Ligature of the Vertebral Artery.—This artery arises from the upper and back part of the first portion of the subclavian, passes directly upward along the anterior surface of the vertebral column, and enters the foramen in the transverse process of the sixth cervi- cal vertebra. It ascends through the foramina in the transverse pro- Above. Brachial plexus. LIGATURE OF ARTERIES. 93 cess of all the vertebra? above this, inclining outward and upward be- tween the transverse processes of the axis and atlas, and finally runs in a deep groove on the upper surface of the posterior arch of the atlas before it ascends to pierce the posterior occipito-atloid ligament. It may be ligatured in three situations : 1, before entering the vertebral canal; 2, between the atlas and axis ; 3, between the atlas and the occipital bone. 1. The linear guide to the artery in the first situation is drawn from the junction of the inner fourth with the outer three fourths of the clavicle, to the posterior border of the mastoid process. The deep guides are the tubercle of the transverse process of the sixth cervical vertebra, and the space between the borders of the longus colli and the scalenus anticus. Contiguous Anatomy. In front. Internal jugular vein and its sheath. Inferior thyroid artery. Thoracic duct (left side). Aponeurosis between longus colli and the scalenus anticus. Vertebral vein. Outer side. j Vertebral { Scalenus anticus. ( artery. ) Behind. Cervical nerves. Vertebral column Operation.—1. The head should be turned to the opposite side and an incision about three inches and a half in length made along the anterior border of the sterno-cleido-mastoid, terminating at the upper border of the sternum. The fascia and the connections between the sterno-mastoid and sterno-hyoid are divided and these muscles sepa- rated, which exposes the common sheath of the internal jugular vein, common carotid artery, and pneumogastric nerve. This sheath is now carefully separated from its connections with the sterno-thyroid and longus colli muscles and drawn outward. The parts are now relaxed by raising the head, the inferior thyroid artery displaced, the tho- racic duct avoided, and the aponeurosis covering the vessel torn through, the vein pushed aside, and the ligature passed from within outward. Mr. Alexander, whose experience in tying these vessels on the living subject is greater than that of any other surgeon, describes his method of operating in the following language : "An incision three or four inches long is made in an upward and outward direc- tion along the hollow which exists between the scalenus anticus and the sterno-mastoid muscles. The incision should begin just outside Inner side. Longus colli. 94 OPERATIVE SURGERY. and on a level with the point where the external jugular vein dips over the edge of the sterno-mastoid muscle, or, if the vein is invisible, about half an inch above the clavicle. The external vein is drawn inward with the sterno-mastoid muscle. The connective tissue now appearing, the wound is opened by a blunt director, until the sca- lenus anticus muscle, the phrenic nerve, and the transverse cervical artery are seen. It can not be too well remembered that the pleura is at the inner side of the wound, while below lies the subclavian ar- tery. It is now only necessary to separate the edges of the scalenus anticus and the longus colli muscles to see the vertebral artery lying in the space between them. The artery is generally completely cov- ered by the vein, which is drawn aside and the artery is then liga- tured." 2. In this position the artery is in a triangular space formed by the rectus posticus major and superior and inferior oblique muscles. It is covered by the rectus posticus major and complexus. Operation.—With the head turned to the opposite side and inclined forward, make an incision three inches in length along the posterior border of the sterno-mastoid, beginning half an inch below the mas- toid process. A second incision is then made, beginning at the upper fourth of the first one and carried backward and downward one inch. The splenius muscle appears in view as soon as the integument and fascia are divided and pulled aside. The fibro-muscular structure of the splenius is divided, its borders separated, the layer of fat that now appears is pushed aside by the finger or handle of the scalpel, and the vessel is seen ; its branches are drawn aside together with those of the second cervical nerve, the artery isolated, and the needle passed from without inward. 3. The incisions are the same as in the preceding, except that the first one begins half an inch above the mastoid process. The skin, fascia, and splenius are divided as before, the occipital artery appears at the upper angle of the wound, and is held aside ; divide the aponeurosis and cellular tissue, separate the borders, enter the triangle, separate the fatty tissue, and the artery will be exposed. Pass the needle from behind forward. Fallacy.—The vertebral arteries may enter the transverse processes of the fifth cervical vertebra, instead of the sixth. Results.—These vessels have been ligatured forty-two times, in thirty-six of which three died ; one each from hemorrhage, embolism, and pleurisy. When done for the cure of epilepsy, about twenty per cent were benefited, some of which ultimately recovered. The per- manent benefit derived thus far in such cases has not been sufficiently ample to warrant the general adoption of this measure for the treat- ment of epilepsy. Ligature of the Internal Mammary Artery.—The internal mam- LIGATURE OF ARTERIES. 95 mary arises from the first portion of the subclavian. It descends be- hind the internal jugular and subclavian veins to the inner surface of the anterior wall of the chest, resting upon the costal cartilages about half an inch from the margin of the sternum. It may be ligatured in any of the five upper intercostal spaces. Linear Guide.—About one-half inch to the outer side of the sternum is a fair indication of its locality. It has no muscular guide. Operation.—Make an incision two inches in length along the up- per border of the costal cartilage and rib. The integument, fascia, and pectoralis major muscle are divided down to the intercostal mus- cles. Beneath the internal intercostal muscle, surrounded by the connective tissue, the artery, accompanied by the venae comites, will be found. The vessel is isolated, and the needle carefully passed to avoid penetrating the pleura. If the vessel be tied in the uppermost intercostal space, a single vein will attend it. Ligature of the Inferior Thyroid Artery.—This vessel arises from the thyroid axis, and passes in a somewhat irregular course upward and inward behind the sheath of the common carotid and internal jugular vein to the thyroid gland. The linear guide to the operation is along the anterior border of the sterno-mastoid, as in ligaturing the common carotid. The body of the fifth cervical vertebra, opposite to which it enters the gland, is an approximate bony guide to the vessel. Contiguous Anatomy. — In front, the common carotid sheath and its contents, and the sympathetic nerve; the recurrent lar- yngeal and the oesophagus ; if low in the neck, carefully avoid the thoracic duct. The respective tissues are pulled aside and the needle passed. No dangers attend the ligaturing other than those incurred by the manipulation necessary to arrive at the ves- sel. Ligature of the Axillary Artery.—This vessel begins at the lower border of the first rib and extends to the lower border of the tendon of the latissimus dorsi. It may be tied in three situations : 1, above the pectoralis minor ; 2, behind ; 3, below that muscle. The first and last, however, are the only ones at which the vessel can be prac- tically secured. First Portion.—There is no linear guide to the vessel. The linear guide to the operation is located about one-half inch below the lower border of the clavicle, extending from within an inch or so of the sternal extremity, outward three or four inches. The muscular guides are superficial and deep. The former is the space between the border of the deltoid and pectoralis major muscles. The latter is the pectoralis minor, its upper border corresponding to the first portion, etc., as before stated. 96 OPERATIVE SURGERY. Contiguous Anatomy. Relations of the First Portion of the Axillary Artery. (Gray.) In front. Pectoralis major. Costo-coracoid membrane. Subclavius. Cephalic vein. Outer side. { Axillary ) Inner side. < artery, > . .„ . Brachial plexus. ( firgt portion> ) Axillary vein. Behind. First intercostal space, and intercostal muscle. First serration of serratus magnus. Posterior thoracic nerve. In this situation the artery lies deeply, and it is better, if possible, to ligature the third portion of the subclavian. Operation (Fig. 141).—Place the patient upon the back with the head turned to the opposite side; elevate the shoulder and carry the arm a little distance from the side of the chest. Make an incision about four inches in length on the linear guide given above, down through the integu- ment, fascia, and platys- ma ; separate the fibers of the pectoralis major, or di- vide them the full length of the wound; tear apart the underlying fascia, when the pectoralis minor mus- cle will be brought in view; bring the arm to the side to relax this muscle, which is then drawn to the outer side ; displace the areolar tissue carefully with the finger or a director, when the vein will be seen, which should be carried upward and in- ward with a blunt hook, and the artery will be noticed beneath it, and in close contact with the inner cord of the brachial plexus, which lies to its outer side and above. The needle is then passed from below upward. The cephalic vein, which empties into the axillary vein, should be cautiously avoided, as it passes between the borders of the pectoral and deltoid muscles to its termination (Fig. 142). Fallacies.—The inner cord of the brachial plexus may be mistaken for the artery. Before tightening the ligature, pressure should be made upon the vessel, and the effect upon the radial pulse noted. Fig. 141.—Ligature of first portion of axillary. LIGATURE OF ARTERIES. 97 The vessel may be reached by making an incision between the borders of the deltoid and pectoral muscles about three inches in length, which should connect with the one previously made below the lower border of the clavicle. The fat and cellular tissue can then be removed or dis- placed as in the pre- vious instance. Results.—No def- inite records are given of the results of this operation. Fig. 142.—Ligature of first portion of axillary artery, a. Pectoralis major, divided in course of fibers, b. Upper border of pectoralis minor, c. Deep fascia (costo-coracoid membrane), d. Axillary vein. e. Axillary artery. /. Inner cord of brachial plexus, g. Acromio-thoracic branch. h. Cephalic vein. Ligature in the Tliird Portion.—TJie linear guide to the artery is Fig. 143.—Linear guide to axillary, third portion. a line extending upward into the axilla corresponding to the junction of its anterior and middle thirds (Fig. 143, a). Muscular Guide.—The inner border of the coraco-brachialis. 1 98 OPERATIVE SURGERY. Contiguous Anatomy. Relations of the Third Portion of the Axillary Artery. (Gray.) In front. Integument and fascia. Pectoralis major. Outer side. Coraco-brachialis. Median nerve. Musculocutaneous nerve Inner side. Ulnar nerve. Internal cutaneous nerve. Axillary vein. ! Axillary artery, third portion Behind. Subscapularis muscle. Tendons of latissimus dorsi and teres major. Musculo-spiral and circumflex nerves. Operation (Fig. 144).—The arm should be abducted and rotated outward. Make an incision three inches in length along the inner border of the coraco-brachialis in line of the arterial pulsation, ob- serving that its center be above the anterior fold of the axilla; cautiously divide the tissue upon a director, drawing the median nerve to the outer, and the ax- illary vein to the inner side ; pass the needle from within outward. Fallacies. — Large branches may be given off at this situation, which will confuse the operator. Pressure upon the vessel prior to the tightening of the ligature will determine the influence upon the circulation beyond. Results.—The operation implies in itself no particular danger to the patient. Ligature of the Brachial Artery.—The brachial artery extends Fia. 144 -Ligature of third portion ot axillary. Fig. 145.—Linear guide cf brachial artery. LIGATURE OF ARTERIES. 99 from the lower border of the tendon of the latissimus dorsi to about one inch below the bend of the elbow-joint. The linear guide is drawn from the junction of the middle and anterior thirds of the axilla to midway between the apices of the bony condyles of the humerus (Fig. 145). Muscular Guide.—At its upper third it lies at the inner border of the coraco-brachialis; in the middle third, at the inner border of the biceps; in the lower third, at the inner border of the biceps tendon. It may be ligatured in three situations : at its upper, middle, and lower thirds. Contiguous Anatomy. Plan of the Relations of the Brachial Artery. (Gray.) In front. Integument and fasciae. Bicipital fascia, median basilic vein. Median nerve. Outer side. Inner side. Median nerve. Internal cutaneous and Coraco-brachialis. J racnial ) ulnar nerve. Biceps. < artery. ) jjedian nerve. Behind. Triceps. Musculo-spiral nerve. Superior profunda artery. Coraco-brachialis, Brachialis anticus Operation— Upper Third (Fig. 145, a).—Abduct the arm, and rotate it outward ; make an incision about three inches in length along the in- ner border of the coraco-bra- chialis. The artery, being ,„^; very superficial, is quickly reached. The median nerve is drawn to the outer, and the ulnar nerve and basilic vein to the inner side ; sep- arate the artery from the vein, and pass the needle ^s&m from within outward. ~ ,. ,T _,_. , „ Fig. 146.—Ligature of brachial in middle third. Operation in the Middle Third (Fig. 145, b).—Place the arm as before ; make an incision three inches in length along the inner side of the biceps muscle (Fig. 146). The median nerve is found lying upon and a little to its outer side ; push it aside, isolate the artery from the venae comites, and pass the needle in the same direction as before (Fig. 147). Operation in the Lower Third (Fig. 145, c).—Abduct the arm and 100 OPERATIVE SURGERY. supinate the forearm. Compress the arm above to distend the medi- an basilic vein; make an incision about three inches in length along the inner border of the tendon of the biceps ; draw aside the medi- an basilic vein, when the artery will be felt pulsating beneath the bicipital fascia; a suitable-sized opening is now cut through this fascia, the forearm partially flexed, the vessel separated from its veins, and the needle passed from within outward (Figs. 148 and 149). Fallacies. — The arteries of the forearm may be given off from the axillary, or the brachial may bifurcate high up, thereby in- creasing the number of the large vessels in the arm. This is determined by the comparative size of the brachial, and the influence of pressure on the circulation on the distal side of the proposed liga- ture. The brachial may run to- Fig. 14*7.—Ligature of brachial artery, mid- dle third, a. Sheath of vessels and nerves. c. Brachial artery, d. Venae comites. f. Basilic vein. g. Median nerve, pulled to in- ner side. k. Internal cutaneous nerve, i. Ulnar nerve. Fig. 148.—Ligature of brachial artery at lower third. Fig. 149.—Ligature of brachial at lower third, a. Aponeurosis divided and turned back. b. Brachialis anticus muscle, in- ner border. c. Sheath of artery, d. Brachial artery, e. Collateral vein. /. Median nerve. gether with the ulnar nerve be- hind the inner condyle. If it be not in its normal site, deep press- ure may detect its pulsations elsewhere, which, together with its effect on the circulation beyond, will determine the size and site of the ves- sel. The incisions in the upper two thirds may be made too far in- ward, leading the surgeon to mistake the ulnar nerve for the median. If the forearm be flexed and traction be made upon either, its course will be determined and the mistake corrected. The median nerve may pass behind the artery instead of in front, LIGATURE OF ARTERIES. 101 when, if the circulation from above be obstructed, the artery may es cape notice. The artery not unf requently lies deeply betAveen the brachialis anticus and biceps muscles. Anomalous muscular slips and unusual muscular development may obscure the artery in its normal course. In such in- stances the pulsation will determine its location. Occasionally, especially in female sub- jects, when the upper extremity is mark- edly concave on its outer surface, due to an unusual length of the internal condyle, the primary incision may be made to the outer side of the vessel. If, however, it be made midway between the tips of the bony condyles, irrespective of the overhanging soft parts, this error will not arise. Results.—It has been ligatured sevens ty-six times for hemorrhage, with fifty-five recoveries. Ligature of the Radial Artery.—This artery arises from the brachial, is an ap- parent continuation of it, and is superficial in its entire course. It may be ligatured in any portion of its course; it is, how- ever, usually ligatured in three situations —at the upper and lower thirds, and at the wrist. The linear guide (Fig. 150, a, b) to this vessel is drawn from midway between the tips of the bony condyles of the humer- us to the inner side of the extremity of the styloid process of the radius. The muscular guide, at its upper portion, is the inner border of the belly of the supinator longus muscle, beneath which it lies. At the lower portion of its course it lies at the inner side of the tendon of the same muscle. The almost universally recognized pulsation of the vessel at the wrist is the best practical guide to it in this location. In fact, it is only when abnormalities of size or situation of it occur at this position that the other guides to it are taken into considera- tion in the living subject, and under these circumstances they are of but little aid to the operator. This same statement will apply with equal force to all arteries that are similarly associated with the super- ficial structures of the body. Fig. 150.—Linear guides to radial and ulnar arteries. 102 OPERATIVE SURGERY. Contiguous Anatomy. Plan of the Relations of the Radial Artery. In front. Integument—superficial and deep fasciae. Supinator longus. Inner side. Pronator radii teres. Flexor carpi radial is. Outer side. Supinator longus. Radial nerve (middle third). i Radial artery i ( in forearm. ) Behind. Tendon of biceps. Supinator brevis. Pronator radii teres. Flexor sublimis digitorum. Flexor longus pollicis. Pronator quadratus. Radius. Operation—Upper Third (Fig. 151).—Supinate the forearm ; press upon the arm above to distend the superficial veins ; make an incision about three inches in length along the linear guide to the vessel (Fig. 150, a). After going through the fasciae, / the inner edge of the supinator longus 0 will be found extending beyond the line J and overlapping the artery ; separate and f ;| / W pull this outward, when the artery will be I •- j( >' seen lying between its veins, with the t: / f f N nerve to the outer side ; separate the ar- ^ ;\ \ | tery, and pass the needle from without f... ' \ * \ inward (Fig. 152). Fig. 151.—Ligature at upper third of radial. Fig. 152.—Ligature of radial artery, upper third, a. Inner border of supinator longus. b. Deep aponeurosis, c. Pronator radii teres. d. Flexor sublimis digitorum. e. Radial ar- tery. /. Venae comites. Operation in the Lower Third (Fig. 153).—In this situation the LIGATURE OF ARTERIES. 103 Fig. 154.—Ligature of radial ar- tery, lower third, a. Flexor carpi radialis muscle, b. Ra- dial artery, c. Venae comites. Fig. 153.—Ligature at lower third of radial. vessel is very superficial, its well-known pulsation being the best guide to it; with the arm placed as in the preceding position, make an in- cision two inches in length along the course of the vessel (Fig. 150, b). After the division •1 of the integument and fascia?, the artery will be seen surrounded by loose areolar tissue, ac- companied by its veins, and lying to the inner side of the tendon of the supinator longus. Separate the tissues and ligature the artery, passing the needle from the nerve (Fig. 154). Operation at Apex of Styloid Process (Fig. 155).—In this situation the vessel is found in a triangular-shaped space, bounded internally by the tendon of the extensor primi internodii pollicis; externally by that of the secundi internodii pollicis, and the base cor- responding to the apex of the styloid process of the radius. If the thumb be forcibly extended, the outlines of the space will be well marked. Operation.—Place the hand midway between supination and pro- nation, and, having ascertained the exact situation of the ten- don of the extensor primi internodii polli- cis, make an incision along its outer border about an inch in length; use care not to divide the superfi- cial veins. The areo- lar tissue and the ex- tensor primi internodii pollicis are pushed aside, and the vessel found somewhat deeply situated. The needle can be carried in either direction. Fallacies.— The radial artery may lie upon the fascia and supinator longus instead of beneath them ; it may pass over the extensor tendons of the thumb instead of beneath them. The artery may be mistaken for a radical of the radial vein. The latter is superficial, and has like- wise other characteristics of a vein. ,**::- Fig. 155.— Ligature of radial at apex of styloid process. 104 OPERATIVE SURGERY. Results.—During the late war it was tied twenty times, with four fatal results. Ligature of the Ulnar Artery.—This vessel is larger than the radial. It is given off from the brachial about one inch below the bend of the elbow, passes, obliquely inward and downward, deeply be- neath the superficial flexors of the forearm, and gains the ulnar side a little above its middle; becoming superficial, passes along the outer side of the flexor carpi ulnaris to the radial side of the pisiform bone, where it terminates in the superficial palmar arch. It may be ligated in three situations : 1. At the junction of the upper and middle thirds. 2. At the lower third. 3. At the wrist. It can be ligatured at its upper third, but such a step has no practical utility except when called for by a direct tying of this portion of the vessel, when, of course, as in all cases, a ligature should be applied at both sides of the bleeding point. The linear guide is drawn from the extremity of the internal con- dyle to the pisiform bone (Fig. 150, c, d, e). The muscular guide is the outer border of the flexor carpi ulnaris. Contiguous Anatomy. Plan of Relations of the Ulnar Artery in the Forearm. In front. Superficial layer of flexor muscles. i Median nerve. \ UPPer half- Superficial and deep fascia?, lower half. Inner side. Outer side. Flexor carpi ulnaris. c Ulnar artery } Flexor sublimis digitorum. Ulnar nerve (lower two thirds). ] in forearm. \ Behind. Brachialis anticus. Flexor profundis digitorum. Operation—Junction of Middle and Upper TJiirds (Fig. 156). —Supinate the forearm and make an incision about three inches in LIGATURE OF ARTERIES. 105 F(G. 158.—Ligature at low- er third of ulnar artery. length, beginning about four finger-breadths below the internal con- dyle, on the linear guide to the vessel (Fig. 150, c). Divide the fascia ^ on a director; seek for the line of connection !( -f between the borders of the flexor carpi ulnaris I ; | and the flexor sublimis digitorum. It is of a y yellowish-white color. Divide it on a director, \ | / / an(* PUU tne muscles apart, when the ulnar nerve / I will be seen, to the outer side of which will be % \ / found the artery with its accompanying veins ; \ / separate the ar- d tery and pass the needle from within outward (Fig. 157). Operation in the Lower Third (Fig. 158). - Place the arm as Fig. 159-Ligature of ulnar artery, jn th preceding lower third, a. flexor carpi ulnaris _r b muscle. 6. Deep aponeurosis, c. operation ; ex- Ulnar artery, d. Venae comites. e. ^en(j tne nan^ to Ulnar nerve. in, ■, make the tendon ulnaris tense ; make an incision about three inches in length along the radial border of this muscle down to the fascia (Fig. 150, d), which should be divided on a director, expos- ing the tendon of the flexor carpi ulnaris, which should be drawn inward, and the artery is seen beneath it. Isolate the vessel from its veins and pass the needle from within out- ward (Fig. 159). Operation at the Wrist (Fig. 160).—Place the hand on its dorsal surface and make an incision about two inches in length along the radial side of the pisiform bone, with its con- vexity outward (Fig. 150, e) ; carry it downward along the side of that bone through the fascia and fatty tissue to the vessel. Flex the hand and pass the ligature from within outward. Fallacies.—Between the upper and middle thirds (150, e), the in- terspace between the flexor carpi ulnaris and flexor sublimis may be mistaken for the space- between the flexor carpi ulnaris and the pal- maris longus, or flexor carpi radialis. If the hand and fingers be moved alternately, the proper muscles can be ascertained. of the flexor carpi Fig. 160.—Ligature of ulnar a.'tcry at wrist. 106 OPERATIVE SURGERY. In the upper third the vessel runs inward to meet its linear guide ; therefore an attempt to find the artery by the linear guide, in this situ- ation, will be futile. The artery may run beneath the fascia, or oth- erwise vary in its course ; if not in its normal situation, deep pressure may define it. Results.—The ulnar artery was lig- atured during the war ten times, with three deaths. The Superficial Palmar Arch can be tied at the seat of injury. It must be remembered that beneath it lie the tendons of the flexors of the fingers and the divisions of the median and ulnar nerves. Linear Guide (Fig. 161).—Extend the thumb at nearly a right angle to the carpus, and draw a line transverse- ly across it corresponding to its palmar border; this will denote the lower lim- it of the arch. Operation.—Make an incision half or three quarters of an inch in length at the seat of the injury, through the integument, palmaris brevis muscle, and palmar fascia, down to the ves- sel. Ligature all bleeding points, and also all un- injured branches arising close to the seat of the injury of the main vessel, to avoid the possibility of secondary hemorrhage. Ligature of the Com- mon Carotid Artery.— The right common carot- id arises from the innom- inate artery, and the left from the arch of the aorta. The left is consequently longer and more deeply situated in the chest. The left, after leaving the aorta, passes oblique- ly upward to a point op- posite the left Sterno-Cla- F.g. 162.-Surgical anatomy of the common carotid. Fig. 161.—Linear guide to superficial arch and flexor tendons. LIGATURE OF ARTERIES. 107 vicular articulation ; and, from this point upward, the right and left common carotids maintain substantially the same course to the upper border of the thyroid cartilage, where each divides into the internal and external carotids. Each vessel may be ligatured in three situations : 1. At the root of the neck. 2. Below the omo-hyoid muscle. 3. Above the muscle. The last two are the situations commonly selected, the first not being employed except under forced circumstances. The linear guide to the vessel is a line drawn from the sterno- clavicular articulation to midway between the angle of the jaw and mastoid process (Fig. 136). The muscular guide to the operation is the anterior border of the sterno-cleido-mastoid. Contiguous Anatomy. Plan of the Relations of the Common Carotid Artery. (Gray.) In front. Integument and fascia. Omohyoid. Platysma. Descendens noni nerve. Sterno-mastoid. Sterno-mastoid artery. Sterno-hyoid. Superior thyroid, lingual, and facial Sterno-thyroid. veins. Anterior jugular vein. Internally. Externally, Trachea. Internal jugular vein. ( Common ") Thyroid gland. Pneumogastric nerve. i carotid > Recurrent laryngeal nerve. artery. ; Inferior thyroid artery. Larynx. Pharynx. Behind. Longus colli. Sympathetic nerve. Rectus capitis anticus major. Inferior thyroid artery. Recurrent laryngeal nerve. Operation below the Omo-hyoid (Fig. 163).—Place the patient on the back, with the shoulders slightly elevated, and the head turned to the opposite side ; make an incision three inches in length, beginning a little above the cricoid cartilage, on the line stated, and carry it downward along the anterior border of the sterno-mastoid (Fig. 136, c); divide the superficial fascia, platysma, and deep fascia on a direct- or, thus exposing the anterior border of the sterno-mastoid muscle. If the sterno-mastoid artery be divided, ligature it. If not injured, push it aside, together with the thyroid vein ; draw the sterno-mastoid muscle outward, and the sterno-thyroid and hyoid muscles inward, when the lower border of the omo-hyoid will be seen above ; divide the fascia beneath these muscles and draw it apart, when the descend- ens noni nerve will be seen resting upon the inner portion of the 108 OPERATIVE SURGERY. Fig. 163.—Ligature below omo-hyoid. common sheath of the carotid, internal jugular vein, and the pneumo- gastric nerve, the artery being to the inner side, the nerve behind and between the two and y„,^ out of sight. Place the finger upon the sheath, to ascertain the exact location of the artery; raise the portion of the sheath, at its inner side corresponding to the site of the artery, with a te- naculum or the thumb- forceps, cut a small opening into it, and pass the needle from without inward, cautiously in- sinuating it between the vessel and its sheath (Fig. 164). This ma- nipulation should be carefully done, else either the vein, pneumogas- tric, or recurrent laryngeal nerves may be injured. Operation above the Omo-hyoid.—The vessel is more superficial in this situation, which is some- times denominated " The site of election" (Fig. 136, b). Place the patient as before, and make an incision along the anterior border of the sterno-mastoid, beginning at about the angle of the lower jaw, and extending it a little below the cricoid cartilage; divide the superficial fascia, platysma, and deep fascia on a director, carefully avoiding the small veins ; expose the ante- rior border of the sterno-mas- toid, and slightly flex the head to relax the tissues of the neck; draw the edges of the wound apart, and the artery will be felt pulsating in its sheath. If the jugular vein Fig. 164.—Ligature of the common carotid, a. Platysma myoides muscle and fascia, b. Ster- no-mastoid, drawn outward, c. Omo-hyoid, crossing the artery, d. Sterno-hyoid muscle. e. Sterno-thyroid muscle. /. Sheath of the vessels, g. Common carotid raised from its sheath. h. Jugular vein, pushed back. i. Pneumogastric nerve, abnormally prominent. j. Descendens noni nerve—sometimes in the sheath. overlap it, it should be emp tied by pressure above and below, and be drawn outward ; then care- LIGATURE OF ARTERIES. 109 fully open the sheath as before, avoiding the descendens noni nerve ; pass the needle carefully from without inward. It is well to observe the upper border of the omo-hyoid muscle before opening the sheath, that the exact location to apply the ligature be assured. Fallacies.—The artery may bifurcate at the cricoid cartilage, and even lower; however, this is extremely rare ; under such circum- stances both branches should be secured. If the vessel be pressed upon before the ligature is tied, it will determine the influence of the ligaturing upon the branches above. The jugular vein may be much dilated, overlie and receive the im- pulse of the artery, and therefore be mistaken for it. This fallacy may be avoided if that vessel be emptied of its blood in the manner before described. The thyroid gland may be enlarged and obscure the ar- tery by displacing or overlapping it. Under these conditions it should be pushed aside. It is reported that the omo-hyoid muscle has been mistaken for the artery ; the fact of its being muscular, taken in con- nection with the direction of its fibers, together with its anatomical relations, should eliminate any danger of this mistake. If branches arise from the main trunk, they may be mistaken for the external caro- tid. The comparative size of the vessel and the influence of pressure on the circulation of the internal carotid will effectually solve the question. If branches be given off from the common carotid near the site of the proposed ligaturing, they should be tied also. Fig. 165.—Surgical anatomy of external carotid. Results.— This vessel has been tied seven hundred and eighty-nine 110 OPERATIVE SURGERY. times, for various reasons, of which three hundred and twenty-three, or about forty-one per cent, have died. Ligaturing of both common carotids, either simultaneously or at variable intervals, has been done thirty-six times. The shortest in- terval between the operations in which recovery has taken place is four and one half days. Instances where the interval varied from thirteen to thirty days are reported, with recovery of the patients. Ligature of the External Carotid Artery.—This artery arises from the common carotid at or just above the upper border of the thyroid cartilage. It ascends in a slightly curved course, with the convexity forward, to a point midway between the neck of the condyle of the lower jaw and the external auditory meatus. The upper part of its course lies in the substance of the parotid gland (Fig. 165). This artery may be tied in two situations : 1, between the posterior belly of the digastric and its origin ; 2, above the belly of th e digas- tric. The former situation is the one to be selected, if possible. The linear and the muscular guides are substantially the same as for the common carotid. Contiguous Anatomy. Plan of the Relations of the External In front. Integument, superficial fascia. Platysma and deep fascia. c External) Hypoglossal nerve. ) carotid [ Lingual and facial veins. ( artery. J Digastric and stylo-hyoid muscles. Parotid gland, with facial nerve and temporo-maxillary vein in its sub- stance. Internally. Ilyoid bone. Pharynx. Parotid gland. Ramus of jaw. Operation below the Digastric Muscle.—With the patient on the back, head slightly extended and turned to the opposite side, make an incision along the anterior border of the sterno-mastoid, beginning opposite the angle of the lower jaw, and carry it downward to a point nearly opposite the cricoid cartilage (Fig. 137, b). Divide the su- perficial fascia, platysma, and deep fascia on a director ; expose the anterior border of the sterno-mastoid. The edges of the wound should be well drawn apart, when the hypoglossal nerve and the digastric and stylo-hyoid muscles will come into view. The end of a grooved director should now be employed to separate and push aside the lingual and facial veins, together with the areolar tissue and lymphatic glands that rest upon the vessel. Expose the Carotid. (Gray.) Behind. Superior laryngeal nerve. Stylo-glossus. Stylo-pharyngeus. Glosso-pharyngeal nerve. Parotid gland. LIGATURE OF ARTERIES. Ill artery and pass the ligature from without inward. The internal jugu- lar vein ofttimes overlaps the vessel, and should be carefully drawn aside, or treated as recommended in ligaturing the common carotid. Before the ligature is tied the following facts should be carefully observed : 1. If it be the external carotid around which the ligature is passed, this can be ascertained by pressing upon the vessel and ob- serving its effect upon the circulation of the facial. 2. The distance of the seat of the ligature from collateral branches ; this can only be determined by carefully exposing the vessel for half an inch above and below the seat of the ligature. If vessels be found within this extent, they too should be ligatured to destroy the possibility of any inter- ference with the formation of the internal clot. 3. That the ligature be not carried around the external and internal carotids at, or just above, their point of bifurcation ; if it be around both, pressure will check the pulsation of both ; if but one, it will have a like effect on the circulation of the vessel pressed upon. Other Fallacies.—Enlarged lymphatic glands resting on the vessel may be mistaken for it. They need cause but momentary thought, since their circumscribed outline and mobility will determine their nature. If enlarged, they should be removed, otherwise they can be pushed aside. The superior thyroid branch may be confounded with the lingual. If the course of the respective vessels be observed, they can be readily distinguished ; the superior thyroid arises nearest the bifur- cation, arches upward and forward, then passes quite directly down- ward. The lingual does not arch downward, but passes upward and inward to gain the upper border of the great cornu of the hyoid bone, which can be easily outlined by the finger. Operation above the Digastric.—Make an incision from the lobule of the ear to the greater cornu of the hyoid bone, along the anterior border of the sterno-mastoid, carefully avoiding the parotid gland. Divide the superimposed tissues as before, down to the digastric mus- cle ; pull it, together with the stylo-hyoid, downward, and if the jugular vein be in the way, push it outward, and pass the ligature from without inward. Results.—The external carotid has been ligatured seventy-eight times, with four deaths from the operation. Ligature of the Internal Carotid Artery.—The internal carotid be- gins at the bifurcation of the common carotid, at or a little above the upper border of the thyroid cartilage, and passes perpendicularly up- ward in front of the transverse processes of the three upper cervical vertebrae, to the carotid foramen in the petrous portion of the tempo- ral bone, through which it enters into the cranial cavity. At its origin and in the lower portion of its course it lies externally and posteriorly to the external carotid artery. It may be ligatured in any part of the course between its origin and the angle of the lower jaw. 112 OPERATIVE SURGERY. The linear and muscular guides of the external carotid artery are suitably adapted to properly locate the internal carotid. Contiguous Anatomy. Plan of the Relations of the Internal Carotid Artery in the Neck. (Gray.) In front. Skin, superficial and deep fasciae. Parotid gland (above the angle of the jaw). Stylo-glossus and stylo-pharyngeus muscles. Glosso-pharyngeal nerve. Externally. Internally. Internal jugular vein. Pharynx. Pneumogastric nerve. j Internal carotid ) Ascending pharyngeal ( artery. ) artery. Tonsil. Behind. Rectus capitis anticus major. Sympathetic. Superior laryngeal nerve. It may become necessary to ligature this artery on account of a penetrating wound received from without or from within the mouth. Ulcerations of and operations on the tonsils have been complicated with injuries to this vessel that have caused death from hemorrhage. It is therefore very important to recall the relations of the tonsil and pillars of the pharynx to this artery, in connection with all injuries and morbid processes of their structures. The angle of the jaw is lo- cated directly externally to the tonsil, and it therefore may become a practical guide to the incision for ligaturing the artery in this situation. Operation.—The position of the neck of the patient and the loca- tion of the primary incision are similar to those for the ligaturing of the external carotid. The respective tissues are carefully divided on a director down to the muscles, which are then pulled aside, and the ligature is passed from without inward, carefully avoiding the jugular vein and the pneumogastric nerve at the center, and the pharynx at the inner side. Fallacies.—The internal carotid may arise from the arch of the aorta, and when this occurs hemorrhage from it can be checked only by ligaturing the internal carotid itself. If but one ligature be ap- plied to the internal carotid for hemorrhage, or if the common caro- tid be ligatured alone for the same reason, the collateral circula- tion may cause a continuation of the bleeding. A ligaturing of the internal carotid at both sides of the bleeding point is the only cer- tain means of arresting the hemorrhage permanently. The inter- nal carotid may lie internal to the external carotid. It may be tor- tuous, or even be absent. Results.—This vessel has been tied alone three or four times ; with LIGATURE OF ARTERIES. 113 either the common or external carotid, or both, fifteen times. Only six of these patients died, and from the causes calling for the pro- cedure. Ligature of the Superior Thyroid Artery.—This vessel comes from the external, or from the common carotid near the point of its bifur- cation. It passes upward and forward, at first quite superficially, then runs downward and less superficially to enter the thyroid gland. Operation.—Make an incision about three inches in length along the anterior border of the sterno-mastoid, its center corresponding to a point opposite the thyro-hyoid space. The carotid sheath should be exposed as in the ligaturing of that vessel, and the artery sought for along its inner border. Ligature of the Lingual Artery.—This vessel arises from the ex- ternal carotid opposite the hyoid bone, and runs upward and inward to about one quarter of an inch above the upper border of its greater cornu, and passes horizontally parallel with it, resting upon the mid- dle constrictor of the pharynx, and is covered first by the digastric and stylo-hyoid muscles, and more internally by the hyo-glossus. It then ascends between the hyo-glossus and genio-hyo-glossus muscles and terminates in the ranine artery. It has no superficial muscular guide ; a linear guide may be drawn parallel with, and a fourth of an inch above, the greater cornu of the hyoid bone (Fig. 136, a) ; practically, however, the upper border of the greater cornu of the hyoid bone marks its situation. It may be ligatured in three situations : 1. At the apex of the greater cornu. 2. Between the cornu and the posterior belly of the digastric. 3. In the triangle made by the digastric and mylo-hyoid muscles, and hypo- glossal nerve. Operation between the Digastric and the Greater Cornu.—Place the patient on the back, and turn the head to the opposite side ; carefully define the greater cornu of the hyoid bone. If the neck be fleshy, this will be somewhat difficult. It can be made more prominent on the side of the operation by pushing against its body on the opposite side, being careful to press it directly toward that point, otherwise it may mislead the operator. After the patient is thoroughly anaesthetized to prevent spasmodic movements of the muscles attached to the hyoid bone, make an incision about two or three inches in length parallel with the upper border of the cornu, which should pass downward and outward to nearly the anterior border of the sterno-mastoid (Fig. 136, a). Divide the superficial fascia, platysma, and deep fascia on a director; draw upward the submaxillary gland and divide the deep aponeurosis, when the digastric and stylo-hyoid muscles and the hypo- glossal nerve will be exposed. Accurately locate the greater cornu with the finger and fix it with a tenaculum, draw up the digastric and the stylo-hyoid muscles and hypoglossal nerve with a blunt hook, push 8 114 OPERATIVE SURGERY. aside the lingual vein if seen, and pick up the fibers of the hyo-glossus with a pair of forceps, and incise them in the direction of the external incision about one quarter of an inch above the greater co*nu ; beneath , them will be found the vessel, sometimes accom- panied by the lingual vein (Fig. 166). Pass the needle from the vein. Before tying the liga- ture, ascertain if pres- sure will stop the pulsa- tion of the artery. Ligature in the Third Situation.—This is often called "the place of election." Make an incision transversely two inches long, con- cavity upward, and its center just within the middle of the cornu of the hyoid bone. Divide the integument, su- perficial fascia, and platysma, carefully avoiding the superficial veins; sl~- Fig. 166.—Ligature of lingual artery. Fig. 167.—Surgical anatomy of the lingual artery. 1. Submaxillary gland. 2. Lingual artery. 3. Lingual vein. 4. Hypoglossal nerve. 5. Stylo-hyoid muscle. 6. Digastric muscle. 1. Mylo-hyoid muscle. 8. Hyoid bone. 9. Hyo-glossus muscle. divide the deep fascia and pull upward the submaxillary gland, when the posterior belly of the digastric will come into view, as also the posterior border of the stylo-hyoid muscle and the hypoglossal nerve, accompanied usually by the lingual vein. Carefully outline the trian- gle before mentioned, pinch up the fibers of the hyo-glossus, and divide them midway between the hyoid bone and the nerve, when the artery LIGATURE OF ARTERIES. 115 will be seen beneath (Fig. 167). Separate it from the vein, if the vein lie beneath the muscle and has not been seen before, and pass the liga- ture. Ligature in the First Portion.—In this situation the vessel is tied between the point of its giving off and the tip of the greater cornu of the hyoid bone. Operation.—Make an incision three inches in length running ob- liquely downward and backward, its center corresponding to the greater cornu. The various tissues are carefully divided as before, and the hypoglossal nerve is exposed. The numerous veins located in the course are now pushed aside, and the artery carefully sought for at the point of the cornu, and ligatured. This operation, on account of the absence of a definite deep guide to the location of the vessel, and the uncertainty of its point of origin, together with the great number of large veins in the course of the search, is much less feasible than either of the other two. Fallacies.—The hypoglossal nerve may be mistaken for the artery. The nerve rests on the hyo-glossus ; the artery runs beneath it. This, together with the pulsation of the artery and other distinctive ana- tomical features, should render the discrimination easy. It is well to know, however, that the movements of the tissues dependent on the acts of respiration make it somewhat difficult, and often impossible, to detect the arterial impulse. If, however, the supposed artery be care- fully isolated, the ligature passed around it, and a good light thrown into the wound, its tortuous outline will be noticed with each pulsa- tion. The pulsation can be seen best in the interval of the respiratory acts, when the tissues are quiet. The lingual vein may be mistaken for the artery. This vessel sometimes runs with the artery behind the hyo-glossus; more fre- quently, however, it rests on this muscle. It has the characteristic color of a vein, and is larger than the artery. The lingual artery may be absent on one side. After the division of the fibers of the hyo-glossus, the search for the vessel must be conducted cautiously to avoid opening into the pharynx. Results.—It has been tied repeatedly with great advantage, for the purpose of controlling hemorrhage from the tongue, and delaying a morbid growth of the same. Ligature of the Facial Artery.—The facial is one of the large branches of the external carotid. It arises from it just above the tip of the greater cornu, or about one inch from the bifurcation of the common carotid, passes forward and upward beneath the ramus of the lower jaw, going through the substance of the submaxillary gland, and gains the external surface of the ramus at the anterior inferior angle of the masseter muscle, lying in a groove in the outer border of the bone. The masseter muscle, therefore, becomes its muscular 116 OPERATIVE SURGERY. guide in a portion of its course. It may be ligatured^ in two situa- tions : in the neck, and as it crosses the ramus of the jaw, the latter being the better. In the former, the head is turned to the opposite side, and an incision of about three inches in length is made obliquely downward and forward a little in front of the anterior border of the sterno-mastoid, its center being at a point about one third of an inch above the tip of the greater cornu. The dissection is carefully made as in ligaturing the lingual at this first portion, pushing aside the facial and other contiguous veins, drawing up the digastric and pass- ing the ligature. Operation at the Ramus of the Jaw.—Place the patient as before, draw the skin upward over the ramus, so that when retraction of the tissues occurs the cicatrix will be beneath the jaw ; make an incision about two inches in length along the border of the jaw, divide the tissues on a director (Fig. 137, c), down to the vessel; isolate it, and pass the ligature. If a resulting cicatrix be of no moment, the pri- mary incision can be made in the long axis of the vessel along the an- terior border of the mas- seter muscle (Fig. 168). Fallacies.—At its or- igin this vessel may be mistaken for the lingual. Interruption of the cir- culation will easily deter- mine the difference. Ligature of the Tem- poral Artery.—The tem- poral is one of the term- inal branches of the ex- ternal carotid. It begins in the substance of the parotid gland between the neck of the lower jaw and the external meatus and passes upward across the root of the zygoma, subcutaneously, where its pulsation can be distinctly felt. About two inches above the zygomatic process it divides into its terminal branches. The zygomatic process is the bony guide to it. Operation (Fig. 137, d).—Make an incision in the line of the ves- sel, as indicated by its pulsation, about one fourth of an inch in front of the tragus and one inch in length; divide the skin and fascia; expose the vessel and pass the needle so as to avoid the vein and nerve (Fig. 168). The Ligature of the Occipital Artery.—This artery arises from the Fig. 168.—Ligature of facial and temporal arteries. OPERATIONS ON VEINS, CAPILLARIES, ETC. 117 external carotid a trifle above the facial, and passes upward and out- ward to the interval between the transverse process of the atlas and the mastoid process of the occipital bone. It then passes over the posterior portion of the skull midway between the external occipital pro- tuberance and the mastoid process (Fig. 137, e). It has no muscular guide. It may be tied at its origin or behind the mastoid process. Operation at its Origin.—Make an incision along the inner border of the sterno-mastoid, about three inch- es in length, its center correspond- ing to a point a little above the apex of the greater cornu of the hyoid bone. Divide the superficial tissues carefully on a director ; separate the areolar tissue with its blunt extrem- FlG. i69._Ligature of occipital artery. ity; push aside the veins and find the posterior belly of the digastric. A little below this will be seen the ninth pair of nerves, winding around the object of search. Pass the needle from the nerve. Operation behind the Mastoid Process (Fig. 169).—Make an incision about two inches in length one-half inch behind and a little below the mastoid process. Divide the integument and attachments of the sterno-mastoid and the splenius muscles ; feel for the pulsation at the bottom of the wound. Isolate the artery and pass the ligature. CHAPTER V. OPERATIONS ON VEINS, CAPILLARIES, ETC. Ligature of Veins.—Veins, like arteries, may be ligatured in their continuity or at their divided extremities. Large venous branches, when divided in the course of an operation, should always be tied, otherwise they may give rise to an objectionable amount of oozing, which will interfere with the rapidity of the union of the divided sur- faces, and possibly require the re-opening of the wound to secure the bleeding points. If a large vein be nicked during an operation—as the internal jugular, during the removal of growths from the neck—liga- tures may be thrown around it, above and below the opening, rather 118 OPERATIVE SURGERY. than to tie the nicked portion. The latter procedure is liable to be followed by secondary hemorrhage. The practice of ligaturing the opening, or of sewing its divided borders by fine catgut, is highly extolled by many writers. If it be determined to tie the vessel, it should be done above and below the wound of the vessel, else the re- turn circulation will cause secondary hemorrhage. If it be possible at the onset to surround the patient with the degree of surveillance necessary to detect and treat secondary hemorrhage, I am of the opin- ion that the practice of sewing the'nick with the continuous or other suitable form of suture—such as is used for intestinal wounds—offers the better opportunity for rapid recovery. Aside from the ligaturing of veins on account of traumatism, they are ligatured in their continuity for the purpose of causing their occlusion in those cases in which they are in a dilated or varicose condition. Operations for Varicose Veins.—When the veins of the lower ex- tremities become too much distended to be amenable to palliative measures, it is often necessary to resort to operative interference, which has for its object the occlusion of the distended canals. Injec- tion, acupressure, and ligaturing are the common means employed. Injection.—The vein is compressed by the fingers above and below the proposed point of injection—leaving an intervening space of an inch or less—or by small pads confined in position with adhesive plas- ter, the latter being the better plan. Into the isolated portion twenty or thirty drops of a twenty-per-cent solution of liquor ferri subsul- phatis and water are then slowly injected. Almost immediately the contents of the vessel become coagulated, when the pressure can be removed. • The limb should be kept quiet for a few days, and any tendency to undue inflammation combated. The results of this operation, while not so favorable as other expe- dients, are, nevertheless, very satisfactory. Of the one hundred and three cases some time since reported, seventy-nine were cured, one died, and of the remainder, sixteen were failures. Acupressure.—This is substantially the same as the application of acupressure for arresting the circulation of arterial trunks. It con- sists simply of carrying thoroughly purified needles or pins, which may or may not have been constructed for the purpose, beneath the vein at intervals of an inch or so, and compressing the superimposed tissues by means of carbolized silk or cotton yarn wound over the protruding ends of the pins. The pins are removed on the sixth or seventh day, depending on the degree of ulceration produced. Cau- tion should be observed that the pins be not passed through instead of beneath the vein, otherwise a serious phlebitis may follow. Subcutaneous Ligaturing.—This is accomplished by passing a car- bolized needle, armed with a fine wire or a catgut ligature, in front of and across the vein, after which the direction is changed so as to OPERATIONS ON VEINS, CAPILLARIES, ETC. 119 carry it beneath the vessel and out at the point of entrance. If wire be used it is then twisted and cut short, and the opening closed anti- septically. Should catgut be employed, it is tied, and cut, and the opening treated in the same manner. Three or four of these constric- tions may be applied at intervals of an inch. If the blood in the in- tervening spaces becomes necrosed, giving rise to fluctuation, it should be evacuated, as absorption is then impossible. In the subcutaneous ligaturing of varicose veins—such as the long and short saphenous veins—that are accompanied by nerves, the nerves may be accident- ally included by the ligature. It is safer, in such instances, to ex- pose the vein and pass the ligatures, as in arterial ligaturing, after which the included portion of the vein can be excised, or simply divided. Thorough antisepsis should be practiced in such cases. Hemorrhoids.— A varicose condition of the hemorrhoidal veins causes a disease denominated hemorrhoids or piles, for the cure of which various radical measures are recommended. The patient is prepared by a saline cathartic, which should be followed by an enema, a few hours prior to the operation. He should then be etherized, placed upon a table of suitable height, with the buttocks drawn down to the edge ; the thighs are then elevated, drawn apart, and the nates separated. If the growths be of the external variety, and not inflamed, they can be nipped off with a pair of scissors, being careful not to cut them too closely, else the resulting cicatrization may cause a narrow- ing of the anal orifice. Local anaesthesia is sufficient to overcome the pain attending this operation. If the hemorrhoid be distended, ten- der, and painful, it is generally necessary to employ general anaesthe- sia. The tumor should be taken between the thumb and finger, raised up, drawn out, transfixed near the base, and cut outward ; gentle pressure will then evacuate its contents, after which a pellet of fine oakum saturated with balsam of Peru, marine lint, or iodoform gauze, should be placed in the bottom of the sack, and the operation is com- pleted. To facilitate union, the transfixing incision is made in the direction of the radiating folds of the anus. Operations for Internal Hemorrhoids.—These are quite numerous, but the following are believed to secure the best results : Excision.—This method is reckoned among those which secure the best results in selected cases. It causes little after-pain, and recovery takes place within a week or ten days. It is applicable to those cases where but three or four tumors exist, which are not very large, and have well-defined bases. The sphincter should be well dilated and the anus opened with a speculum or retractor. The pile is then seized at the base with a volsella, and cut off with a pair of scissors above the point grasped, which should be held till all arterial hemorrhage is stopped by twisting the bleeding points. After it has ceased, pledgets of lint saturated with tannin and water, or with liquor, ferri subsul- 120 OPERATIVE SURGERY. phatis, are applied to the cut surfaces, and the patient kept quiet for twenty-four to forty-eight hours. Results.—This method of operating has been frequently per- formed, and with eminent success. Crushing.—This method consists in crushing the pedicle of the growth by an improvised in- strument or one especially con- structed for that purpose (Fig. 170). It is not suitable for universal application, but rather to those Fig. 170.—Allingham's screw crushing instrument for hemorrhoids. , ... possess well-defined bases. The integument, if it be connected with the tumor, should be incised, otherwise too great pain will be caused. Operation.—The patient being prepared as in the preceding in- stance, the pile is pulled between the bars of the instrument by the aid of a hook or a volsella, after which the screw is turned tightly against it. The projecting portion is then cut off. The instrument is retained in position for half a minute or so, to insure against the danger of hemorrhage. While this method may be classed among the satisfactory ones, it possesses no superiority over the treatment by ligature, and as a rule causes more pain, less speedy recovery, and exposes the patient to the possible danger of subsequent hemorrhage. Ligaturing.—This method may be employed with or without in- cision, the latter being preferable. The treatment without incision is to pass a needle, armed with a double ligature of stout carbolized silk or catgut, through the base of the growth, tying each half separately, after which the pile is cut off below the ligature. If strong catgut be used, the ends should be divided close to the pedicle, while with silk, one end may be allowed to hang from the anus. Ligature with incision consists in drawing down the tumors by aid of forceps or volsella to the anus, or beyond it, and with a pair of curved scissors dividing them from their connection with the sub- mucous membrane from below upward, parallel with the bowel, far enough to leave the pile connected only by a slim pedicle, around which a strong ligature should be cast and securely tied. The liga- tured portion is then cut off and the parts returned. The vessels connected with the growth enter it from above downward, parallel with the gut, and are therefore secure from injury, if ordinary caution be observed. OPERATIONS ON VEINS, CAPILLARIES, ETC. 121 Injection.—The injection of carbolic acid and astringent agents, together with the application of caustics, is hardly entitled to the dig- nity of being considered an operation. Nor fere the results, notwith- standing the claims of some to the contrary, on the whole better than by ligature, either with or without incision. The occasional severe inflammatory reaction, often followed by abscesses and gangrene, de- tract from that which might otherwise become an extremely satisfac- tory remedy. The full explanation of these methods can be found in systematic treatises upon the subject. Varicocele.—This is caused by a varicose condition of the spermatic veins (Fig. 171). The treatment of the varicose veins of the cord, like that for varicose veins in other sit- uations, is divided into the palliative and radical methods, the object of the latter being to obliterate the lumen of the vessels. The same dangers apper- tain to operations upon these veins as upon those of other portions of the ve- nous system. Erysipelas, phlebitis, pyae- mia, to which may be added a conse- quent atrophy of the testicle depending upon the occlusion of the vein or arte- ry, may follow ; therefore, radical mea- Fig. 171.—Varicose spermatic veins. Fig. 172.—Morgan's suspensory. sures directed to the vessels should not be entertained, except in old age, until the disease becomes a source of discomfort and even dis- tress. The palliative treatment consists in shortening the cord by raising the scrotum and its contents, which lessens the weight of the column of blood contained in the vessels. This is achieved by the various forms of suspensories, as Morgan's (Fig. 172), or the one in ordinary use. Should these serve to relieve the urgent symptoms, the patient may not deem it desirable to submit to an operation of any kind. If, however, the characteristic symptoms recur or continue, x 122 OPERATIVE SURGERY. then the palliative operation for shortening the scrotum should be made. Excision of the Scrotum.—The instruments required for this sim- ple operation are the scrotal clamp—the one devised by Dr. Henry being in every way suitable (Fig. 173)—a sharp bistoury, needles armed with silver wire or carbolized silk, artery forceps, and catgut ligatures. The scrotum should be thoroughly cleansed and the patient anaesthetized ; the clamp is then applied to the side afflicted by drawing the bottom of the scrotum be- tween the blades, which should be applied as nearly as possible parallel with the raphe ; all danger of including the testi- cle is obviated by pressing it upward to the external abdominal ring. When a sufficient amount of tissue is grasped to meet the indication, the blades are tight- ened to cut off all circulation, at the same time to securely hold the scrotal tissue ; the protruding portion is then transfixed, on a level with the adjustable bar (Fig. 173, a), by a sharp, narrow-bladed bistoury, and cut off. Before the blades are loos- ened it is better to pass the sutures, which should be at least ten inches in length, through the divided borders. Having ad- justed them, remove the clamp, tie the bleeding points, and close the wound. Care must always be taken to stop all bleeding points before the edges of the wound are united ; else, owing to the looseness of the scrotal tissues, an ordinary oozing may cause the formation of large bloody clots, which must be removed. If a drainage-tube be introduced throughout its course and allowed to protrude at its most dependent extremity, this danger will be further avoided. Place the patient in bed, elevate the scrotum, and dress the wound antiseptically. It usually heals quickly, and affords sufficient relief to amply recompense the patient for the annoyance incurred from the operation. If the instrument just described be not at hand, the operation should not be rejected for this reason. A clamp of practical utility may be extemporized from long-handled forceps, or by adjusting to the scrotum two narrow bars of metal or stiff wood, the extremities of which can be firmly held by the hands of an assistant. Fig. 173.—Henry's scrotal clamp. OPERATIONS ON VEINS, CAPILLARIES, ETC. 123 Radical Treatment for Varicocele.—The means employed to ob- literate the dilated vessels are quite numerous. They all, however, accomplish the result by compression. Only such as are considered practically consistent with the safety of the patient are here described. In all the operations great care must be exercised to avoid the vas deferens and artery. They lie posteriorly to the enlarged and worm- like congeries of vessels, around which the compression is to be ap- plied. If the patient be caused to lie down with the hips elevated, the blood will return from the varicose veins into the general circulation, after which the vas deferens and the artery can be easily isolated and separated from the veins. If the patient then assume an erect posi- tion the veins will again become distended, when, if pressure be main- tained upon the cord at the external ring, the vessels can be distinctly outlined if the patient be again placed in the recumbent position. The operator having thus carefully located the vas deferens and the artery, the patient can be etherized and the operations proceeded with. Compression by Pins (Fig. 174).—This consists simply of passing operation.) operation.) operation.) a strong pin through the scrotal tissues in front of the vas deferens and the artery, and throwing around its protruding extremities an elastic ligature, or cotton yarn, drawn sufficiently tight to cut off the circulation. This procedure should be repeated at about one inch from the first application. The pins can be withdrawn at the end of three or four days. Compression by Wires (Videl's).—This is done by passing a stout wire either in front of or behind the veins, preferably the latter, then passing a second but smaller one at the opposite side, but through the same opening in the integument (Fig. 17")). They are then twisted together till the veins are thoroughly compressed and rolled around them (Figs. 176 and 177). Subcutaneous Ligaturing.—This is accomplished by carrying a 124 OPERATIVE SURGERY. needle armed with a silver wire between the veins and the remaining vessels of the cord, returning it at the point of entrance, going in front of the veins. The wire is then twisted firmly. A strong silk ligature can be applied in a similar manner. The amount of tissue in their grasp renders the separa- tion somewhat tedious. The process of separa- tion can be hastened by tying the ligature over a small cylinder of elas- tic tubing (Levis), the resistancy of which will exercise a constant trac- tion (Fig. 178). If this be done, a button- should be introduced between the tissues and tubing to protect the skin (Pancoast). Strong catgut ligatures, or antiseptic silk, can be carried around the dilated veins, an inch or so apart, by means of an ordinary needle —or by an instrument especially devised for the purpose—and caused to emerge at the point of entrance, tied, ends cut short, and permitted to remain until they are absorbed. The veins may be divided subcu- taneously between the ligatures after they have been tied. The expedient advised by Prof. E. L. Keyes for passing the liga- tures is not only ingenious but also simple. A needle with a fixed handle, having two eyes at its point (Fig. 179), is armed with two antiseptic ligatures—one carried through each eye. The ends of the Fig. 178.—Elastic traction. Fig. 179.—Keyes' needle. posterior ligature are tied to form a loop ; the anterior ligature is permitted to hang loosely, with an equal portion at each side of the needle. The enlarged veins are isolated, and the point of the needle is pushed through the scrotal tissues in close contact with their posterior surfaces. One end of the untied ligature is then drawn through the tissues with forceps, and caused to remain in this position, while the needle is withdrawn sufficiently to permit its point to be carried in front of the distended veins, out through the original point of exit, when the distal end of the untied ligature is passed through the advanced portion of the looped one and drawn by it through the point of entrance to the scrotal tissues by the OPERATIONS ON VEINS, CAPILLARIES, ETC. 125 Fig. 180.—Ricord's loops. complete withdrawal of the needle. The deposited ligature is then freed from the scrotal tissues by making one or two sharp pulls upon it, tied firmly around the veins, its extremities cut short and allowed to disappear within the scrotum. If thorough antiseptic precautions be observed, the ligatures will rarely cause subsequent local trouble. The Double-Loop Compression of Ricord (Fig. 180).—This is an excellent plan, and can be readily exe- cuted by passing a needle armed with a silk ligature between the veins and the vas deferens ; to this is fastened a double ligature, which is drawn through and left in position. The needle with its silk ligature is then passed in front of the veins in the opposite direction, entering and emerging at the points pre- viously made. A second double ligature is then drawn through and left in position. The extremities on the respective sides are now tucked through the loops on the same side and drawn tight, and tied over a narrow roller or piece of elastic tubing. The ligatures will cut their way through in five or six days. The methods of cure by ex- posure, division, and ex- cision of the vessels are more dangerous, and have infrequently re- sulted in death from pyaemia. Venesection.— While the withdrawing of blood from a vein can hardly be classed as an operation of much moment in a surgical sense, yet the infrequency of its em- ployment at the present time is quite apt to ren- der the details connected therewith somewhat un- certain in the minds of a majority of the practi- tioners of the present generation. The veins selected for the proce- dure are the internal saphenous at the ankle, the median basilic, or median cephalic at the bend of the elbow, and external jugular in the neck. The instruments required are the or- Fig. 181.—Opening the vein with scalpel. 126 OPERATIVE SURGERY. dinary thumb-lancet, or a curved or straight sharp-pointed bistoury ; the first, however, possesses the greater number of traditional virtues. Should the lancet be not at hand, either of the others can be used as satisfactory substitutes. If the region of the elbow be selected, the median cephalic vein is preferred on account of its greater distance from the brachial artery. The arm should be constricted by a band- age drawn sufficiently tight to obstruct venous return, without inter- fering with arterial circulation : this will cause the veins to become prominently distended, unless the patient be very fleshy. The veins should be well defined by the finger, and held in position by the thumb or finger placed just below the point for incision, which is made obliquely to the transverse diameter, and of sufficient depth to freely open the vessel without severing it (Fig. 181). The flow may be increased by causing the patient to firmly grasp a stick or broom- handle ; it may be impeded by the interposition of the subcutaneous fat, which should be pushed aside. The amount drawn will be gov- erned by the strength of the patient, as well as his position. If stand- ing or sitting, its effects will be felt sooner than if in a recumbent posture. Usually, however, from half a pint to a pint will suffice. The flow is arrested by removing the bandage above and applying the finger to the bleeding point, after which a small compress is placed over the incision, and confined in position by adhesive plaster, so ar- ranged as not to impede the venous return. These directions will apply with equal force to venesection in all situations other than the external jugular. If this vein be selected, the compress is placed just above the clavicle, and confined in position by a bandage carried under the opposite axilla. The finger is then placed above the point of proposed incision, and the vessel opened at a right angle with the fibers of the platysma myoides muscle. The finger must always be placed on the opening before the compress is removed, in order to prevent the entrance of air into the circulation. Transfusion.—This is a means sometimes employed to overcome the exhaustion produced by disease or the loss of -blood, the latter being the only condition to which it can, thus far, be said to be prac- tically adapted. It consists in conveying the blood from one person to another, either directly, or by collecting it in a suitable receptacle, removing the fibrin, and introducing the remaining plasma and cor- puscles. The dangers to be avoided are, the introduction of air, blood- clots, and too great a quantity of blood into the patient's veins, which might overpower an already weakened heart. From six to eight ounces are usually sufficient, and should be thrown in slowly and carefully, watching the effects upon the circulation, respiration, and sensorium of the patient. If its introduction cause a depression of the pulse, or give rise to nervous tremors, or difficulty in breathing, it should cease at once. The blood to be transfused should be taken OPERATIONS ON VEINS, CAPILLARIES, ETC. 127 from a person of strong physique, and free from any constitutional taint. Direct Transfusion from Arm to Arm.—The requirements for this are an apparatus for the transmission of the blood, together with a pair of forceps and a scalpel to open the vessels, and a basin of water or sa- line solution, at a temperature of about 100° F., into which the appa- ratus should be laid to impart to it the requisite degree of warmth, and to exclude the air. The arm of the donor and receiver are constricted above the point for incision, "=&:: ..... Fig. 182.—Introducing the tube in transfusion. phlebotomy ; the skin covering the distended vessels is pinched up, transfixed, and cut through, leaving the veins exposed at the bottom of the wounds ; they are then seized with a pair of forceps, and a V-shaped opening made with the scissors for the purpose of introducing the tube (Fig. 182). The tube A (Fig. 183) is then taken from the bottom of the basin, and, with the thumb applied to its larger extremity to keep it filled, it is inserted into the opening in the vein of the receiver ; the tube B is inserted in like manner into the vein of the donor, after which the propelling power—the apparatus—likewise filled with fluid and kept so by turning the stop-cocks, is attached to the two tubes; the cocks are now opened, and the fluid contained in the instrument is thrown into the circulation by squeezing the bulb C, while the tube D' is compressed. After the bulb C is emptied, and before it is per- mitted to expand, the compression should be changed from D" to D. If the bulb be now allowed to expand, it will become filled with the 128 OPERATIVE SURGERY. blood of the donor, which can be injected into the circulation as in the preceding instance. The bulb should be allowed to fill slowly, Fig. 183.—Direct transfusion. and the amount introduced is estimated by counting the number of times it is emptied. After the operation is completed, the incisions are treated the same as in phlebotomy. The instrument devised by Fryer (Fig. 184) differs from the former in being cast whole, with an Fig. 184.—Fryer's transfusion apparatus. additional bulb, which does away with the metallic couplings, and presents a continuously smooth surface to the blood current; and, moreover, the additional bulb saves time by producing an almost con- tinuous current. It will be seen that a funnel is added to this instru- ment which allows it to be employed in mediate transfusion. Mediate transfusion is collecting the blood from the arm of the donor and injecting it into the circulation, either with or without the removal of the fibrin. For this purpose the instrument devised by Collins (Fig. 185) can be especially recommended. It consists of a pump attached to a funnel in such a manner as to carry the blood easily and without danger of coagulation or the introduction of air. OPERATIONS ON VEINS, CAPILLARIES, ETC. 129 It can be used equally well with the defibrinated or with the un- whipped blood ; with the latter it is particularly con- venient, since the blood can be caught in the funnel and injected while flowing from the donor, which saves time, and avoids the blood-changes induced by exposure. In Fig. 185.—Collins' instrument the use of this, and all other implements brought in contact with the blood, the temperature of the instrument, and of the blood injected, should be kept at about 100° F. by means of warm water, or a warm saline solution.* If defibrinated blood be employed, it should be pre- pared by agitation (Fig. 186), after being collected in a vessel of the temperature stated, then strained into the funnel of the instru- ment and pumped into the system. The introduction into the funnel, or into the bulbs, of two or three ounces of a sa- line solution, or of a carbon- ate of ammonia solution, four to six grains to the Fig. 186.—Removing fibrin. * R Chloride of sodium................................ 3 j- Chloride of potassium............................. gr. vj. Phosphate of soda................................gr. iij. Carbonate of soda...............................• 3 j. Aquae.......................................... % xx. M.—Heat to 100° F. 130 OPERATIVE SURGERY. ounce, prevents the entrance of air into the instrument, and also has a stimulating effect upon the patient. Fig. 187.—Bull's apparatus for injection of saline solutions. Injection of Saline Solutions.—The introduction into the veins, and the arteries, of various solutions, the chief ingredients of which are common salt and carbonate of soda, is highly recommended. The following is the formula of Schwartz : Distilled water, 32 ounces; common salt, 1£ drachm ; officinal solution of soda, 2 drops, raised to 100 or 104° F. Szumann recommended the following: Water, 32 ounces ; com- mon salt, 14, drachm ; carbonate of soda, 15 grains. The saline solu- tion on page 129 is suitable for this purpose. The amount of fluid to be injected will depend on the condition of the patient, also upon its effect. It is seldom that less than eight ounces are used, frequently eighteen or twenty, and even more may be advisable. The introduc- tion of the fluid should be made slowly, occupying fifteen or twenty minutes, by means of the apparatus already figured, or by an extem- porized siphon. If an aspirating needle a sixteenth of an inch in diam- eter be attached to a small rubber tube, connected with a receptacle containing the solution, and raised three or four feet above the pa- tient, no trouble will be experienced in carrying the fluid into the general circulation. The vein is exposed, distended, and punctured under complete antiseptic precautions, if possible. The apparatus devised by Dr. W. T. Bull, of this city, for this purpose, is admirable, owing to its simplicity, and being accompanied by the saline ingredi- ents necessary to charge the instrument (Fig. 187). These fluids seem to meet the indications quite as well as blood, are easily obtained, and 642 OPERATIONS ON VEINS, CAPILLARIES, ETC. 131 do not expose the patient to the dangers attendant on the use of the latter. Intra-venous injection of milk has been done to counteract the conditions similar to those calling for the use of blood. The milk should be freshly drawn from the cow and covered with a fine gauze, through which it is strained into a transfusion in- strument, which can be ex- temporized by joining a glass funnel to one end of a rub- ber tube, and to the other a small conducting canula. If the canula be introduced into the vein, and the funnel be raised after having been filled with six or eight ounces of milk, the force of gravity will become the propelling agent. Arterial transfusion has been advocated on the basis that it conveys the blood more equably to the heart, with less danger of exciting undue dis- turbance of the circulation. The admission of a small amount of air does no harm, and the dan- ger of phlebitis is avoided. The vessel selected should be the radial at the wrist, or the posterior tibial at the ankle, either one of which is exposed, and three ligatures are placed around it; the distal one is ligatured and the proximal one tightened sufficiently to interrupt the circulation in the vessel. The vessel is now opened and the tube in- serted and tied in position by the third or middle ligature, then the proximal one is loosened and the fluid injected into the circulation. It is better to inject the fluid against than with the natural flow of the blood current, to avoid over-distention of the capillaries. As soon as the injection of the fluid is completed the proximal one is tied, and the intervening portion of the vessel removed with the tube. The vein may be tied in venous transfusion with two ligatures in the fol- lowing manner : Tie the distal one, open the vein, introduce the tube, then tie the proximal one, including the tube ; this will prevent all loss of blood. Operations on the Capillaries. — This system of vessels, like the venous, may undergo dilatation of sufficient size to create distinct but slowly developing and painless deformities, or tumors. The morbid —Straining the blood. 132 OPERATIVE SURGERY. process may be, and usually is, limited entirely to the capillaries of , the integument; however, the larger vessels are not infrequently in- volved, in the beginning, or during their development; they likewise vary in size, shape, and color. The simplest form is known as the " Mother's mark," " Birth-mark," etc. A birth-mark can be treated by pressure, caustic, hot needles, vac- cination, etc., depending upon its size and situation. It is not well to interfere with it at all except by simple means, unless it increases rapidly in size. The majority of these growths will disappear of them- selves before their presence becomes a source of annoyance or regret to the possessor. There are, however, several simple means which will often hasten their departure—the use of simple compresses, repeated application of collodion, or vaccination, if the birth-mark be located suitably therefor. The following method, introduced by Dr. Squire some time since, which bade fair at one time to meet the desired end, can be employed : The " mark " is frozen with an ether spray, and numerous parallel incisions are made about one sixteenth of an inch apart and extending the same depth, and the whole covered with blotting-paper, held upon it with sufficient force to prevent any gaping of the cuts and escape of blood ; after fifteen or twenty minutes the paper is thoroughly wet with water and removed. Sometimes a thin underlying clot of blood will be found ; this must be carefully washed away with water and a soft brush. It is sometimes necessary to repeat the operation, when the incisions should be made at right angles to the previous incisions. If proper care be taken, in suitable cases a perfect cure is secured without any scarring. The injection of ergot, liquor ferri subsulphat- is, or various other astringents, has been recommended. They are, however, uncertain in their action, and are liable to be followed by inflammation, ulceration, and sometimes by embolism. The solutions can be injected by aid of the ordinary hypodermic syringe, three or four drops at a time, in various portions of the growth, or, red-hot needles can be introduced at different points. The application of red heat around the base and over the surface of the growth by means of the Paquelin cautery is an admirable method, provided it involves the skin alone or only the capillaries in the tissue immediately be- neath it. It is usually followed by more or less disfigurement, depend- ing upon the extent of the cauterization. Subcutaneous Ligaturing.—If the naevus be of large size, persist- ent, of a dark color, and markedly elevated, it is suitable for this meas- ure, which is done in several ways, depending upon the size and shape of the tumor, and fancy of the operator. Fig. 189 represents a simple method. In it the needle, armed with a strong, well-carbolized hemp or silk ligature, is thrust through the integument at its base, carried as far as possible around the base, OPERATIONS ON VEINS, CAPILLARIES, ETC. 133 and passed out, to be again introduced at the point of exit, and car- ried still farther around, and pushed through as before, and so on until it is caused to emerge at the first point of insertion ; the ends are then tied in a firm, hard knot. In Fig. 190 a double ligature is carried through the base and Fig. 189.—By a sin- Fig. 190 —By a double Fig. 191.-Ligation in quar- gle ligature. ligature. ter sections. divided ; each portion is then carried around its half of the base as be- fore, and tied. This is applicable to those having a larger base. Fig. 191 represents the application of the ligature to quarter-sections of the base. It is employed when the growth is large. Pass a double ligature through the center of the base, cut the loop near to its center, leaving one end of the divided thread in the eye of the needle ; then, after threading the needle with the other end of the portion of the ligature which was liberated by the division of the loop (Fig. 192), pass the needle through the base at right angles to its primary course. The ends are then to be firmly tied after the integument has been in- cised, to allow the ligature to sink deeply into the base, as well as to avoid the pain and ulceration incident to the constriction of the in- Fig. 192.—Quarter sec- Fig. 193.—Tying lig- Fig. 194.—Ligature of elon- tions, second step. ature. gated base. tegument (Fig. 193). It will simplify the selection and uniting of the proper extremities if one half the ligature be colored before its primary introduction. Fig. 194 represents the ligation of a growth with an elongated base. In this the double ligature is required, and should be colored as suggested above ; pass it through the base from side to side, commencing and terminating just outside of the extreme limits of the growth ; if the white loops be now divided on one side and the black on the other, independent sets of ligatures will be had, which should be tied ; the skin coming within the grasp of each ligature is incised 134 OPERATIVE SURGERY. as in the preceding instance. The separation of the growth is has- tened by the use of an elastic or rubber ligature, applied in a similar manner. Division and Ligation.—Cirsoid growths of the scalp can be suc- cessfully treated by making a free incision nearly around and outside of them, down to the periosteum, leaving that portion of the growth that contains the largest vessel undisturbed to form a pedicle to nour- ish the flap. The flap is raised and all bleeding points are tied, after which it is kept separated from its former bed by antiseptic gauze until the new surfaces granulate. The granulating surfaces are then placed in contact, and soon unite, thereby destroying the growth without loss of substance. If the pulsations in the flap continue for four or five days, the dilated vessel entering it should be tied at a distance from the pedicle. The hemorrhage is, to a degree, con- trolled during the primary operation by passing a strong rubber band around the head, beneath which compresses are placed corre- sponding in situation to the course of the vessels that supply the scalp. The bleeding points can also be closed by direct pressure against the underlying bone ; yet, notwithstanding these means, the loss of blood may be quite severe, and the operation should not be attempted if the patient be already exsanguinated or otherwise debili- tated. Care should be taken to form a pedicle of sufficient width to nourish the flap ; from half an inch to an inch, depending on the size of the flap, has, in my experience, been ample for the purpose. If the dressing be applied too firmly, the integrity of the flap will be en- dangered. CHAPTER VI. OPERATIONS ON THE NERVOUS SYSTEM. The brain, spinal cord, and the nerves arising from the cerebro- spinal axis, owing to the various morbid processes and injuries to which they, together with their coverings, are subjected, are often the seat of common and yet important surgical procedures. Hydrocephalus.—Tapping for the removal of the superfluous fluid is the only practical surgical procedure to which this condition is amenable. This may be done with a small aspirating trocar, or, what is better, with an aspirator. In either instance the puncturing agent is introduced through the anterior fontanelle, close to its outer border, and passed perpendicularly into the fluid accumulation, cautiously avoiding the brain substance when possible. The fluid must be slowly OPERATIONS ON THE NERVOUS SYSTEM. 135 withdrawn, accompanied by moderate and equable pressure upon the external surface by means of a skull-cap bandage. Whenever any manifestations referable to the circulatory or nervous centers appear, the needle should be withdrawn and the puncture carefully closed with a catgut suture and dressed antiseptically. Often the removal of less than three or four ounces will cause feebleness of the pulse, con- traction of the pupil, and evidences of approaching convulsion. After the withdrawal of the fluid, gentle and uniform pressure should be maintained by aid of bandages, adhesive plaster, or a tightly-fitting perforated rubber cap. Care is necessary, else the combined pressure of the reaccumulating fluid and external dressing will cause alarming symptoms. Meningocele is a protrusion of the meninges of the brain, caused often by an accumulation of the hydrocephalic fluid within the cra- nium, and must of necessity occur before the closure of the fontanelles. It may be present at any point of separation between the cranial bones, although it occurs more frequently at the posterior fontanelle than elsewhere. As a rule, little can be done, other than to pro- tect the tumor from external irritation. If it have a well-defined pedicle, this can be clamped and the fluid withdrawn, either by in- cision or with a small trocar. The clamp must be applied with cau- tion, else the pressure caused by it may produce convulsions or other nervous phenomena. If it be determined to puncture it, a small amount of fluid may be withdrawn, when the clamp can be the more readily adjusted. As long as the pedicle is open, any operative in- terference is liable to be followed by death from a resulting menin- gitis. If the pedicle be occluded, the sac may be incised and the tumor removed. In all instances where it is removed, sufficient in- tegument should be left to insure a complete and proper closure of the divided surfaces. Hydro-rachis.—This is a congenital defect, comprising a cleft in the laminaa of the vertebrae, and a protrusion of the membranes of the spinal cord. It occurs most frequently in the lumbar region, al- though it is found in the other portions of the spinal column. Vari- ous operative expedients have been employed to cure the defect, nearly all of which have, at one time or another, resulted in occasional cures. The two methods which have secured the best results are : 1. Re- peated punctures with a small needle at various points through the sides of the sack, followed by gentle and uniform pressure over the surface. 2. Consists of injecting into the sack, after having been par- tially emptied of its fluid, one or two drachms of the iodo-glycerin solution, which is made by dissolving ten grains of iodine and thirty grains of iodide of potassium in one ounce of glycerin. Exercise cau- tion that none of the fluid escapes after the operation. This must be 136 OPERATIVE SURGERY. repeated from time to time, always allowing the irritation due to the previous operation to subside before it is again repeated. Results.—The latter method has been very successful. Of forty- four cases treated, thirty-five were cured. Trephining the Cranium is an operation which is, without doubt, performed more frequently than the requirements of many of the cases Fig. 195.— Fig. 196.— Fig. 197.—Gait's Fig. 198.— Fig. 199.— Fig. 200. Crown tre- Handle of trephine. Elevator. Elevator. —Eleva- phine. trephine. tor- warrant. In every instance, before attempting it, the indications should be most carefully studied. The special instruments required for the operation are the trephine (Figs. 195,196,197), the conical, or Gait's, being by far the safer ; an elevator (Figs. 198, 199, 200) and rongeur (Fig. 201), sequestrum for- Fig. 201.—Rongeur. from the track of the trephine, while not absolutely necessary, have, nevertheless (especially the former), be- come so closely associated with the operation as to be entitled to a most respectful consideration. The patient is prepared by shaving the head 374307 OPERATIONS ON THE NERVOUS SYSTEM. for a considerable distance around the seat of the proposed operati Fig. 202.—Van Buren's sequestrum forceps. If unconscious, an anaesthetic is unnecessary. Strict antiseptic pre- cautions should be enjoined. Operation.—Make an incision Of an oval shape through the scalp Fig. 203.—Ferguson's sequestrum forceps. down to the bone, expose the portion of the cranium be pot oerated upon, and at the same time avoid large vessels and secure good drainage when possible. Lay back the integumentary flap, together with the Fig. 204.— Fig. 205. Fig. 206.—Szy- Fig. 207.—Hoffman's Fig. 208.—Lead Straight —Curved manowsky's gouge forceps. mallet. gouge. gouge. gouge. 138 OPERATIVE SURGERY. Fig. 209.—Course of arteries and sinuses. periosteum covering the portion of bone to be removed. Lower the cen- b ter-pin a little below the teeth i of the trephine, and fasten it firmly in position by means of its adjusting screw ; place the point of the center-pin as nearly as practicable upon that portion of the solid and undepressed bone which, when removed, will allow the best opportunity of elevating that which is depressed, pro- vided, however, that it be not placed, when avoidable, over the course of the middle me- ningeal artery, or a large sinus (Fig. 209). The trunk of the middle meningeal artery (Fig. 209, a) is located an inch and a half be- hind theexternal angu- lar process of the fron- tal bone, and the same distance above the zy- goma. The median line of the skull, from the root of the nose to the occipital protuberance, corresponds to the su- perior longitudinal si- nus (Fig. 209, b). The course of the lateral si- nus (Fig. 209, c) is indi- cated by a line drawn from the occipital pro- tuberance to the ante- rior border of the mas- toid process. Bear firm- ly upon the instru- ment, at the same time turn it quickly from right to left, till asuita- ble track is established to retain it in position (Fig. 210). The center- pin is then withdrawn and fastened back in place, otherwise it may perforate the membranes. Fig. 210.—Applying the cylindrical trephine. OPERATIONS ON THE NERVOUS SYSTEM. 139 The instrument must be held perpendicularly to the point of sec- tion, and the pressure evenly distributed ; if not, one side of the circle will be penetrated more quickly than the other, thereby jeopardizing the integrity of the membranes. During the process the trephine must be frequently raised from the track, that it may be cleared of bone-dust, the color of which should be carefully noticed ; at first it is of a pale white, but as soon as the diploe is reached it becomes red- dened ; from this time on the tooth-pick must be frequently used to clear out the track as well as to detect the first point of complete sec- tion. But little pressure is now allowable, since to use it might force the crown of the instrument through the membranes and into the brain structure itself, especially if the trephine be of a horizontal pat- tern. Gait's, or the conical trephine (Fig. 197), is far safer than the crown pattern, since, as soon as the inner table is divided, it is con- verted into a -screw and becomes immovably fixed in the opening. If the button of bone be percussed with the handle of a scalpel or forceps, it will emit a low-pitched sound, and vibrate when a considerable por- tion of the circle is cut through ; moreover, it can, probably, be raised from its bed at this time by the aid of the elevator. As soon as the button is removed, the elevator is inserted beneath the depressed por- tion, and it is raised to its proper level. This is sometimes difficult to accomplish, owing to the dovetailing of the fragments. The solid bone is used as a fulcrum when much force is necessary. If great force be employed, and a fragment be suddenly loosened, its distal, sharp, or jagged border may cut through the mem- branes ; it is therefore necessary that force be used in a guarded manner. All detached fragments are removed; those that will retain their position when elevated, owing to continuity of structure, may be al- lowed to remain. All projecting points of bone must be cut away with the rongeur, else the pulsation of the brain may cause them to perforate the dura mater. Clots of blood and pus are likewise to be cleared out by a stream of antiseptic fluid. If the compressing agents be below the dura mater, it may be opened sufficiently to ad- mit of their escape ; before this is done, however, their presence should be clearly established. If the dura mater be lacerated, it may be closed by fine catgut sutures, especially when the opening is large enough to predispose the formation of hernia cerebri. If the middle meningeal branches be divided or a sinus opened, the hemor- rhage is controlled by antiseptic compresses, so applied as not to exert undue pressure on the brain. If the membranes be lacerated, the fragments of bone removed must be fitted to each other, in order that the absence of any osseous portion may be ascertained and it be 6ought after. The opening in the skull made by the trephine can be enlarged more rapidly and safely by the rongeur (Fig. 201) than by repeated applications of the trephine. 140 OPERATIVE SURGERY. The wound should now be thoroughly cleansed with carbolic acid, the flaps adjusted, suitable drainage established, and the antiseptic dressing applied. It is often possible to elevate the fragments with- out the use of the trephine, an expedient that should always be tried, if a reasonable prospect of success be apparent. Results.—The nature of the cause calling for the operation, the length of time intervening prior to its performance, and the ability to secure complete drainage and asepsis, are the chief factors that modify the prognosis. A death-rate of from four to fifteen per cent, is a fair estimate in civil practice. The advance which is being made in cerebral localization is worthy of the closest scrutiny of the operating surgeon. Not only should he operate on the skull in the accepted sense of the term, but he should also note the exact seat of the lesion calling for his action. The va- riations in the symptoms, before and after the procedure, should like- wise be carefully scrutinized. The precise seat of an operation can be determined by measurements made from established points, as from the external auditory meatus, the external angular process of the Fig. 211.—Relation of chief fissures and convolutions to external surface of skull, a. Inferior frontal fissure, b. Superior frontal fissure, c. Fissure of Rolando, d. Calloso- marginal fissure, e. Inter-parietal fissure. /. Parietooccipital fissure, g. Parallel fis- sure, h. Fissure of Sylvius. frontal bone, various sutures, etc. Fig. 211 shows the relations borne by important convolutions and fissures of the cerebrum to the su- tures, and to other external points on the skull. Fig. 212, showing the exterior of the skull, is of especial importance when studied OPERATIONS ON THE NERVOUS SYSTEM. 141 Fig. 212.—Location of fissure of Rolando (R) and the special areas. in connection with the preceding figure ; upon it are indicated the measurements necessary to properly locate the underlying convo- lutions with which definite functions have been found to be asso- ciated. Operations on the Nerves of the Cranium.—It may become neces- sary, owing to neuralgia, spasm, tremor, etc., after all ordinary means have failed, to operate upon the trunk of the nerve involved, either by division, excision, or stretching. The first method can afford but temporary relief, since the divided extremities will speedily unite. , If excision be done, not less than two inches, if possible, should be removed from the continuity of the trunk ; otherwise, at a greater or lesser period, the extremities will become united. If the nerve be a small one, the tendency to union is less, but the rule to remove a long piece must not be deviated from. Stretching consists in cutting down on the affected nerve, seizing it with the fingers, and making firm and steady traction for from half a minute to a minute. It is applied more properly to the large nerves, and those which can not be divided without the sacrifice of important functions. Supra-Orbital Nerve.—This may be divided or excised at its exit from the supra-orbital foramen or notch at the junction of the inner and middle thirds of the supra-orbital arch. It is covered by integu- ment, fascia, and the combined fibers of the orbicularis oculi, occipito- frontalis, and corrugator supercilii muscles. To divide it, locate the notch by the fingers of the left hand, then 142 OPERATIVE SURGERY. pass the point of a narrow bistoury beneath the integument, from its inner to its outer side ; turn the edge backward, and cut firmly down and across the opening upon its inferior wall. Excision and Stretching.—The nerve can be found by elevating the brow and making an incision between it and the lid, one inch in length, through the tissues down upon the site of the nerve ; the connective tissue is then displaced by a director and its branches are sought for, and excised or stretched, as seems better. The nerve may be pulled out with a small blunt hook from the roof of the orbit, and excised before it enters the foramen; or it may be stretched and allowed to remain. The Infra- Orbital Nerves are the terminal branches of the supra- maxillary division of the fifth pair ; they escape from the infra-orbital foramen. The infra-orbital foramen is about four lines below the lower edge of the orbit, and nearly on a line extending from the bicuspid teeth to the supra-orbital foramen. The nerve may be divided through the mouth by first recognizing the location of the foramen, and placing the finger upon it ; then make a narrow incision, beginning at the fold of the cheek and maxilla, carrying it upward in the line before indicated, till within a short distance of the foramen, when with a sharp-pointed pair of scissors the nerves are divided as they emerge. They may also be divided through an external incision made directly down upon the foramen. In the latter the incision should be crescentic with the concavity upward, and be located about one-half inch below the lower border of the orbit; the muscles and cellulo-adipose tissue are displaced, nerves isolated from the vessels and divided. The nerves may be divided subcutaneously at this situation by a slender-bladed knife passed in the line of their emergence, and its edge directed toward the inferior wall of the canal. The Superior Maxillary Nerve.—This may be excised, divided, or stretched in its course along the floor of the orbit, or at its exit from the foramen rotundum. It may be reached on the floor by passing a tenotome about an inch backward in the line of its course, turning the edge downward, and cutting upon and through the thin floor of the orbit. Its termination at the infra-orbital foramen can then be exposed, and the severed portion pulled out (Langenbeck). Through a narrow incision of the soft parts, in this situation, a blunt hook can be introduced, the nerve caught up and stretched. The whole of the nerve can be removed from the canal, and sometimes farther poste- riorly, if an incision be made about an inch and a half in length along the lower border of the orbit, the tissues elevated and the nerve iso- lated from the artery, raised on a hook and divided ; or by pulling out the central portion, either by a ligature previously applied, or OPERATIONS ON THE NERVOUS SYSTEM. 143 with a pair of forceps. If the more formidable operation of its division, as it escapes from the foramen rotundum, be attempted, the initiatory incision through the soft parts should be of a shape and extent to best expose the site of the proposed operation ; the V, +, U, T shaped ones are selected, according to the wish of the operator. In either instance its central portion should correspond as nearly as possible to the infra-orbital foramen. After the flap is raised, the crown of a large trephine or drill is applied to the bone so as to open into the antrum along the course of the nerve, which is carefully followed backward to the spheno-maxillary fossa by cutting away the floor of the canal with a sharp, delicate chisel. It is then carefully isolated from the tissues in the fossa back to the foramen of exit, and divided with a pair of curved scissors (Carnochan). The internal maxillary artery runs through the fossa, and should be carefully avoided. If it be cut, it should be ligatured if possible ; not infrequently firm pressure will check the hemorrhage ; when other means fail, ligaturing of the external carotid will become necessary. The posterior wall of the antrum is quite vascular, and, when broken, or cut through by the small trephine, it often bleeds vigor- ously. There seems to be good ground for the belief that quite as good results follow an excision made anterior to Meckel's gangli- on as behind it. In either in- stance the operation ought not to be attempted unless a strong light can be thrown upon the field of action. The second and third branches of the fifth pair can be exposed at their exit from the skull by the ingenious method of Prof. Pancoast. Operation.—Make an incision the entire width of the perpen- dicular ramus of the lower jaw near where it joins the body; connect to its extremities two par- allel incisions carried upward to the zygoma and malar bone, care- fully avoiding Steno's duct (Fig. 213). Dissect this flap down to the bone, its upper border remaining attached at the zygoma. The coronoid process is now sawn off, de- tached from the temporal muscle and removed. The temporal muscle is then pushed beneath the zygoma. The fatty matter now exposed is Fig. 213 144 OPERATIVE SURGERY. removed, and the internal maxillary artery within it is ligatured. The upper head of the external pterygoid is detached from the greater wing of the sphenoid bone by the finger, and all hemorrhage checked, when the nerves within the zygomatic fossa are readily seen, and can be easily excised. If it be desired to expose the second branch as it crosses the spheno- maxillary fossa, extend the incisions upward and seek the spheno- maxillary fissure at the anterior lacerated foramen. The nerve should now be carefully isolated and a strong ligature passed around it. This last step is often attended with difficulty, especially when the fissures leading to it are narrow. If more room be necessary, the posterior wall of the antrum can be crushed in. The Inferior Dental Nerve.—This nerve may be divided, excised, or stretched, before it enters the jaw, in its course through it, and at its exit from the mental foramen. In the first situation an incision is made about an inch and a half in length along the anterior border of the vertical ramus of the jaw, within the mouth down to the ante- rior fibers of the internal pterygoid muscle ; the connective tissue be- tween this muscle and the inner surface of the ramus is now pushed aside, and the nerve detected as it enters the canal. The small spine surmounting the opening for the entrance of the vessel and nerve can be quite readily located, and will be a valuable guide to the nerve as it enters the dental canal. It can now be isolated, hooked up, and divided. About an inch and a half can be easily excised in this situ- ation, if after its isolation a strong ligature be thrown around it and tied. It is then divided by curved scissors as it enters the canal; traction by means of the ligature can then be made, which will not only draw the nerve down to admit of the division of the proximal end, but also add the good that may be derived from the stretching process. It may be approached in this situation from without, by making an incision from the sigmoid notch to the angle of the jaw. The parotid gland is turned aside, and the masseter muscle detached from the ramus sufficiently to allow the application of a trephine at a point three fourths of an inch behind the last molar tooth. When the but- ton of bone is removed, about half an inch of the nerve can be iso- lated, exposed, and excised. The nerve may be exposed in its course through the body of the jaw, by raising the soft parts, by means of an incision through them, about two inches in length, beginning in front of the facial artery. After the bone is thoroughly exposed, a trephine is applied in two or more situa- tions, and the bone removed down to the canal, when the intervening portions may be chiseled out, and the whole nerve removed ; or it may be excised at each of the openings. The former is the surer method. It may also be divided as it emerges from the mental foramen by turning the lower lip outward and making an incision about an inch OPERATIONS ON THE NERVOUS SYSTEM. 145 in length at the junction of the buccal fold, downward three fourths of an inch, in the line of the bicuspid teeth, when a careful search will disclose the filaments as they escape from the opening. Seize them with the forceps, draw them slowly and carefully out, and cut them off. The Lingual Nerve.—This may be reached in two situations: 1. As it passes just below the insertion of the pterygo-maxillary liga- ment. 2. Beside the tongue and sublingual gland. In the former, the mouth is opened widely, and the fold of mucous membrane covering the ligament is readily seen behind the last molar tooth. The nerve can be felt just below the insertion of the ligament, close to the tooth. Make an incision backward from the tooth over the course of the nerve, about one inch in length, carefully push aside the submucous tissue, and the nerve will appear in the wound, when it can be raised and cut. It has been successfully divided on several occasions near this situation by entering the point of a curved bistoury, three fourths of an inch behind, and below the last molar, cutting downward and outward to the bone in an imaginary line extending from the angle of the jaw to the last molar tooth. In the second situation, the tongue is drawn forward and to the opposite side, and an incision made about one inch in length, parallel with the tongue, and about one fourth of an inch from the attach- ment of the mucous membrane to it; then push aside the submucous tissue, and the nerve will be readily seen. The Facial Nerve.—This escapes from the cranium at the stylo- mastoid foramen, passes through the parotid gland and divides into the temporo-facial and cervico-facial branches. Operation.—Make an incision about two and a half inches in length along the anterior border of the mastoid process and sterno-mastoid muscle. After the division of the integument and fascia, the parotid gland is pushed forward with the handle of the scalpel, and the wound carefully deepened by the same instrument. At about three fourths of an inch from the surface the nerve will be seen passing forward and outward from its foramen of exit. At about a fourth of an inch to the inner side of its foramen the jugular foramen is located ; for this reason caution is essential to avoid wounding the jugular vein. The search should be carefully conducted in order not to injure the parotid gland. The nerve is somewhat deeply situated, being separated from the bone by connective tissue. The temporal branch can be di- vided where it crosses the condyle of the jaw through an oblique incision extending from the zygoma to the posterior border of its ramus. Operations on Spinal Nerves.— Great Occipital Nerve.—This is a large branch of the posterior cervical plexus arising from the internal division of the second nerve. It pierces the complexus and trapezius muscles near their attachment and supplies the integument as far for- ward as the vertex of the skull. 10 146 OPERATIVE SURGERY. Operation.—Locate the occipital protuberance and make an in- cision one inch and a half in length downward, forward, and outward at its outer side, beginning about an inch above the protuberance; carefully separate the tissues in the line of the incision and the nerve will be exposed where it escapes from beneath the trapezius muscle. Auricularis Magnus Nerve.—This nerve is one of the ascending branches of the cervical plexus. It emerges at the posterior border of the sterno-mastoid muscle near its middle, and ascends on that muscle to the lobule of the ear. Operation.—Make an incision two inches in length obliquely up- ward and backward, its center corresponding to the lower extremity of the lobule of the ear. On dividing the skin and fascia the nerve will be found resting on the sterno-mastoid muscle, from which it can be raised with a hook and stretched or cut. Spinal Accessory Nerve.—This nerve is excised to overcome spas- modic actions of the muscles which it supplies with filaments. It can be found through an incision made behind (De Morgan, Fig. 214), or in front of (Sands) the sterno- mastoid muscle. The latter is the better plan. Operation.—Make an incision three inches in length along the anterior border of the sterno-mas- toid, beginning close to the mas- toid process ; expose the sterno- mastoid, pull it backward, and the nerve will be found beneath as it crosses the jugular vein, which should be cautiously avoid- ed ; close and dress the wound antiseptically. Branches of the Brachial Plexus.—It may become necessary, on account of a severe neuralgia involving the branches of this plexus, or located in a painful stump, to excise or stretch the cords near their origin. It is best done prior to its division into its three terminal cords ; that is, where only two cords are found. Place the patient upon the back, raise the shoulders, and turn the head backward and to the opposite side. The course of the external jugular is determined by pressure just above the clavicle. Make an incision along the pos- terior border of the sterno-mastoid, three inches in length, extending down to the clavicle ; a second incision of the same length is now made outward from this point, along the upper border of the clavicle, care- fully avoiding the external jugular ; turn the flap upward and seek for the posterior belly of the omo-hyoid ; when found, draw it upward with a hook or ligature, push aside the loose connective tissue, and the Fig. 214.—De Morgan's operation, sc. Sterno-cleido-mastoid muscle, n. Spi- nal accessory nerve, s. Splenius mus- cle. OPERATIONS ON THE NERVOUS SYSTEM. 147 two cords will appear located above and to the outer side of the third portion of the subclavian artery, which should be carefully avoided. The inner cord is cautiously hooked up, and a ligature applied to it, by which it can be raised from its bed and divided with a pair of scis- sors near the outer border of the scalenus anticus muscle, being careful to avoid the muscle and the phrenic nerve. If gentle traction be made upon the ligature, the distal extremity will be raised, and can be again divided an inch or so from the point of the first section, and removed. The second or outer cord is then divided in the same manner. Musculo-Cutaneous Nerve.—This can be exposed in two situations : 1. As it escapes from the axilla. 2. Near to the elbow joint. Operation.—-To excise it in the first situation, carry the arm from the body and rotate it outward ; make an incision three inches in length along the outer border of the coraco-brachialis muscle ; divide the skin and fascia on a director, draw the muscle inward, and the nerve will be easily found at its outer border. In the second situation it is found by making an incision two and one half inches in length, between the biceps and the supinator longus, through the integument, fascia, and aponeurosis ; separate the mus- cles and the nerve will be readily seen. Musculo-Spiral Nerve.—This can be exposed in two situations : 1. By making an incision about four inches in length, between the outer border of the triceps and the brachialis anticus muscles, beginning it two and one half inches above the external condyle. Divide the fas- cia on a director, separate the connective tissues with the handle of a scalpel or by the finger, and the nerve will be easily found. 2. Make an incision, three inches in length, in the space between the supinator longus and the brachialis anticus muscles ; divide the fascia, separate the connective tissue beneath it, and the nerve will be readily exposed. Median Nerve.—It can be easily exposed in its course along the arm and lower half of the forearm by modifying either of the incis- ions for ligaturing the brachial to correspond to the relations of the nerve to that vessel. In the forearm, by making an incision about three inches in length, along the inner border of the tendon of the flexor carpi radialis, be- ginning about two inches above the wrist-joint. Divide the tissues in the usual manner. Separate the tendons of the flexor carpi radialis and palmaris longus, when the nerve will be discovered emerging from beneath the fleshy fibers of the flexor sublimis digitorum. The Radial and Ulnar Nerves—like the median in the arm—can be reached readily through the same incisions employed to ligature the vessels bearing similar names. Branches of the Sacral Plexus.—Great Sciatic Nerve.—This is best exposed just after its escape from beneath the lower border of the 148 OPERATIVE SURGERY. Fig. 215.—Great sciatic nerve e nerve, gm. Gluteus maximus. oh string muscle—biceps flexor cruris. n, n. Scintic Outer ham- gluteus maximus. Place the patient on the abdomen and make an incision three or four inches in length, beginning at the gluteal fold, at a point midway between the tuber-ischii and the trochanter major (Fig. 123, a), or the vertical may be joined by a short horizontal incision (Fig. 215); divide the integument and fascia on a director, separate the connective tissue with the fingers and handle of the scalpel down to the nerve. It can then be stretched by passing one or two fin- gers around it, and mak- ing firm and steady trac- tion upon it. Division or excision can be done easily through the same open- ing. The wound should be carefully closed and dressed under antiseptic precautions. Bloodless Stretching of the Sciatic.—Administer an anaesthetic and place the patient on the back. Extend the leg fully on the thigh, and hold the pelvis firmly. Flex the thigh on the pelvis, while full extension of the leg on the thigh is continued. This causes extreme tension of the muscles and other structure! on the posterior surface of the thigh, thereby stretching the nerve. The manipulation must be firmly yet cautiously made to attain the object, and at the same time not tear asunder the ham- string muscles. Results.—Obstinate sciatica has been relieved, and even apparently cured, by this simple manipulation. Not infrequently the degree of the resulting ecchymosis indicated rupture of the muscular struct- ures. Internal Popliteal Nerve.— This can be reached by the same method and with the same caution as the popliteal artery. It is, however, less deeply situated and somewhat nearer the center of the popliteal space than the vessels. Extreme caution should be exercised in operating upon it, on account of its nearness to the popliteal vein, which lies beneath it and to its inner side. External Popliteal Nerve.—It can be easily reached by making an incision, two or three inches in length, along the inner side of the tendon of the biceps cruris, when the nerve can be readily found be- neath the fascia, surrounded by fat. TJie Small Sciatic, Anterior ani Posterior Tibial Nerves can be OPERATIONS ON THE NERVOUS SYSTEM. 149 exposed through the incisions adopted in ligaturing the vessels of the same names. The Plantar Nerves.—These are the terminal branches of the pos- terior tibial, and are given off just after the nerve winds around the internal malleolus. They can be exposed by making an incision about three inches in length, beginning just in front of the center of a line extending from the anterior border of the internal malleolus to the inner tuberosity of the os calcis, and extended forward along the ex- ternal border of the abductcr pollicis. If the space between the short flexor and the abductor be now opened at the posterior portion, the nerves will be found accompanied by the arteries, of similar name. Perineal Nerve.—This may be exposed in the perineum of the male by making an incision along the rami of the pubes and ischium in the same manner as directed for ligaturing the pudic artery at this situation. In the female perineum the nerve may be exposed either by an incision made without or within the vagina. In the former, make it through the superficial tissues, about three inches in length, in the groove between the labium and the perineum, just inside the rami of the pubes and ischium. The nerve is surrounded by connect- ive tissue, and it is difficult to find it in this situation ; however, if the blade of the knife be turned inward and the outer coats of the vagina b3 divided down to the inner one, the nerve will not escape section. It is more easily severed from within the vagina. If the finger be introduced an inch or more, and lateral pressure be made, the nerve will be felt, cord-like in character and sensitive to touch. Make a vertical incision through the coats of the vagina, and the nerve will be ex- posed for division or ex- cision. Branches of Lumbar Plexus.—Anterior Cru- ral Nerve.—This nerve is the largest branch of the lumbar plexus, and enters the thigh beneath Poupart's ligament, about three fourths of an inch to the outer side of the femoral artery (Fig. 216). Operation. —Make an incision three inches in length directly downward, beginning about an inch above Poupart's ligament, in the line of the nerve. The super- imposed layers of tissue are then carefully divided on a director down Fig. 216.—Anterior crural nerve exposed. «, oral artery, n. Anterior crural nerve, pi. and iliac muscles, s. Sartorius muscle. Fem- Psoas 150 OPERATIVE SURGERY. to the groove between the iliac and psoas muscles, in which it rests. The pulsations of the femoral artery will always suggest the location of the nerve. The Internal or Long Saphenous Nerve is given off from the ante- rior crural and supplies the inner surface of the leg. It is accompa- nied by a vein of the same name in its course along the leg. It can be reached easily in many situations, but practically, however, it is best exposed at the inner side of the knee, where it escapes beneath the sar- torius, and at the middle of the leg. In the former situation recognize the tendon of the sartorius. Press upon the internal saphenous vein above this point to distend it, make an incision two inches in length close to and parallel with the vein, draw it aside, and the nerve will be found emerging from beneath the tendons of the sartorius and gracilis. At the middle of the leg make an incision three inches in length, parallel with the properly distended vein, which should then be pulled aside, and the nerve will be found beneath it. The External or Short Saphenous Nerve arises from the internal popliteal, escapes between the heads of the gastrocnemius, pierces the fascia below the middle of the leg and becomes subcutaneous, passes down on the fibular side of the posterior surface to the malleolus, ac- companied by the external saphenous vein. Distend the vein by press- ure, make an incision close to and parallel with it, near the border of the tendo Achillis ; pull the vein aside, and the nerve will be seen be- neath. Suturing of Nerves.—This is a procedure of modern introduction, employed to unite the extremities of divided nerves. The earlier the attempt is made the better, provided the tissues surrounding the nerve be, not inflamed. Every antiseptic precaution should be taken ; if possible, it should be done under the douche of the bichloride solution. Operation.—A free incision is made down upon the ends of the nerves to be united, being careful not to disturb unnecessarily the surrounding soft parts. The extremities are refreshed by the removal of a small portion, drawn in contact with each other, and retained in apposition by fine antiseptic catgut passed through their respective sheaths and tied. It is wise, owing to the easy absorption of the cat- gut, to re-enforce it by one or two horse-hair or fine silk asepticized sutures. If it be necessary, a fine catgut suture can be passed through the nerve structure and tied, in order to properly oppose and maintain the extremities. If the distance between the extremities be too great to allow a ready apposition of them, something may be gained by mak- ing traction on them and by the relaxation of their associated soft parts. If a sufficient amount of the nerve be present to admit of it, the splicing should be made obliquely, since it offers a better oppor- tunity to securely unite the ends. After the ends are united, close the wound, dress antiseptically, and place the part in an easy position. OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 151 Results.—The results thus far point to the eutire feasibility of the operation ; it hastens the resumption of nerve action by lessening the distance between the divided extremities, and in no instance has it boen followed by neuritis or other untoward symptoms. Nerve Transplantation.—Nerve transplantation is, as yet, limited to experimentation. Sections of nerves can be transplanted and union will readily take place ; but nervous influence is not quickly estab- lished. Future experimentation in this line will no doubt secure some great practical advance in the surgery of the nervous system. CHAPTER VII. OPERATIONS ON TENDONS, FASCIAE, AND MUSCLES. Tenotomy consists in making a subcutaneous division of the ten- dons of muscles to overcome or alleviate a deformity. In order to accomplish this successfully, the exact location of the offending structure must be known, together with its important contiguous vessels, nerves, etc. Many of the large tendons are easily located by their natural prominence. Others that ordinarily lie concealed become apparent if contraction has occurred, and still more conspicuous if they be placed upon the stretch. The principles governing tenotomy should be well considered ere a tendon be divided, otherwise an expedient of great good becomes mischievous and even destructive in its results. Muscles and fasciae, either singly or con- jointly, are also the direct causes of, or may be in- directly connected in, causing deformities. They, too, are amenable to a similar treatment. The instruments employed are few in number and simple in character. Fig. 217 represents the tenotomes used by Prof. L. A. Sayre. They are excellent instru- ments for the purpose. Fig. 218 represents the ordinary tenotome found in the pocket-cases of the day. It is too fragile to be safely em- ployed in the division of tissues requiring any outlay of force. A detailed description of either is unnecessary, since they can be ordered from the instrument-maker by simply naming the designer. The blade of the tenotome used for dividing fasciae and muscles (Fig. 219) is of necessity much longer than either of the former ; the Fig. 217.—Teno- tomes. 152 OPERATIVE SURGERY. Fig. 218.—Tenotome. principles embodied in it, however, are substantially the same. A cocaine solution may be injected near the point of division. An ob- servance of the following simple rules will obviate the pos- 1'sibilityof doing violence to other than the tissues directly concerned in the operation : 1. Mark the handle to indicate the direction toward which the cutting edge looks. 2. Care- fully note the length of the blade, that it may be inserted only far enough to divide the contracted tissues. 3. Place | the structure to be divided upon the stretch (Fig. 220). Pinch up, or press aside the skin ovrer the part to be cut, so that when it is released, after the completion of the opera- tion, the opening will not correspond to the divided tissues. 4. The blade should be made aseptic before being used. 5. Pass the knife-blade from important vessels and nerves. 6. •f- Insert the blade on the flat, close to the surface of the tissue II to be divided ; turn the edge toward it, and carefully sever <||k it by a guarded sawing motion, aided by pressing the tendon raili upon the cutting surface of the knife. If unguarded force I ||| be used, the tendon and its superimposed tissues may be di- | °lIf vided, which will seriously complicate the recovery. 7. Withdraw the blade upon the flat, follow it by firm pressure | upon the parts with the thumb, which should finally rest OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 153 upon the incision ; this will press out all blood and exclude the air. 8. Seal the wound carefully with adhesive plaster or collodion ; or stitch it with asepticized silk, and apply the antiseptic dressing. 9. Rectify the deformity and confine the part to which the tendon is attached until repair shall have commenced. 10. Avoid the division of a tendon as it passes through its sheath, if possible. 11. Divide the offending tissue at the point of greatest forced prominence, pro- vided it be consistent with its relation to important structures. If reflex spasm results from "point pressure," the tendon should be divided, and at the pressure-point inciting the reflex action. Cocaine injections act admirably. Tenotomy—Upper Extremities. — The tendons of the flexor sub- limis and flexor profundus digitorum may be divided by a transverse, subcutaneous incision carried through them down to the bone at about the middle of the first row of anatomical phalanges. Antiseptic pre- cautions should be observed carefully in this instance, otherwise severe inflammation of the sheaths of the tendons may follow. After the division of the tendons reduce the deformity and keep the parts quiet for five or six days, till the danger from inflammation has subsided, when they may be cautiously moved. Extensor Communis Digitorum.—The tendons of this muscle can be readily divided as they pass along the carpus or upon the dorsum of the phalanges. In the former instance, pinch up the skin, pass the knife beneath the tendon as before directed, and cut toward the surface. They may be divided by passing the blade above the tendons and cutting down upon the bone. On the dorsum of the phalanges the blade should be passed beneath the skin, and the tendons divided upon the bone. In the division of the tendons of both flexor and ex- tensor muscles, the joints and palm of the hand above the transverse line should be avoided, also the course of the vessels and the spaces between the metacarpal bones. The Extensor Primi Internodii, Secundi Internodii, and Ossis Mvtacarpi Pollicis Tendons can readily be made prominent by forcible extension of the thumb in the living subject, with the forearm mid- way between supination and pronation. The primi internodii and ossis metacarpi pollicis tendons form the inner boundary of the " snuff- box," at the apex of the styloid process of the radius, the ossis meta- carpi pollicis being the innermost of the two. The tendon of the extensor secundi forms its outer boundary. They can be divided in this situation by first making them as prominent as possible, then in- troducing the knife beneath from the anterior surface of the wrist and cutting toward the integument. The radial artery is to be avoided as it passes beneath them, and likewise the radicle of the radial vein as it crosses the intervening space. Flexor Carpi Radialis.—The tendon of this muscle is situated 154 OPERATIVE SURGERY. immediately to the inner side of the radial artery, at the lower third of the forearm, and can be readily divided by passing the knife from the artery beneath the tendon. Flexor Carpi Ulnaris.—This is the most internal tendon on the anterior surface of the forearm, and has the ulnar artery at the outer border. It can be easily cut by passing the knife beneath it, from without, inward. Biceps Muscle at the Forearm.—The tendon of insertion of this muscle may be divided either above or below the giving off the bicipi- tal fascia. The former is the safer. Make the veins in the region prominent by constricting the arm above, extend the forearm to make the tendon prominent and tense ; enter the knife at its inner border, pass it cautiously between it and the brachial artery, and cut upward, being careful not to injure the distended veins. Tenotomy—Lower Extremities.—Tibialis Posticus.—The tendon of this muscle is intimately associated with the deformity of talipes varus. It runs along the inner border of the tibia, behind the inter- nal malleolus, in a separate sheath, being the innermost tendon at this situation ; after leaving the internal malleolus, it passes beneath the calcaneo-scaphoid articulation to its insertions. In the normal foot it lies well concealed within its closely fitting groove ; but it can be readily outlined between the tip of the malleolus and the calcaneo-scaphoid articulation. In talipes varus it is raised from its groove and becomes more prominent above the tip of the internal malleolus, as well as below it. It can be divided in either situation, but it is better done at a point about an inch and a half above the tip of the malleolus in the adult, and one inch in the child or infant. The tendon is made tense by strongly abducting the foot, and the knife is passed with the usual precautions between the posterior border of the tibia and the tendon ; the division is made by cutting outward. The section between the tip of the malleolus and the calcaneo- scaphoid articulation is not advised, on account of the contiguity of the ankle-joint and the internal plantar artery ; if, however, it be thought advisable to operate at this situation, the foot should be strongly abducted, and the point of the tenotome carefully insinuated beneath the tendon, and between it and the internal plantar artery; the handle is then depressed so as to carry the point away from the joint, and the section made from within outward. Flexor Longus Digitorum.—The tendons of this muscle are some- times productive of contraction of the toes, after the correction of the deformity of the tarsus caused by the tibialis posticus. It lies imme- diately posterior to the tendon of that muscle, behind the internal malleolus, and is often divided by the same cut which severs the tendon of the tibialis posticus. It can, however, be divided independently. OPERATIONS ON TENDONS, FASCIyE, AND MUSCLES. 155 If, after the division of the posticus tendon, the influence of the flexor longus digitorum be objectionable, it may be divided by intro- ducing the tenotome beneath it through the same incision, and cut- ting toward the surface as before. The posterior tibial artery and its venae comites, which in the adult are often varicose in this situation, must be carefully avoided by pressing them outward with the finger. If from contraction of the toes, unassociated with deformity due to the tibialis posticus, it be deemed advisable to sever its tendon, the posterior tibial vessels must be first detected, pushed outward by the thumb, which should then be pressed firmly between them and the tendons at the inner side ; pass the tenotome perpendicularly through the integument, midway between the posterior margin of the tibia and the end of the thumb ; carefully insinuate it between the ten- dons of the posticus and the flexor longus digitorum down to the bone, turn the edge upward, and carefully divide it toward the surface. Flexor Longus Pollicis.—It may become necessary to divide the tendon of this muscle, on account of the crippled action of the foot in walking, dependent upon undue flexion of the great toe. The toe should be forcibly extended, and the knife carefully in- serted beneath it at the point of its greatest prominence, which will be at the anterior and inner side of the foot. The instrument must always be passed from the internal plantar artery. The Tendo Achillis is the most prominent tendon of the human system, and should be divided at its narrowest portion. The posterior tibial artery is at the front and inner side, but sufficiently remote to be secure, if ordinary care be exercised. The short saphenous vein lies superficially and closely to its outer border. It can be readily divided if the foot be forcibly flexed, to render it tense ; pinch up the skin, push it outward to protect the vein, enter the knife beneath it from within outward, turn the edge toward the tendon and carefully sever it with a sawing motion while the foot is firmly flexed and the tendon pressed upon the edge of the knife by the finger. Great care is necessary, else a sudden giving way of the tendon may cause the knife to sever the superimposed tissues. All the precautions enjoined in tenotomy should be carefully observed in this instance. Peroneus Longus and Brevis.—Their tendons pass in a common groove behind the external malleolus, and are inclosed by the same sheath, the latter passing the most anteriorly. It leaves its fellow after passing behind the malleolus, and is inserted into the base of the metatarsal bone of the little toe on the outer side. The longus, after passing behind the malleolus, gains the sole of the foot, enters the calcaneo-cuboid groove, and is inserted into the base of the metatarsal bone of the great toe at its outer side. The tendon of either may be divided in two situations : 1. About one and one half inch above the 156 OPERATIVE SURGERY. « tip of the malleolus. 2. Three fourths of an inch in front of it. They are commonly divided in the former situation. They can be severed connectedly or singly in either situation. If it be decided to sever both simultaneously above the malleolus, seek the anterior and external border of the fibula, about an inch and a half above its tip, pass the knife between the bone and tendons, turn the edge outward and cut toward the surface. The short saphenous vein should be pushed inward to avoid injury. If either is to be divided separately, push the integument back- ward with the thumb, to protect the vein, then push the thumb firmly down to the bone behind the tendons ; pass the tenotome perpendicu- larly midway between the end of the thumb and the external border of the fibula, carefully insinuate it between the tendons, after which it is passed outward or inward, as the case may be, beneath the ten- don to be severed, the edge turned upward, and the division made as in the preceding instances. If the division be made below the malleolus, make the tendons tense, enter the knife about one half or three fourths of an inch in front of the tip of the malleolus, between the tendons;, when either or both may be divided. Tibialis Anticus.—This muscle, like the posticus, is of importance in connection with the deformity of talipes varus. It is the innermost tendon of the leg and foot on its anterior sur- face, and can be easily outlined unless the foot be fat and chubby, when some difficulty may be experienced. In well-marked cases of talipes varus it is displaced considerably to the inner side, and, if the foot be abducted, will become quite promi- nent. It is best divided about one inch above its insertion into the internal cuneiform bone. Make the tendon tense, pass the knife from without inward, to avoid the dorsalis pedis artery. Extensor Proprius Pollicis.—As it passes across the dorsum of the foot, it can, like the preceding, be quite easily distinguished. It may become necessary to divide it after the division of the extensors of the tarsus, on account of its causing undue extension of the great toe. The toe should be forcibly flexed, and the tenotome carried beneath it from without inward, to avoid the dorsalis pedis vessels. Extensor Longus Digitorum.—The tendons of this muscle may not only cause an obstinate extension of the toes, but aid in maintain- ing the tarsus in a state of forced flexion. They can be divided sepa- rately, as they pass along the dorsum of the foot, provided either require it. If all be cut at once, it is done by flexing the toes, enter- ing the knife beneath them, a little below the bend of the ankle, from within outward, to avoid the dorsalis pedis vessels. Peroneus Tertius.—This may be divided together with the extensor longus digitorum, of which it is a part; or it can be done separately OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 157 before its insertion into the dorsum of the metatarsal bone of the little toe, by extending the tarsus, and passing the knife beneath it, from without inward. It is the most external tendon on the dorsum of the foot, in front of the external malleolus. Biceps of ths Leg.—This tendon forms the external hamstring, and is inserted into the head of the fibula and the outer tuberosity of the tibia. The external popliteal nerve is located immediately at its inner side. To divide it, the leg should be extended, and the tenot- ome passed from within outward, beneath the tendon about an inch and a half above the head of the fibula. The inner hamstring tendons are the semi-tendinosus, semi-mcm- branosus, gracilis, and sartorius ; the two first, however, are the ones principally concerned. The tendon of the semi-tendinosus is felt as the longest, smallest, and nearest to the median line of the popliteal space ; that of the semi-membranosus is internal to it, somewhat less superficial, and runs parallel with it. Either of these tendons can be divided by extending the leg to make it tense, and entering the knife beneath and from the outer side, at the most prominent portion, and cutting towrard the surface. Their division to relieve forced flexion of the leg will not always admit of complete extension, due, among other things, to the contraction of the heads of the gastrocnemius, which are inserted into the condyles of the femur. The forced exten- sion of the leg under these circumstances often causes a tearing asun- der of the attachments of this muscle, especially in the inner head, which is larger, stronger, and inserted higher than the external. The hemorrhage resulting therefrom may be severe enough to infiltrate the calf of the limb, even extending throughout the popliteal space. The liability to this rupture and consequent bleeding may be lessened, if not obviated, by first dividing the tendo Achillis ; or, what is per- haps better, by first dividing the hamstring tendons, when, if, on at- tempting to straighten the limb, the foot becomes extended, the tendo Achillis can then be divided. Gracilis and Sartorius.—They may be divided, after forcible ex- tension of the leg. Pass the tenotome close at the inner side of the tendon of the semi-membranosus, between it and the gracilis, depress the handle outward or inward, as the case may be, and divide these structures toward the skin. The Quadriceps Extensor Tendon may be divided above the pa- tella by making an incision down to the tendon parallel with the base of the patella ; enter the point of the knife above it cautiously, and with a sawing motion divide the tendon. A careful and continu- ous attempt should be made to flex the leg while the tendon is being cut, that its deepest fibers may be ruptured, thus avoiding, as far as possible, entering the synovial extension of the knee-joint, which lies beneath it. However, the limb should not be flexed farther than is 158 OPERATIVE SURGERY. necessary for this purpose, and after the division should be placed in a comfortable position till repair is well advanced. Pectineus.—This muscle, which acts as a flexor and adductor of the thigh, may require division on account of malposition of the limb. The pelvis is steadied, thigh extended and abducted, which causes the fibers to become tense and prominent. A long-bladed tenotome is then introduced at the outer border, about an inch below its origin, and carried inward and upward, till the division is complete. The internal circumflex artery, which runs between the psoas magnus and the outer border of the pectineus, is the only vessel of any size exposed to injury. The danger to this is obscure, unless it arises higher than usual. If the division be made downward and inward the femoral vessels will be less exposed than when made in the opposite direction. The Adductor Longus is situated farther to the inner side of the thigh than the preceding, forming the inner border of Scarpa's tri- angle. It is, however, located on about the same plane as the pecti- neus. It is tendinous at its origin from the pubes, and can be easily divided, when made tense, by passing the knife beneath its outer bor- der, and cutting upward and inward. The Tensor Vagince Femoris can be severed without difficulty by introducing a long-bladed tenotome beneath it, from either border of the muscle, about an inch below its origin, and cutting toward the surface. The Sartorius forms the outer boundary of Scarpa's triangle, and can be divided by making its fibers tense, by strong abduction ; then introducing a long tenotome beneath it, at its inner border, two or three inches from its origin, and cutting upward toward the sur- face. Muscles of the Trunk.—The Multifidus Spince lies on either side of the spinous processes, in the groove formed by the spines and trans- verse processes, from the sacrum to the axis. This muscle is quite su- perficial in the sacral region, opposite to the posterior superior spinous process of the ilium. Raise a fold of skin parallel with the long axis of the muscle ; pass a long-bladed tenotome from the spine outward to the outer border of the muscle, and cut toward the spine. Latissimus Dorsi.—The tendon of this muscle may be divided separately at the lower border of the axilla, or conjointly with that of the teres major, a short distance below their insertion into the hu- merus. In either instance the arm is forcibly raised to render them tense and prominent, and a long, narrow-bladed tenotome is inserted along the anterior border, and they are carefully severed by a sawing motion. It may likewise be divided at the lower angle of the scapula. Make the muscle tense as before, pass a long, strong tenotome beneath it, and cut carefully outward ; close the opening with a compress. OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 159 The Erector Spince forms the principal portion of the muscular prominence on either side of the spine to be seen in the lumbar re- gion. This is a thick, strong muscle, which arises from the sacrum and contiguous structures, and divides at the lower border of the last rib into the longissimus dorsi and sacro-lumbalis, which are inserted into the angles of the ribs and the transverse processes of the dorsal vertebrae. The erector spinae can be divided by a long tenotome passed from within outward, to the outer border of the muscle, just below the last rib, and carried downward and inward toward the spine. Trapezius.—This is a muscle possessing an extensive origin. The portion which arises from the inner third of the superior curved line of the occipital bone is often divided, on account of abnormal devi- ations of the head. This is readily accomplished by making the muscle tense, and severing it with a tenotome entered beneath it, just below the occipi- tal protuberance, the edge turned toward the integument. Sterno-cleido-mastoid.—Division of this muscle is often necessary in cases of wryneck dependent upon abnormal muscular force. It is divided at its lower extremity, either at its sternal or its clavicular attachment; often at both. For the division at either, the muscle is put on the stretch by turning the head, and the blunt-pointed teno- tome passed beneath it from the outer side, about half an inch above its insertion, and divided toward the surface. The division of the clavicular portion may be ample to correct the deformity ; if not, the sternal portion should be severed in the same manner. It is necessary to closely hug the under surface of the portions to be divided, else the deep-seated and important vessels may be injured. It is not safe to attempt a subcutaneous section of the muscle above this point, on account of its relation to the common carotid artery and the internal jugular vein. Plantar Fascia.—This tissue is an exceeding dense, white fibrous membrane of great strength, with the fibers arranged longitudinally. It is divided into three portions, the middle and two lateral. The former is the one especially concerned in those deformities requiring division. It is narrow behind and attached to the inner tubercle of the os calcis ; broader and thinner in front, and divides into five pro- cesses opposite the middle of the metatarsal bones, being one for each of the toes. Each of these processes divides opposite the metatarso- phalangeal articulations into two slips, which embrace the sides of the flexor tendons, and are inserted into the sides of the metatarsal bones and the transverse metatarsal ligament. It likewise sends prolonga- tions between the groups of the plantar muscles. This fascia serves the important function of assisting in maintaining the integrity of the plantar arch. 160 OPERATIVE SURGERY. It is divided by placing it upon the stretch, and passing a teno- tome beneath the inner border of the most prominent portion, and cutting toward the sole. The deformity is then overcome as much as is practicable, and the foot is placed and fixed in the corrected po- sition. Palmar Fascia.—Like the plantar fascia, this is divided into three portions—two outer and a middle part, the middle division being one of special significance. It is narrow above, and attached to the lower border of the annular ligament ; below it is broad and thinner, and opposite the heads of the metacarpal bones divides into four slips, one for each finger. Each slip subsequently subdivides into two processes, Fig. 221.—Fascial contractions, a. Fascial contractions, b. Flexor tendons. which inclose the tendons of the flexor muscles, and are attached to the sides of the first phalanx, and to the glenoid ligament, and extends upward over the flexor tendons nearly to the tip of the finger. This fascia is intimately connected with the integu- ment of the palm, and sends vertical septa between its muscles. From various causes it may undergo structural changes, which result in contractions of the fingers on the palm, as well as shortening of the palm it- self. The anatomical arrangement of the fascia fully explains the mechanism of the deformity. Dupuytren's Contraction.—This deform- ity depends upon the contraction of the prolongations of fascia of the palm, con- nected with the digits ; the morbid process more frequently manifests itself in the ring and little fingers, causing them oft- times to become opposed to the palmar surface of the hand. Operatiow.—Anaesthetize the patient ; render the restricting bands tense by a firm extension of the affected digits, and then, under anti- Fig. 222.—Transverse incisions lor Dupuytren's contraction. OPERATIONS ON TENDONS, FASCIA, AND MUSCLES. 161 septic precautions, divide the restraining bands at short intervals, subcutaneously, with a narrow-bladed knife, its edge being directed from the surface of the palm. When sufficiently liberated the digits can be freely extended, in which position they are to be confined by dorsal splints until repair is completed. Passive motion and forcible extension until the tendency to contraction is overcome, comprise the important elements of the after-treatment. Goyraud made longitu- dinal incisions over the tense digital prolongations of fascia, dissected the integument from them, after which they were divided sufficiently to admit of extension of the digits ; the integumentary incisions were closed and the fingers confined in a straight position until healed. His success was gratifying. Fallacy.—This deformity may be confounded with that dependent upon contraction of the flexor tendons. An examination of Fig. 221 will enable the surgeon to make a clear distinction between the two conditions. The fascia in other situations may become contracted, as the fascia lata, at its upper or lower extremities. Whenever these contractions cause a persistent deformity they should be divided, and upon the same principles as like tissues in other portions of the body. The employment of an anaesthetic is advisable in tenotomy, especially when the section is to be extensive, or contiguous to important struct- ures. In all instances antiseptic precautions should be taken. Tendon Suturing.—The uniting of divided tendons by catgut or by fine silver wire is an accomplished fact. Hereafter the practical surgeon, instead of assigning as a reason for the permanent immobility of an extremity, that " The tendon was cut," should first make an earnest effort to unite its extremities. The especial functions of the divided tendons can be determined by causing movements of the car- pus and fingers, independently of each other, and watching the effects of these movements on the distal extremities of the divided tendons. Some difficulty is often experienced in finding the respective ends of the severed tendons, since they—especially the ends connected with the muscular belly—are notably drawn into their sheaths. Operation.—Under full antiseptic precautions, flex the part so as to produce the greatest relaxation of the muscles associated with the divided.tendons ; if necessary, open their sheaths sufficiently to catch their extremities, draw them down and unite them by an oblique splice, if possible, with catgut or fine silver wire, close the wound, dress antiseptically, and confine the extremity in the position best calculated to cause muscular relaxation and quiet during the healing process. Fallacy.—If great care be not taken, in case more than one tendon be divided, the tendons of muscles acting diversely will be united, with manifest results. 11 162 OPERATIVE SURGERY. CHAPTER VIII. OPERATIONS ON BONES. The injuries and diseases to which bones are liable, although not differing in any essential particular from the same conditions when occurring to the soft parts, require an independent consideration, on account of the dissimilarity of the function and structure of the osse- ous system. Tendons, muscles, nerves, and fasciae are divided and ex- cised ; so are bones. The integument and soft parts generally, become the seat of inflammation, ulceration, and gangrene. Bony tissue is like- wise preyed upon by the same morbid processes, named, however, quite differently ; ulceration of the soft parts being comparable to caries of bone, necrosis of bone finds its synonym in gangrene of soft parts. To preserve the function of a tissue unimpaired is the greatest end that can be attained by surgery. To relieve a patient of the local effects of an injury or disease constitutes conservative surgery in its fullest sense. The functions of bones being, in & practical sense, to support the body, protect important organs, and act as levers for purposes of pre- hension and locomotion, we have but to act with a knowledge of these purposes, and of the methods to maintain them, to give to the patient the full benefit of our art. The operations upon bone are denominated gouging, sequestrotomy, excision, osteotomy, and osteoplasty. Fig. 223.—Volkmann's scoop. Fig. 224.—Hebra's Scoop. Gouging is applied to the removal of carious bone, and should not be attempted until the process has become chronic. Fig. 225.—Chisel. The instruments required to meet the exigencies of a case are gouges (Figs. 204, 205, 206, 207), scoops and chisels (Figs. 223, 224, OPERATIONS ON BONES. 163 and 225), of various sizes and shapes, together with a suitable mal- let (Fig. 208). Operation.—Having arranged the patient in a position suitable for the convenience of the operator, administer an anaesthetic, apply Fig. 226.—Marshall's osteotrite. the elastic bandage if practicable, carrying it lightly over the site of the disease, and make a free incision down upon the carious bone; separate the soft parts with retractors; then, with the drills, gouge, osteotrite, etc., remove all the diseased structure. It is important to be able to determine the line between the healthy and diseased bone; and this is often very difficult. If the portions removed, when washed, present a whitish, grayish, or blackish appear- ance, and are porous and fragile, instead of being vascular, red, and tough, then the operation should be continued. If the gouged sur- faces bleed freely from numerous points, and have a normal firmness and color, then the operation should cease. It is important in gouging the extremities of bones to use extreme caution, or the joint cavity may be opened directly, or become second- arily involved. After the removal of the elastic constriction, all hemorrhage should be arrested, the wound washed thoroughly with a suitable antiseptic solution, good drain- age secured, the soft parts united, and dressed antiseptic- ally. Sequestrotomy.—This operation is employed to remove dead bone en masse, and is therefore applicable to necrosis. The additional in- struments necessary are small crown trephines, bone-cutting forceps of various shapes (Figs. 227, 228, and 229), gnawing forceps, small Fig. 22V.—Liston's straight forceps. Figs. 228, 229.—Liston's curved forceps. saws (Figs. 241, and 242, 230, 231) and periosteal elevators (Figs. 232 and 237), etc. There are two methods employed, depending on the nature of the case—viz., direct and indirect. 164 OPERATIVE SURGERY. The Direct Method.—Having detected the situation of the necrosed bone, and being satisfied, either from the long course of the disease, or by movement of the dead portion, that detachment has occurred, apply the elastic bandage, using care not to force deleterious matters Fig. 230.—Lente's saw. into the circulation, select a strong scalpel (Fig. 234), and connect the fistulous openings with each other, down to the bone ; choosing Fig. 231.—Langenbeck's key-hole saw. such openings, of course, as will cause the connecting incision to be consistent with good drainage, easy access to the diseased parts, and safety to the underlying structures. The surfaces of the incision Fig. 232.—Sayre's Figs. 233, 234.—Strong scalpels. Fig. 235.—Retractors. periosteotome. should now be separated with retractors (Fig. 235), to fully expose the openings in the involucrum. If the sequestrum can be drawn out of the opening with suitable forceps, it should be done carefully ; oth- erwise the reparative tissue upon which it rests will be injured, and the process of recovery deterred. If it be too large, or be interlocked with healthy bone, the opening must be enlarged sufficiently to admit of its withdrawal ; or, if this be impracticable, an incision through OPERATIONS ON BONES. 165 the periosteum should be made, corresponding to the long axis of the sequestrum. The periosteum should be carefully raised upon either side of the incision to permit the application of a small crown trephine, with which the involucrum should be perforated a sufficient number of times to admit the easy removal of the dead portion, either with or without the chiseling away of the irregular borders. The gnawing forceps, chisels, the mallet, and even small saws, may be used in lieu of or in conjunction with the trephine. Should there be but one sinus, and evidences of disease exist above and below it, the center of the incision should correspond to the sinus, if the anatomical relations will admit of it. It is necessary to use great caution in making these incisions in the vicinity of joints, or their synovial pouches will be opened. After the removal of the dead bone, the wound, through its whole extent, should be thoroughly cleansed, suitable drainage provided, the lips of the wound closed, and anti- septic dressing applied ; or, after washing, it can be lightly filled with oakum saturated with balsam of Peru, or carbolic acid and oil, and the whole confined in place by a mass of carbolized oakum, held in position by a roller bandage. In the latter instance it should be dressed frequently to secure proper cleanliness. If the antiseptic plan be employed, the rules applicable to the method should be strictly ob- served. When the portion of bone removed is large, or the remain- ing part is small and fragile, the limb must always be supported by a splint; otherwise it may bend or break, and thereby complicate the ultimate result. If the sequestrum be as yet unseparated from the healthy bone, it should be allowed to remain until the process of separation is com- pleted, when it can be removed. The indirect method is preferable when the bone is superficial and its disease progressive, as in ostitis of the lower jaw, clavicle, bones of the arm, forearm, or tibia ; in fact, all the long and many of the flat bones can be reproduced by this method. It consists in making a free incision down upon the diseased bone, through the surrounding periosteum, and separating the membrane by means of the handle of a scalpel, spatula, periosteal elevator, or any instrument of a like character. This must be done at intervals, and not extend beyond the diseased portion ; the length of the intervals will depend entirely upon the rapidity of the morbid process. This plan is necessarily te- dious, both in detail and in time ; yet sooner or later the dead bone can be raised from its new osseous trough, which will soon become filled, and ofttimes serve the purposes of its predecessor. The free incision necessary to expose the dying bone will provide good drain- age ; nothing is necessary other than this, than to keep the wound clean by ordinary means. Excision.—Excision of bone is a conservative operation, directed 166 OPERATIVE SURGERY. to the extraction of such portions of it as are inconsistent with its future usefulness or the symmetry of the part, together with the re- moval of the condition directly demanding the operation. It is em- ployed in lieu of the more radical measure—amputation. It may be directed to the articular extremities or to the shaft of a bone ; and, in either instance, it may be partial or complete. The articular extremi- ties or joints are excised on account of injury, disease, or ankylosis in a faulty position. In estimating the prognosis for life, the sur- roundings of the patient, his previous habits, present condition, and the existence of constitutional taints, must be considered; also the nature and extent of the cause demanding it. The prospective useful- ness of the limb will depend on the ability to leave the muscular attach- ments intact; and also upon the condition of the nerves that animate, and the blood-vessels that nourish them. If the patient be a manual laborer, or be one over-sensitive of a deformity, it is well then to con- sider if additional advantages can be derived from artificial limbs and appliances, when it may be deemed the wiser to sacrifice the offend- ing member for the relief afforded by amputation. The incisions pre- paratory to the necessary exposure of the parts to be removed should be free, and, when possible, be made in the long axis of the bone. They are often, however, varied, to suit the peculiar demands of the individual cases. They are likewise varied for the different joints, being in one instance longitudinal, in another U, H, or == shaped, according to the proposed extent of the operation and the contiguous anatomy of the part. In every instance, however, they should be made with a view to good drainage, when the same incision will ren- der the parts accessible, and not expose adjacent important struct- ures to unwarranted danger. Future usefulness being one of the most important factors to be gained, the insertion of all muscles, having especially defined functions, as flexion or extension, must, if possible, be carefully avoided. If it be necessary to divide tendons, they should be incised obliquely, the better to facilitate subsequent union. Should it be necessary to remove the bony surfaces, into which they or the ligaments are inserted, the periosteum covering these surfaces should be carefully peeled off, together with all tendinous attach- ments. All diseased and loose pieces of bone should be removed, to- gether with irregularities and isolated portions of articular cartilages. The synovial membrane should be preserved, unless it be diseased, and its diseased portions cut or scraped off. The removal of the entire shaft of a bone may be necessary on account of injury or disease, notably the latter. In such cases the incision should be free, and made over its most superficial aspect, provided that important struct- ures do not intervene ; the periosteum is then elevated proportion- ately to the extent of the disease, gradually or rapidly, as the circum- stances indicate, and the diseased bone removed, leaving, if possible, OPERATIONS ON BONES. 167 the epiphyseal extremities. If the epiphyseal cartilage be destroyed, the growth of the bone in its long axis will be interrupted. This is very important to observe in operations upon the bones of adolescents, since to destroy this cartilage will cause a subsequent shortening of the limb. The consultation of any standard work on anatomy will enable the surgeon not only to accurately locate the epiphyseal junc- tions, but likewise inform him of the age at which the shafts become united to their epiphyses. The time of operating must be governed by the condition of the patient, and also by the part to be operated upon.. If the patient be suffering from shock, reaction should take place prior to oper- Fig. 236.—Retractor. ative interference. Should inflamma- tion of the bone have occurred, good drainage should be established, and the operation deferred until the acute symptoms subside. If the operation be for necrosis, the diseased bone should be allowed to sepa- rate before the attempt is made. The instruments required for excision are varied in number and shape, and must be selected according to the peculiarity of the case. The knives should be broad and strong (Figs. 233, 234). The retractors (Fig. r .„, „ ,, noK, , n>1 v P Fig. 237.—Sands'periosteotome. Mb) must likewise be strong, and possess a hook-like curve, otherwise they will slip from the wound. A sharp-hooked retractor may be employed (Fig. 236). The periosteotomes, or elevators (Figs. 237, 232), vary in shape, but should possess a blunt, non-cutting edge ; and if compactness be de- sired, the elevator may be connected with the handle of the knife (Fig. 234). However, it is not so handy or efficient as the independ- ent instrument. These instruments must be used with care, other- wise the function of the periosteum will be destroyed, and may even be followed by sloughing. The bone-cutting instruments are forceps, and saws of various sizes and shapes. The straight bone forceps are the most available for general purposes. The blades should fit accu- rately, and be sufficiently sharp to make as clean a cut as possible. In order that bone intricately located may be reached, the blades are bent at various angles (Figs. 227, 228, 229). The gnawing forceps or rongeur are of inestimable value in removing bony projections. Bone-holding Forceps (Fig. 238) vary somewhat in their grasping and holding powers ; consequently the surgeon will be governed in his selection of an instrument by its suitability for the purpose. The varieties of saws are numerous, among which are the chain-saw (Fig. 168 OPERATIVE SURGERY 239), the straight saw, with an adjustable back (Fig. 241), and the curved, for right and left sawing. These are of use in removing por- Langenbeck's. Ferguson's. Farabceufs. Fig. 238.—Bone-holding forceps. tions of thin bones from flat surfaces. The chain-saw, as the name indicates, is composed of numerous links or sections, having a handle Fig. 239.—Chain-saw. for working it attached to each extremity. To apply the saw, remove the handle from the hook and carry it beneath the bone, with the cut- Fig. 240.—Chain-saw carrier. OPERATIONS ON BONES. 169 ting edge upward, by means of a thread and curved needle, or an in- strument known as the " chain-saw carrier " (Fig. 240) may be employed Fig. 241.—Lifting-back metacarpal saw. instead ; readjust the handle, and draw it from side to side at an angle of about 45° with the bone. It should not be jerked, or be allowed to kink, but should be kept taut while be- ing used, for fear of clamping or breaking it. This instrument is employed in divid- ing those bones which are nearly surrounded by the soft parts. Fig. 242 represents a saw of great practical worth. The blade is ad- justable, and its cutting surface can be turned in any direction ; it has therefore a universal application, which renders it su- perior to the chain-saw, except in isolated cases. The gouges, chisels, and mallet are required to thoroughly remove all diseased bone. They vary in size and shape, in order that the intricacies of the wound may be reached. The instruments to seize the fragments of bone are also variously shaped, to be better able to grasp them. The Surgical Engine.—This is the out- come of the dental engine, the former being the stronger and associated with suitably constructed knives, trocars, burrs, and saws. These instruments are connected by a hand- piece which is attached to a flexible wire cable that permits the easy holding and di- recting of their rapidly revolving surfaces. The rapidity of their action—two to three thousand revolutions per minute—lessens the pain and the injury done to important parts. The engine can be used with advan- tage in bone surgery. It is expensive and somewhat cumbersome, and therefore bet- ter fitted for hospital use than for general Fig. 242.—Szymanowski's saw. practice. The treatment of excision wounds is in nearly all instances sub- stantially the same. Rest and thorough drainage, together with strict antiseptic measures, constitute the basis of the future treatment. 170 OPERATIVE SURGERY. Rest can be secured by the various forms of splints, either movable or immovable in character. The older dressings of these wounds con- sisted of oakum, lint, marine lint, or a fine silken oakum, either with or without saturation with carbolic acid and oil, or balsam of Peru. If treated by this method, they should be dressed with sufficient fre- quency to prevent any septic infection, once daily being usually enough. If the antiseptic methods be adopted, the rules governing the readjustment of the dressings should be enforced. Excision of the Upper Jaw.—This operation is done for various diseases, connected either with the bone structure itself or the cavi- ties with which it is associated. In all instances the periosteum should be preserved, except those in which it is invaded by malignant disease. The special instruments requisite—in addition to those already enumerated for excisions—are a trephine, or a bone-drill and a strong pair of forceps to turn or twist the bone out of its cavity, together with forceps to draw the teeth in the line of section. The patient is anaesthetized and placed upon the back, either with the head slight- ly raised or markedly depressed. In the latter position the blood does not escape into the larynx, but into the upper and posterior part of the pharynx. This position, however, impedes respiration by undue stretching of the tissues of the anterior cervical region. However, this may be obviated, in a great degree, if the foot of the table be raised, as for the reduction of the abdominal contents by taxis. If the head be elevated, the blood can, with care, be kept from the larynx, either by constant sponging or tamponing the pharynx around a large catheter or rubber tube, or permitting the patient to be sufficiently conscious to dislodge it. Still another method is to confine the patient in a rocking-chair, which can be tipped forward or back- ward as circumstances require. The surest of all is to perform a pre- liminary tracheotomy, and then tampon the floor of the pharynx. This is not as a rule necessary unless the operation be complicated with a very vascular morbid process requiring a separate removal. If the important associated anatomy be carefully considered before beginning the operation, it will save much time and not a little blood. In complete removal, the bony connections which must be divided are : 1. With the malar, below the outer angle of the orbit. 2. With the fellow of the opposite side in the roof of the mouth. 3. The nasal process of the bone, with its body below the inner angle of the orbit. 4. The slight connection between it and the palate bone and pterygoid processes of the sphenoid. The internal maxillary artery in the spheno- maxillary fossa and the branches of the facial artery running through the external soft parts are the only vessels that will cause troublesome hemorrhage. Steno's duct must be avoided, as it runs from the pa- rotid gland to empty into the mouth opposite the second molar tooth, on a line extending from the lobule of the ear to midway between the OPERATIONS ON BONES. Ifl border of the lip and the ala of the nose. The superior branches of the seventh pair of cranial nerves may be divided unnecessarily if the course Fig. 243.—Linear guides for removal of upper jaw. or extent of the incisions be too great. All anticipated complications should be carefully studied, and provisions made for their treatment. Loss of blood, however, is the only one in addition to the shock com- mon to all operations that requires close attention. Hemorrhage from the facial and internal maxillary arteries, while often profuse, can be easily controlled. The Lines of Incision.—They may be made within or without the buccal cavity. To attempt the removal from within is too tedious, the space being limited and the ability to control hemorrhage entirely inadequate. At the present time external incisions only are practical. These can be classed as the outer, and the median. The former (Lizar's) com- mencing at the angle of the mouth and passing in a curved course upward and outward to the malar process (Fig. 243, a) ; if more room be needed it may be supplemented by an incision through the upper lip to the nostril, also by extending the first. This incision exposes Steno's duct and the branches of the seventh nerve to injury, and is followed by a conspicuous scar. Liston made an incision from below the external angular process of the frontal bone to the angle of the month ; if necessary, a sec- ond was also made along the zygoma joining the first (Fig. 243, c), and even a third from the nasal process of the maxilla downward to 172 OPERATIVE SURGERY. the lip in the median line. Velpeau, like Lizar, made a single curved incision with the convexity downward from the angle of the mouth to the malar bone, and even to the angle of the orbit if necessary. The last (Ferguson's), and an admirable one, is made at the middle of the upper lip, and, following the furrows between the cheek and nose, terminates about half an inch below the inner angle of the eye (Fig. 243, b). To this may be added an incision of an inch or so in length, extending outward half an inch below the orbit, and at a right angle with the vertical one, or it may be extended to the external angle of the orbit and the zygoma if necessary. In this incision the coronary and angular arteries only are divided. Operation by the Median Incision, with Removal of the Whole Bone.—The middle incisor tooth corresponding to the side to be oper- ated upon is drawn, and the facial artery compressed on both sides by an assistant. The incision is begun at the border of the lip, and in or- der to prevent blood from entering the mouth, it is not carried through it until later, from the upper attachment of the lip, through the re- mainder of the course, the incision is rapidly made down to the bone, and the flap dissected outward as far as the malar bone above, and the tuber- osity of the maxilla below ; during the dissection the bleeding points are controlled by the fingers of the assistant or by the serrefine forceps. All vessels should be ligated with catgut before the bone is removed. The cartilage of the nose is separated from the bone and turned inward, the edge of the orbit gained, and the periosteum on the floor separated and pushed backward and upward by means of an elevator or han- dle of a scalpel to the border of the spheno- maxillary fissure. The malar process is now divided by sawing, or cutting through it with bone - forceps, from the outer extrem- ity of the sphenomax- illary fissure. The thin floor of the orbit is divided with a scalpel from the spheno-max- illary fissure obliquely forward and inward, and the nasal process severed with forceps (Fig. 244). The mucous membrane of the roof of the mouth is then divided transversely in- ward to the center, on a line with the last molar tooth, then from the Fig. 244.—Division of processes of superior maxilla. OPERATIONS ON BONES. 173 center forward, in the median line, to the incisor teeth. The hard palate is divided at the side of the septum, corresponding to the bone to be removed, by a saw or bone-forceps, and the bone seized and pressed downward to break up its posterior connections, after which it is raised and twisted slightly from side to side and pulled out, bringing with it some portions of the palate bone and pterygoid process of the sphenoid, together with the muscular fibers connected with them. If the mucous membrane of the mouth be not diseased, it can be saved by making an incision through it along the alveolar border, and pushing it inward together with the periosteum to the median line. After the removal of the bone the periosteum can be stitched to the side of the cheek. Excision Below the Floor of the Orbit.—After the exposure of the external surface of the superior maxilla, as in the preceding method, perforate the anterior wall of the antrum with a drill or trephine; then, with the bone forceps or saw inserted into the opening, divide the bone through into the nasal fossa, and separate it from its outer connections by sawing or cutting through the malar bone. Aside from this the steps of both are similar. After the operation the wound is washed with carbolic acid, and all bleeding points checked either by ligature, pressure, or cautery, the first being the best. The external incision is then closed with sutures or pins, and readily unites in three or four days. The raw surfaces within should be kept thoroughly cleansed while repair is taking place. These cases make a satisfactory recovery from the opera- tion, although some deformity always remains. The stitches are removed from the soft parts the third or fourth day, un- ion, as a rule, being complete. The results of this operation are good, so far as im- mediate loss of life is concerned. About one in five or six die. If the removal be done for malig- nant growths, the prognosis for ulti- mate recovery is un- favorable. pIG. 245.—Subperiosteal excision of upper jaw. Subperiosteal Excision.—This can be done with any of the median incisions, but an 174 OPERATIVE SURGERY. external one is preferred by some (Fig. 245). The external incision is made from the middle of the malar bone to a point on the upper lip, one third of an inch from the angle of the mouth (Oilier). It is some- times necessary to make a second incision from the middle of the lip upward to the nose (dotted line, Fig. 245), as in the preceding oper- ation. The mucous membrane on the external surface of the alveolar process is divided down to the bone ; beginning at the line of junction between the lateral incisor and canine teeth and carried backward to and around the posterior molar to the inner surface of the alveolar process, forward parallel with the external incision to a point opposite the commencement of the external incision, then obliquely backward and inward on a line corresponding to the intermaxillary suture of that side, to the median line. The anterior extremities of the external and internal incisions are now connected with each other by a transverse incision, carried on a line extending between the lateral incisor and ca- nine teeth. The periosteum is then peeled off from the external and orbital surfaces of the bone, and also from the inner surfaces of the al- veolar process, and the hard palate of that side. The nasal and malar processes are divided as before, the canine tooth drawn, and the inter- maxillary bone separated, together with the hard palate of the maxilla to be removed, from the contiguous bone, by the chisel, saw, or for- ceps. The maxilla is then twisted out, and the periosteum from the inner and outer surfaces of the alveolar process united. Fig. 246.—Removal of both superior maxillae. The superior maxillse may be removed simultaneously by either of two methods. 1. Make an incision from each angle of the mouth OPERATIONS ON BONES. 175 to the middle of the malar bone on the respective sides (Fig. 246, a), and dissect upward the intervening flaps; or, 2, make a vertical one (Fig. 246, b) along the ridge of the nose through the lip, beginning at a point one fourth of an inch below the lower border of the orbit (Dieffenbach). To this may be added a transverse incision one fourth of an inch below, and extending to opposite the middle of each orbit, across the upper end of the vertical incision (dotted line, Fig. 246) ; the outer bony attachments are divided as in the single operation ; the nasal processes are divided either by forceps or the saw, and both bones removed at once—not separately. In all operations for the complete removal, the superior maxillary nerve should be divided as far back as possible. The bones may be removed separately in the manner de- scribed for the removal of a single superior maxilla. Results.—About thirty per cent die from whom both bones are removed simultaneously. Excision of the Inferior Maxilla.—The operations on the lower jaw require no additional instruments ; the precautions referable to the patient are almost of equal importance, and the contiguous anatomy is even more important than for the upper. The facial artery runs beneath and across its lower border and on its outer surface at the anterior border of the masseter muscle ; the parotid gland lies behind the ramus, and often overrides it. The external carotid artery, as it passes through the gland, is closely associated with its posterior bor- der. The internal maxillary artery runs closely behind and to the inner side of the neck of the condyle. The inferior dental artery runs along the inner surface of the ramus to enter its canal. The superior division of the seventh pair of nerves passes across the outer border of the neck of the condyle. Steno's duct passes across the masseter muscle to its opening opposite the second molar tooth, on a line par- allel with and about an inch below the lower border of the zygoma. The lingual nerve runs along the inner surface of the ramus, close to the bone just below the last molar tooth. The genio-hyo-glossus muscle is attached to the superior genial tubercles, and, if incautiously detached, will permit the tongue to fall backward and close the glottis. It is very important, when possible, to preserve the attachments of the muscles of mastication, on account of their action on the resultant tissues. The operation may be directed to a complete or partial removal of the bone. A partial removal may include any fractional portion of it. The incisions for the removal may be made within the mouth or on the external surface. If the whole or a lateral half is to be re- moved, an external incision must be made. The portion in front of the molar teeth, and even in front of the ramus, can be excised by in- ternal incisions alone ; the latter is, however, often attended by vex- atious difficulties, and is hardly warrantable, except in selected cases. 176 OPERATIVE SURGERY. The ramus and portions of the body behind the teeth can be removed through an external incision without opening into the buccal cavity, provided the periosteum be carefully raised from its surface. In the same manner the body, or any portion of it, may be taken away if the teeth be absent. If the teeth be present, the periosteum may be care- fully detached, and the bone with the teeth removed, after which the openings of the buccal cavity, caused by the withdrawal of the teeth, can be closed by sutures applied internally. If the jaw be the seat of phosphoric or other necrosis, it may be gradually enucleated, through an external opening, from its surrounding involucrum, by the indi- rect method, and the teeth may even remain in the new growth. Un- fortunately, however, when processes of a malignant nature call for the operation, these conservative methods are of no avail, since the operation must be directed to the removal of all the diseased tissues. When possible, the incision in the buccal lining should be closed, and the wound drained externally. This will keep the mouth clean, and prevent swallowing the discharges. Excision of the Central Portion.—Pass a stout ligature through the tongue well behind its tip, to prevent tearing out, and tie the ends to form a loop, which will be convenient for keeping it from falling backward. The assistant stands behind the head of the patient, holds the loop firmly, at the same time compressing the facial arteries where they pass across the jaw ; or seizes the lower lip at the angles between the thumbs and fingers, rendering it tense, and at the same time arrest- ing its circulation. The operator, standing in front, makes a vertical incision through the median line down to the bone, extending to the lower border of the symphysis mentis, raises the periosteum from its surfaces, if practicable, to the extent of the proposed section, draws a tooth at each point where the bone is to be divided, saws it at these points, and draws the fragment forward and separates the attachments of the muscles as closely as possible to their insertion. The flaps are then united with silver wire, extending through the mucous membrane. The vermilion border of the lip is carefully adjusted, and united with pins or silver sutures. If the tongue fall backward, its severed mus- cular attachments can be drawn forward, and connected with the in- cision in the median line by a deep suture passed through the lip. The bone can be easily reached through a curved incision made along its lower border, or by an internal one corresponding to the fold of the buccal membrane. The lip is depressed over the symphysis mentis, and the bone is removed. Excision of the Lateral Portion of the Body.—-Make an external incision along the under border of the portion to be removed, down to the bone. If necessary, the incision may be turned upward at a right angle toward but not through the lip. If the condition of the parts will permit, the periosteum is reflected off, the bone divided in front, OPERATIONS ON BONES. 177 Fig. external to insertion of the genio-hyo-glossus muscle, and if possible turned outward, and the tissues separated back to the point of posterior section ; it is then removed with a chain-saw, and dressed as before. Excision of Half of the Lower Jaw.—Commence the incision about an inch and a half below the arch of the zygoma, and carry it downward along the posterior border of the ramus, and beneath the body of the jaw to the sym- physis mentis, carefully exposing the facial artery and tying it. If the operation be for necrosis, this incision will be sufficient; if for other disease, the lower lip is cut perpendicularly through its center to meet the longitudi- nal incision (Fig. 247). The bone is exposed in front by peel- ing off the periosteum or other- wise, and sawn through just to the outer side of the insertion of the genio-hyo-glossus muscle if possible, the end pulled outward, and the remaining attached tissues separated either by cutting or by a periosteotome, back to the begin- ning of the incision. Depress the fragment forcibly, and if possible detach the temporal muscle with scissors or the periosteotome, then turn the bone outward, and divide the insertions of the pterygoid muscles in the same manner, care- fully avoiding cutting the lingual nerve, draw the bone forward for- cibly and twist it from its socket (Fig. 248). If it be impossible to accomplish its re- moval in this manner, extend the incision up- Fio. 248.—Severing connections of inferior maxilla. ward to the neck of the 12 247.—Linear guide for removal of lialf the lower jaw. 178 OPERATIVE SURGERY. bone (dotted line, Fig. 247), avoiding if possible the division of Steno's duct and the cervico-facial branch of the seventh pair of nerves, and enucleate the condyle. In this situation the condyle must be closely followed, otherwise the internal maxillary artery may be injured, as it passes immediately behind it. If the primary incision be sufficient to expose the bone above the seat of the disease, it should be sawn through at this point and the upper portion allowed to remain. Excision of the Entire Lower Jaw.—Remove the left half first, or the right if it best suits the convenience of the operator, in the manner before described. A ligature is then passed through the tongue, given to an assistant, and the remaining half of the bone excised in a similar manner. Arrest all hemorrhage, and close the wounds with sutures in such a way as to accurately coaptate the divided buccal borders. In all situations, when the nature of the disease will permit, the periosteum should be reflected by a careful yet vigorous use of the elevator. The insertions of ligaments and tendons will offer the only obstacle, and these should be carefully detached by a sharp knife, that a continuity of the periosteal and fibrous tissues may remain. The periosteum in young subjects may reproduce enough bony material to give a fair outline to the face and serve an important func- tion in mastication. If bone be not reproduced, the periosteum will furnish a firm fibrous base, which may be utilized for artificial appliances. If the anterior portion of either or both sides be removed, the gap may be filled in by an artificial dental appliance, which will often happily maintain the symmetry of the face and become useful in mastication. Excision of the Alveolar Process.—When the extent of the disease will permit, the alveolar process can be removed down to the body of the jaw through either an external or internal incision, the former be- ing the better. The diseased part is then removed, and the wound closed as before. After recovery, the body of the jaw will form an excellent foundation for a compensatory dental appliance. Whenever the disease is malignant, the periosteum should be removed with the bone, and care taken that none of the diseased membrane remains in the wound. It is also necessary in such cases to remove all associated structures when diseased—such as glands, floor of the mouth, and even the tongue itself. Results.—Out of two hundred and forty-six excisions in the con- tinuity, forty-six died. Of one hundred and fifty-three disarticula- tions of one half the bone, thirty-six died. In twenty operations for removal of the entire jaw, one died. It will be seen that death has followed in twenty per cent, of all the cases. Pyaemia, erysipelas, and exhaustion were the principal causes. Operation for Anchylosis of the Inferior Maxilla.—This consists in establishing a false joint in front of the cause of the immobility, which is usually dependent on cicatricial contraction, irreducible dislocation, OPERATIONS ON BONES. 179 or anchylosis. The removal of a wedge-shaped piece from the lower border of the jaw, or from the alveolar process, has been practiced ; or a transverse section of the ramus with a sharp chisel introduced through the mouth, or even fracture of the neck when the condyle is involved, has relieved the condition. Operation for Removal of a Wedge-shaped Piece (Esmarch).— Make an incision two inches in length down to the bone, along the lower border of the jaw, beginning at or in front of its angle, depend- ing upon the location of the cause of the immobility. Avoid or tie all important vessels in the course of the incision ; expose both surfaces of the bone up to the summit of the alveolar process, and pull a tooth if necessary. Divide the bone with a chain-saw at one extremity of the exposed surface, force the other extremity through the wound, and remove the wedge-shaped piece with the rongeur or saw, the base of which should not exceed a third or half an inch. While the patient is still under the influence of the anaesthetic and before the wound is closed, ascertain the distance the liberated portion can be separated from the upper jaw with moderate force. Provide suitable drainage, close the wound, and prevent union of the bones by passive motion. Rizzoli, of Bologna, recommends a simple section of the bone in- stead of the removal of a wedge-shaped piece ; however, the results of this method do not warrant its substitution for the former. If the cause of the immobility be due to anchylosis of the temporo-maxillary articulation, the condyle should be removed, or the ramus be so di- vided as not seriously to impair the functions of the masseter muscle, that is, divided beneath that muscle. The division of the neck of the bone by a straight chisel introduced through the mouth (Grube) has been practiced. After either operation it may be necessary to divide the masseter muscle before the full benefit can be experienced from the di- vision or the removal of the bone. If it be determined to remove the condyle, a curvilinear incision, corresponding to the location of the por- tion of bone to be removed, is made down to it, when, by means of a chisel, saw, or forceps, the neck of the bone is divided at the proper place, the fragment turned outward by forceps, its attachments divided, and the bone removed. Passive motion should follow the same as before. Excision of the Sternum.—No definite plan for this operation can be outlined. The form and length of the incisions must be governed by the location and extent of the disease. The diseased bone should be freely exposed, and removed in the usual manner. Care must be observed, else the pleural cavity will be opened. When possible, sub- periosteal excision should be done, as the bone is quite readily repro- duced. The entire sternum is reported to have been removed by Konig on account of a sarcomatous tumor involving its structure, and, even though the pericardium and pleural cavity were opened, the pa- tient ultimately recovered. 180 OPERATIVE SURGERY. Results.— Partial excision, cautiously done, results most favorably; only one in eighteen died. Excision of a Portion of a Rib.—This may be done for the removal of necrosed bone, or to make a permanent opening into the thorax for the escape of pus. If for diseased bone, make an incision in the mid- dle of the long axis of the rib of sufficient length to include the dis- eased portion. This may be crossed at the middle by a transverse incision. Separate the periosteum along with the superimposed tis- sues, liberate the bone, and raise it from its bed. If the sequestrum be not loose, time should be allowed for its separation. If the opera- tion be for pyo-thorax, select the sixth or seventh rib ; make an incis- ion in a line with the axilla about two or three inches in length down upon the middle of the rib, through the periosteum ; bisect this by a horizontal one of the width of the rib, expose the bone on both sur- faces by raising the periosteum together with its surrounding tissues, being careful as yet not to open into the pleural cavity; exsect one half or three fourths of an inch of the bone, dividing it with a chain- saw. If the intercostal artery, which lies beneath its lower border, be cut, tie it; then make a suitable opening through the intervening structures into the pleural cavity. It is well to make the first incision corresponding to the long axis of the rib, and thus the more surely avoid the intercostal vessels and nerves. The wound should be dressed antiseptically. Excision of the Clavicle.—This operation is performed for necrosis and for morbid growths of the clavicle. The patient is placed on the back, with the shoulders elevated from the table and the head turned to the opposite side. Contiguous Anatomy.—The muscular and ligamentous attachments of the clavicle must be carefully studied, for it is by a knowledge of them that the surgeon is enabled to raise the bone safely from its more important relations. In front. Attachments of— Pectoralis major muscle. Sterno-mastoid muscle. Trapezium and deltoid muscles. Above. External jugular vein. Branches of thyroid axis. i i Below. Subclavian artery. ( Clavicle, j- Cephalic vein. Brachial plexus. Behind. Internal mammary artery—sternal half. Subclavian vein, " " External jugular vein. Innominate vein at the right. Thoracic duct at the left. Pleura. OPERATIONS ON BONES. 181 The intimate association of the clavicle to important arteries, veins, nerves, etc., surrounds its removal with great difficulties and dangerous complications; especially, if it be attempted for a well- developed malignant or other morbid growth. With the patient in the proper position for the operation, the foregoing plan shows the important anatomical relations of the clavicle. The whole or a portion of the bone can be removed. If the whole bone is to be removed, it may be raised by its scapular extremity, or divided at its middle, and each half taken away separately. Excision of the entire Clavicle.—Anaesthetize and place the patient in the position above described ; if the operation be for necrosis, make an incision the whole length of the bone parallel with its long axis. If necessary, a short transverse incision is added; expose the clavicle, divide the periosteum, and with the elevator enucleate the diseased bone from the surrounding tissues. The clavicle can be divided through the center and each half removed separately, or the acromial end can be detached and the entire bone raised from without inward. In either instance, the articular ends and their connecting ligaments should be preserved if possible. If the involucrum be weak and liable to bend or break after the bone is removed, the shoulder must be held outward, backward, and upward by means of the method employed in treatment of fracture of that bone. The indirect method of sequestrotomy can be performed in some instances. If the operation be for the removal of a tumor of this bone, espe- cially of one acutely malignant, and involving any considerable portion of its surrounding tissues, it is certain to be an exceedingly tedious and bloody procedure. The smaller the size of the tumor and the less its vascularity, the easier will be its removal. Operation.—Make an incision in the long axis of the bone, from its sternal to its acromial extremity ; if necessary, this is crossed by a vertical incision, extending from the posterior border of the sterno- mastoid muscle to the upper third of the pectoralis major muscle. Make these incisions as deep as the nature of the growth will permit, and dissect the flaps from the tumor; separate the insertions of the deltoid and the trapezius muscles on a director, cutting them either with a knife or strong curved scissors, being careful to avoid the cephalic vein which lies at the inner border of the deltoid muscle. Divide the coraco- and acromio-clavicular ligaments; raise the acro- mial extremity of the clavicle, and thus elevate the morbid growth, which should then be cautiously separated from the surrounding tis- sues. The nearer the approach to the sternal extremity of the clavi- cle, the greater will be the necessity for caution, since the growth may be connected with the important structures located in this situation ; 182 OPERATIVE SURGERY. finally, divide the insertions of the sterno-mastoid and the pectoralis major muscles, and rhomboid ligament, and carefully disarticulate the sternal extremity while the tumor is lifted upward and inward to- gether with the clavicle. Either extremity of the clavicle may be excised by making a cru- cial incision down to the bone corresponding to the portion to be removed, exposing and dividing it with a chain-saw, and removing the fragment with the same precautions as before described. The results of the operation of complete excision have been quite favorable ; of thirty-four cases, six proved fatal. Exhaustion, due to loss of blood, erysipelas, etc., were the principal causes of death. Partial excisions give a death-rate of about eight per cent from all causes. During the operation the entrance of air into the veins of the neck is especially to be guarded against. Excision of the Scapula.—This bone is excised on account of gun- shot injuries, necrosis, and morbid growths. The whole bone may be removed, or its body, angles, and spine may be removed separately. Its contiguous anatomy is extensive, but not of the dangerous character of that associated with the clavicle. To its spine, borders, and surfaces numerous and powerful muscles are attached. At the upper border are found the supra-scapular vessels and nerves ; the posterior scapular artery passes down its vertebral bor- der ; while at the axillary border the subscapular, and dorsalis scap- ulae arteries, and even the axillary artery itself, and the brachial plex- us, are in close connection with the bone. Excision of the entire Scapula (Fig. 249).—Make an incision from the tip of the acromion process along the spine to the posterior border of the scapula, a, b. Join it by a second incision extending from near the middle of the spine, c, to the inferior angle of the bone; dissect up and turn aside the flaps thus formed. Divide the attachments of the deltoid and trapezius; disarticulate the acromio-clavicular articulation; secure the subscapular artery ; divide the ligaments and tendons around the glenoid cavity ; raise the cora- coid process and carefully sever its ligaments and muscular attach- ments ; raise the scapula by the inferior angle and divide its remain- Fig. 240.—Excision of entire scaoula. OPERATIONS ON BONES. 183 ing muscular attachments with a knife or strong pair of scissors, care- fully avoiding the subscapular and posterior scapular vessels; tie all the bleeding points ; wash with an antiseptic solution ; thoroughly drain and close the wound, and dress antiseptically. Sir W. Fergu- son and Mr. Pollock thought it better to raise the vertebral border of the scapula first, that the subscapular artery might be the better con- trolled. Spence thought that the anterior angle should be raised first, the better to control the subclavian artery. All danger of hemorrhage during the operation is easily obviated by pressure on the subclavian artery above the clavicle by means of a short crutch or a large key, also by direct pressure on the subclavian after the anterior angle of the scapula is elevated. The results of this operation are good. Of sixty-six cases of com- plete excision, fourteen died. The rate of mortality from the opera- tion is about eight per cent; it is greater when due to traumatic causes than when due to disease. Excision of the Body of the Scapula (Fig. 250).—Make an in- cision the whole length of the spine, a, b; begin a second incis- ion at the posterior superior spine, and carry it along the posterior border of the bone to its inferior angle, c, d; dissect the resulting triangular flaps from their corre- sponding fossae, carefully avoiding the supra - scapular artery and nerve ; saw through the acromion process close to the body, divide the muscles attached to the anterior and superior borders of the scapula; raise the bone upward and saw through the anterior superior angle behind the coracoid process, turn the bone outward and sever its posterior connections with a knife or strong scissors. The Acromion Process and Angles of the Scapula may be sepa- rately removed. To remove the former, make an incision, which may be curved if necessary, along its upper border—expose the process, divide the muscles attached to it, and with a pair of bone-forceps remove the desired amount. This process can be re- moved by making a curved or crucial incision over it; exposing its upper surface, dividing the muscles connected therewith, disarticulat- ing the clavicle, and removing the requisite amount with a chain- saw. To remove an angle, make a V-shaped incision over it, dissect off Fig. 250.—Excision of body of scapula. 184 OPERATIVE SURGERY. the flaps, separate the muscles from the bone, and divide the exposed portion with the bone-forceps. Subperiosteal Excision of the Scapula (Oilier) (Fig. 251).—Make an incision from the outer extremity of the acromion process along the spine of the scapula to its posterior border, a, b. Make a second in- cision from the posterior superior angle of the scapula along its poste- rior border, crossing the former, to the inferior angle, c, b, d. Sever the muscular attachments to the acromion process and spine ; divide the periosteum at the posterior border of the scapula between the attachments of the rhomboideus major and infra-spinatus muscles, and separate it from the infra-spi- nous fossa. Remove the muscular attachments of the superior border Fig. 251.—Subperiosteal excision. of the scapula. The periosteum is then raised from the supra-spinou3 fossa, being careful to not injure the supra-scapular vessels, as they pass in close contact with the supra-scapular notch ; disconnect the muscles attached to the borders of the scapula, closely hugging the bone; raise it upward by its inferior angle, denude the subscapular fossa, leaving its periosteum connected with the subscapularis muscle; lib- erate the posterior border, allowing its cartilaginous portion to remain —when present. Turn the bone upward and forward, and remove the remaining periosteum from its under surface up to the neck of the scapula, and divide the neck with the chain-saw. If the extent of the disease will not permit this, the neck can be enucleated, leaving the ligaments connected with the periosteum. Excision for Malignant Groivths.—Make an incision from the pos- terior superior angle to the lower border of the tumor, carrying it downward, forward, and inward, with the convexity posteriorly. A second incision, beginning five inches or so in front of the preceding incision, is carried downward and backward, crossing the other at or near its middle, and terminating at the lower border of the growth. The flaps are then reflected from the tumor, and the muscular at- tachments are separated from the spine of the scapula, and the acro- mion process sawn through behind the clavicle; expose the su- perior and posterior borders of the scapula, and free them of their attachments; raise the bone upward and forward by its posterior border, and sever the serratus magnus muscle from it; free the axillary border, and divide the neck of the bone with a saw, if prac- OPERATIONS ON BONES. 185 ticable. When necessary, complete the entire removal by disarticula- tion. It is not possible to lay down definite rules to govern the number, extent, or direction of the incisions ; each of these must depend on the size and situation of the growth, together with the amount of bone to be removed, and the ease and safety with which it can be done. After the removal, arrest hemorrhage, provide good drainage, unite the cut surfaces, and dress antiseptically. The results of the operation are flattering : nineteen per cent died from entire removal of the scapula due to disease. The mortality was twenty-six per cent in partial excisions for disease, and about twenty per cent when done for injury. Excision of the Humerus.—The humerus can be removed entirely or in part. The Important Associated Anatomy.—The insertions of the mus- cles acting upon the upper end of the bone, the course of the superior profunda and circumflex arteries, the relations of the circumflex, musculo-spiral, and ulnar nerves ; the points of insertion of the liga- ments of the joints, together with the connections of the important muscles, must be carefully considered before attempting the operation. This oper- ation has been done for the relief of old dislocations, caries, necrosis, gun- shot injuries, arthritis, malignant dis- ease, etc. Excision of the Upper End of the Humerus (Langenbeck). — Place the patient upon the back, with the shoul- ders raised; make an incision about four inches in length downward from the anterior border of the acromion process, close to its articulation with the clavicle, in the line of the bicipi- tal groove (Fig. 252). The bone at this region is quite superficial ; liber- ate the long head of the biceps tendon from the groove, by carrying the point of the knife upward in the groove at the outer side, through the capsule to the acromion, and raise the tendon out of the groove (Fig. 253); rotate the arm outward and divide the subscapu- laris tendon and inner portion of the capsule; then rotate the arm inward, and cut the external rotators Fig. 252.- -Excision of upper end of humerus. 186 OPERATIVE SURGERY. and posterior portion of the capsule (Fig. 254); force the head of the bone through the opening in the soft parts (Fig. 255), seize it with a strong pair of forceps, divide the inferior portion of the capsule, and remove the head of the bone with a chain- or a small straight saw. Fig. 253.—Raising tendon. Fig. 254.—Attachments to tuberosities of humerus. a. Teres minor muscle, b. Infra-spinatus mus- cle, c. Supra-spinatus muscle. d. Subscapu- laris muscle. /. Tendon of long head of biceps muscle in the groove. Subperiosteal Excision of Head of Humerus (Langenbeck).—Expose the bicipital groove and split up the capsu- lar ligament as in the preceding opera- tion. Divide and raise the periosteum from the inner border of the bicipital groove, passing inward and separating it together with the subscapu- laris and the fibrous capsule from the lesser tuberosity. Rotate the humerus outward and complete the separation to the required extent with the elevator and knife ; rotate the arm inward, displace the ten- don of the biceps to the inner side of the head of the humerus, and separate the periosteum from it in connection with the capsule and the insertions of the external rotators, being very careful not to sever its connection with the bone below. To force the head of the bone Fig. 255.—Sawing head of hu- merus. OPERATIONS ON BONES. 187 through the external opening is practically impossible without de- stroying the periosteal connections; it is necessary, therefore, to divide the bone in its position with a chain or nar- row-bladed saw. Partial removal of the upper extremity of the humerus is often necessary on account of disease or injury. The variety and extent of the incisions to reach the part must be gov- erned by the amount of the disease. Either the vertical, V- or U-shaped incision can be selected as best suits the exigencies of the case. Excision of the Glenoid Angle of the Scap- ula.—This operation is only applicable to those conditions of injury or disease that are limited to the glenoid articular surface of the scapula. If a penetrating wound exist, its course should be followed to reach the bone ; if not, then a curved incision is made around the posterior border of the acromion process dividing the fibers of the deltoid, and expos- ing the posterior and upper surface of the joint (Fig. 256). A second incision is then made, commencing at the center of this one, at the upper margin of the glenoid cavity, and, passing downward through the capsule, upon the center of the greater tuberosity, between the tendons of the supra- and infra-spinatus muscles through the deltoid in the di- rection of its fibers. Open the wound widely by means of retractors and divide the tendons of the biceps at their origin ; separate the periosteum from around the neck of the scapula, if possible leaving the attachments of the capsular ligaments. Cut through the exposed bone with a chain-saw, and remove it carefully to avoid injury to the periosteum. Excision of the Shaft of the Humerus.—In this operation, unless great caution is observed, the musculo-spiral nerve and the superior profunda artery will be injured in their course along the musculo- spiral groove, as well also as the circumflex nerves and vessels, if the incision be extended (Fig. 257) upward too far. The upper portion of the shaft is easily exposed by making an incision of sufficient length through the outer surface of the deltoid, commencing at its lower third and dividing it carefully upward, to avoid the circumflex nerve and artery ; the bone is then denuded of its periosteum, or the morbid growth connected with it is circumscribed and removed. If the lower portion of the shaft is to be operated upon, make the incision along Fig. 256.—Excision of gle- noid angle. 188 OPERATIVE SURGERY. the outer border of the brachialis anticus muscle, carefully avoiding the musculo-spiral nerve ; expose the bone and remove it as before. Fig. 257.—Musculo-spiral and circum- Fig. 258.—Relation of ulnar nerve flex nerves. to elbow-joint, a. Inner condyle of humerus, b. Ulnar nerve, c. Olecranon process. Excision of the Lower Extremity of the Humerus.—The relation of the ulnar nerve (Fig. 258, b) to the internal condyle, a, and of the brachial artery to the anterior surface, must not be forgotten. Make an incision on the posterior and external surface of sufficient length to thoroughly expose the bone ; elevate the periosteum and divide the bone with a chain-saw; pull the upper end of the fragment down- ward and disarticulate it from without inward. If it be necessary to remove the entire humerus, make incisions as if to remove the upper and lower portions, observing the same precau- tions relative to the anatomy of these parts. The musculo-spiral nerve in this operation is to be most cautiously avoided. In all the preceding operations, substantially the same after-treat- ment is required : arrest the hemorrhage, irrigate the exposed surfaces with an antiseptic solution, provide drainage, close the lips of the wound, envelop the entire limb with antiseptic dressing, and place it OPERATIONS ON BONES. 189 ! ,1 ' -—1 '. upon a splint affording an easy support at the proper angle. Extension is often necessary to maintain the limb at a suitable length during the healing process. The results depend much upon the nature of the injury, the period of the operation, and the employment of antiseptics. Of gun-shot wounds of the shoulder-joint requiring excision, about thirty-five per cent die; the rate of mortality be- ing increased when the inflammatory stage exists at the time of operation. When excised for dis- ease eighty-two per cent recovered, of which the limb was useful in three fourths of the cases. Thorough antisepsis will lessen this death-rate at least fifty per cent. Excision of the Elbow-Joint (Huter).— With the forearm extended make a slightly curved in- cision about an inch in length down upon the tip of the internal condyle, and carefully separate the muscular and ligamentous at- Fig. 259—Hitter's in- cision. Fig. 261.—Langen- beck's incision. Fig. 262.—Liston'a incision. Fis. 260.—Ligaments of elbow-joint. tachments to the condyle ; make a second longitudinal incision from three to four inches in length down to the head of the radius (Fig. 259). Draw aside the soft parts and cut the exter- nal lateral and orbicular ligaments (Fig. 190 OPERATIVE SURGERY. 260). Expose the head of the radius and cut it off with a saw or bone-forceps. Separate the capsular ligament from its attachments on the anterior and posterior surfaces of the humerus ; force the ex- tremity of the bone out of the external wound. This movement admits of its division, and at the same time raises the ulnar nerve from its bed and away from the bone. Saw off the lower end of the humerus, and carefully expose and remove the olecranon. Subperiosteal Excision of Elbow-Joint (Langenbeck).—Make a lon- gitudinal incision down to the bone, three or four inches in length, a little to the inner side of the middle of the olecranon process, about two thirds of its length extending below the tip of the olecranon, carefully avoiding the ulnar nerve (Fig. 261). Remove the periosteum from the portion of the olecranon process and ulna at the inner side of the incis- ion. Separate by short parallel incisions the attachments of the inner half of the triceps tendon to the olecranon process. Push the tissues at the internal condyle, together with the ulnar nerve, inward toward the tip of the condyle, and elevate the periosteum from the inner con- dyle sufficiently to separate the internal lateral ligaments and the at- tachments of the muscles from the bone, and leave them connected with the periosteum. The liberated tissues are now permitted to return to their former position, and the outer portion of the tendon of the triceps is drawn outward and disconnected from the olecranon process by short transverse incisions, closely hugging the bone and allowing it to remain continuous with the periosteum which is reflect- ed upon the inner surface of the olecranon and shaft of the ulna; expose the external condyle by separating the capsular ligament at its attachment, above the trochlea and capitulum ; the tissues, including the detached periosteum and tendon of the triceps, are separated well from the bone by retractors. Flex the forearm and force the extremi- ties of the bones through the opening ; saw off the head of the radius, then the lower end of the humerus, and finally the olecranon process. It is necessary to remember in all cases of excision about the elbow- joint, to respect the insertions of important muscles, such as those of the brachialis anticus, biceps, triceps, etc. To unnecessarily destroy the power of one of these, is to be guilty of an unpardonable oversight. Variously formed incisions, other than the longitudinal, have been employed ; as the H, with the horizontal portion corresponding to the articulation ; the T, with the horizontal on a line with the condyle; U-shapsd or semilunar, with the convexity downward. Excision of the Elbow-Joint by the h- -Shaped Incision (Liston, Fig. 262).—Flex the elbow to an obtuse angle, the operator facing its pos- terior surface, open the capsule between the olecranon process and in- ternal condyle by a longitudinal incision about four inches in length along the inner border of the olecranon, dissect and draw the soft parts over the internal condyle with the thumb (Fig. 263), increasing OPERATIONS ON BONES. 191 the flexion gradually till the condyle is fully exposed, divide the in- ternal lateral ligament, extend the arm and carry a transverse incision Fig. 263.—Exposing internal condyle. from the point of articulation of the radius with the humerus directly across to the center of the former incision. The periosteum on the inner surface of the olecranon process and ulna is raised and left connected with the tendon of the triceps, which is carefully separated from the bone. Open the flaps wide and divide the external lateral ligament, flex the forearm, and the articular sur- faces will separate. Seize and saw off the lower extremity of the humerus, the olecranon process, and finally the head of the radius. Results.—Excision of the elbow-joint has been performed with such good success that its high rank is thoroughly established. Al- though when due to injury the rate of mortality is about twenty per cent, when due to disease it is less than eleven per cent. Partial excis- ions are followed by better results, so far as motion is concerned, than complete excisions. 192 OPERATIVE SURGERY. It would appear that the saving of the synovial membrane exerts a more conservative influence upon the usefulness of the joint than the saving of bone; provided, of course, that the bony insertions of the muscles acting directly upon the joint be respected. The amount of bone removed will determine the usefulness of the joint. If too little, the movement will be limited and insufficient; if too great, it will dangle, and be of little use except for prehension. If the operation be for traumatism, remove the fragments ; if for disease, remove the dis- eased portion ; in both conditions trim the extremities of the bones so as to afford symmetrical support to opposed bony surfaces. The wounds should be washed with a suitable antiseptic solution, closed with proper drainage, dressed antiseptically, and kept extended until repair is be- gun ; when the limb should from time to time be placed at various angles for a day or so. By this course the newly formed tissue will thereafter conform more readily to the various movements of the joint. Excision of the Ulna.—An incision is made along its posterior sur- face of sufficient length to expose the diseased bone, the periosteum is pushed aside, and section is made at the requisite point and the dis- eased bone is removed. If it be a partial excision of its upper extremity, expose that por- tion by an incision in the same line, as for removal of the entire bone, elevate the periosteum, leaving, if possible, the attachments of the brachialis anticus and triceps muscles, and avoid the ulnar nerve, at the inner condyle. Excision of the Radius.—Make an incision, extending from the styloid process of the radius, along the outer border of the anterior surface of the forearm to the radio-humeral articulation, through the integument and fascia. Seek the outer border of the supinator longus, pass upward, separating it from the flexor longus pollicis, and going down to the bone, divide the supinator brevis, also the periosteum in the long axis of the radius ; elevate the periosteum ; divide the bone in the center, and remove each half separately. The insertion of the biceps and pronator radii teres should be carefully preserved. If an extremity of the bone is to be excised, expose the portion to be re- moved by an incision made in the same line as the preceding; raise the periosteum with equal caution, and remove the diseased portion. The results of this operation are good ; a patient seldom dies, and fair use of the extremity is secured. Excision of the Lower Extremities of the Bones of the Forearm (Bourgary).—Make an incision two inches in length along the inner border of the ulna on the dorsal surface, from just below the apex of the styloid process (Fig. 264). Divide the periosteum at the inter- space between the extensor and flexor carpi ulnaris muscles in the same line, and reflect it from the dorsum of the bone inward to the interosseous membrane. A second longitudinal incision is made along OPERATIONS ON BONES. 193 the outer side of the radius from just be- low the apex of the styloid process two or three inches upward; the periosteum is divided through the same incision, the at- tachment of the supinator longus sepa- rated, and the periosteum raised on the dorsal surface together with the sheaths of the extensor tendons. The periosteum is then elevated from the like portions of the palmar surface of the lower ends of both bones around to the interosseous membrane. Protect the soft parts carefully while the bones are being sawn through. The operation can be extended to the bones of the carpus if necessary, by continuing the lateral incis- ions downward. Excision of the Wrist-Joint. — This joint properly consists of the radius, ar- ticulated with the outer two of the first row of carpal bones. In cases where ex- cision is necessary, it is not usual to find the disease or injury limited entirely to these structures. It, therefore, becomes necessary to remove all bony structures involved, even though they include the two rows of carpal and the contiguous extremities of the metacarpal bones. The intimate relation exist- ing between the carpal bones and the continuity of their synovial sur- roundings, renders them especially liable to progressive disease as well as to inflammatory processes (Fig. 265). They are intimately bound to- gether by strong ligaments admit- ting of but limited movement be- tween their surfaces (Figs. 266 and 267). Since these bones are in close relation to the tendons of important muscles, the sheaths of which should be scrupulously preserved together with themselves, this operation is surrounded with difficult and tedi- ous details. Fig. 265.—Synovial membranes of carpus. All diseased or detached bone 13 264.—Lateral incisions. 194 OPERATIVE SURGERY. should be removed. If a portion of a carpal bono be diseased, it is better that the entire bone be removed. The insertions of all muscles acting on the carpus should be preserved, if possible. Fig. 266.—Ligaments of dorsal surface Fig. 267.—Ligaments of palmar surface of carpus. of carpus. A tendon is not to be divided, except it forms an insurmountable obstacle to the incision necessary to the removal of the bones, and it should afterward be sutured. If the tendons be divided at a distance from the immediate seat of the operation, and subsequently sutured, the chances of union will be enhanced. The radial and ulnar arteries and the branches associated with the carpus should be cautiously avoided. Complete Excision of the Wrist-Joint (Langenbeck).—Place the forearm and hand of the patient with the palm downward on a table of convenient height for the operator and his assistant. An incision is then made through the integument, beginning at the middle of the metacarpal bone of the index-finger at its ulnar border, and extending longitudinally to three fourths of an inch above the lower extremity of the radius, at its middle (Fig. 268). The deeper course of the in- cision passes to the radial side of the extensor indicis without opening its sheath, upward, over the tendon of the extensor carpi radialis brevior, to the inner side of its insertion ; then, if the tendons going to the index-finger be pushed to the ulnar side, the incision extends upward to the beginning of the tendons of the extensor secundi inter- nodii pollicis and the extensor indicis, dividing the lower portion of the posterior annular ligament. Draw the tissues apart with suitable retractors and separate from the bone with a periosteal elevator the OPERATIONS ON BONES. 195 fibrous sheaths of the extensors of the carpus on the posterior surface of the radius; the insertion of the supinator longus muscle, and the annular and capsular ligaments are then dis- connected and drawn to the radial side to- gether with the perios- teum ; the tendons, liga- ments, and periosteum on the posterior surface of the ulna are sepa- rated in the same man- ner and drawn to the ulnar side. Open well the radio-carpal joint, flex the carpus and ex- pose the articular sur- faces, and separate the bones of the first row from their connection with each other, leaving the periosteum if pos- sible. Liberate the sca- phoid from the trape- zium and trapezoid, the semilunar from the os magnum, and the cuneiform from the un- ciform ; lift them out, leaving their perios- teum—if possible—to- gether with the trape- zium and pisiform bones. The bones of the second row are taken out after severing the connections between the trapezium and trapezoid, and the heads of the metacarpal bones. The extremities of the radius and ulna can now be forced through the wound, carefully exposed and sawn off, avoiding the radial and ulnar vessels. The divided tendons should be sutured and the resulting wound treated by antiseptic measures. Con- tinuous extension from the fingers should be early and constantly em- ployed during the after-treatment. There are other incisions intended to meet the indication (Lis- ter): Begin the incision on the dorsal aspect of the radius, opposite the styloid process, and carry it toward the inner side of the metacarpal articulation of the thumb parallel with the secundi internodii pollicis Fig. 268.—a. Extensor carpi radialis longior. b. Extensor longus pollicis. c. Extensor carpi radialis brevior. d. Posterior annular ligament. /. Langenbeck's incision. 196 OPERATIVE SURGERY. tendon (Fig. 2C9, a). When at the radial border of the second meta- carpal bone, carry the incision along one half the length of that bone; separate the soft parts on the ra- dial side, divide the tendon of the extensor carpi radialis longior at its insertion, raise it, together with the extensor carpi radialis brevior and secundi internodii pollicis tendons, open the wound well, and disconnect the trapezi- um from the remaining bones, which are to be taken away. Ex- tend the carpus and separate the soft parts on the dorsum at the ulnar side of the incision. Make a second incision along the anterior and internal border of the forearm on the inner side of the flexor carpi ulnaris, begin- ning it about two inches above the styloid process and extending Fig. 269.-Lister's incisions. it to the middle of the metacar- pal bone of the little finger (Fig. 269, b). Expose the dorsum of the ulna, divide the tendon of the ex- tensor carpi ulnaris at its insertion, separate it from the groove in the ulna, raise the extensors of the fingers from the carpus, leaving their attachments to the radius intact; expose the anterior surface of the ulna, hugging the bone closely; separate the pisiform bone with the flexor carpi ulnaris ; flex the hand and separate the flexor tendons in the same cautious manner ; divide the remaining ligaments connecting the bones of the forearm wTith the carpus ; separate the process of the unciform bone, also the carpus from the metacarpus with cutting for- ceps ; expose the extremities of the radius and ulna through the ulnar incision, remove with the saw or forceps the diseased portions, care- fully avoiding the grooves for the passage of the tendons; remove the trapezium without injury to the tendon of the flexor carpi radialis. All articular surfaces of bones—metacarpal bones, pisiform, and be- tween lower extremities of radius and ulna—should be removed, as well as all diseased portions of bone. Many other incisions may be made through which to effect the removal of the wrist-joint; but only such as admit of it being done through longitudinal incisions are ad- visable, since transverse incisions may sacrifice the tendons which im- part usefulness to the remaining portion of the carpus. All hemorrhage having ceased, suture the divided tendons, close the wound, allowing the most dependent incision to remain open for OPERATIONS ON BONES. 197 drainage. Envelop the limb in antiseptic dressings, causing the whole to be properly supported by a splint. The subsequent treatment con- sists in cleanliness, extension, and passive motion. Results.—Ten per cent die after excision for disease, and fifteen per cent for gun-shot injuries without antiseptic treatment. In about thirty-three per cent of those who recover, the operation has been of no service ; in about eleven per cent, entirely satisfactory ; in the re- mainder, useful. The prognosis for usefulness is better when excision is performed for injury than for disease. Excision of the Metacarpo-phalangeal Joints.—This operation can readily be done by making an incision about one inch and a half in length at one side of the extensor tendons and along the dorsum of the bones composing the joint. The tissues in contact with the bone are carefully raised and turned aside, the joint exposed, and the re- quisite amount of bone removed by the chain-saw, cutting forceps, or dental engine. Excision of the Phalangeal Joints,—These articulations may be ap- proached either through a longitudinal incision made along the side of the joint, or by a curved incision at the same situation with the convexity downward. In either instance separate the tissues carefully down to the extremities of the bones, which, when properly exposed, can be caused to protrude through the incision by lateral flexion and the extremities can then be removed. The after-treatment consists in placing the fingers in an immov- able position properly protected by an antiseptic dressing, and when repair begins passive motion is made and continued until the recovery is complete. Excision of the Joints of the Lower Extremities.—The phalangeal joints of the tarsus are removed in a similar manner to those of the upper extremity. The Metatarso-phalangeal Joints are removed through longitudinal incisions, made over the dorsal surface of the bones constituting the joints, at either side of the extensor tendons, which are pushed aside together with the remaining surrounding soft parts, the bones ex- posed, and their extrem- ities severed by the chain- saw or bone-forceps. The removal of the metatarso- phalangeal articulation of the great toe can be and often is done by a different method. Make a curved incision with the convexity downward, Of Sufficient length to Fig. 270.—U-shaped incision. 198 OPERATIVE SURGERY. freely expose the bones to be removed, at the inner side of the joint, its center corresponding to the joint center (Fig. 270). Dissect the soft parts from around the bones, carefully pushing aside the tendons; expose and remove the necessary amount of the articulation with a chain-saw or forceps. If the operation be done for the correction of the deformity caused by prominence of the head of the metatarsal bone, enough bone should be removed from its extremity to permit the easy return of the displaced toe to its natural position ; where it is to be retained quietly till repair is well advanced, and then passive motion is to be commenced. The Tarso-metatarsal Joints can be excised through a straight in- cision or by raising a semilunar flap over their dorsal surfaces, avoid- ing division of the extensor tendons, which are raised and pushed aside, while the dorsal ligaments connecting the bones are divided and the joint cavity exposed by forced flexion, after which the bones of the distal row can be divided with a saw or bone-forceps. The corre- sponding extremities of the tarsal bones can be treated likewise. Tarsal Joints.—When separate tarsal joints become involved by disease or traumatic violence, they can be removed by making an in- cision over the injured or diseased portions, often following in the line of the course of the violence, or in the tracks of sinuses leading from the disease. This treatment is, however, better adapted to those joints having a limited synovial membrane, than to those where that membrane ex- tends between several contiguous bone surfaces ; in the latter case it is often better to remove the bones entire by aid of the chisel, saw, or gouge. In either instance curved incisions are preferable, provided they do not divide important tendons and vessels. Excision of the Calcaneum.—It is important that as much as pos- sible of this bone be saved, as it forms the posterior pillar of the arch of the foot, and also gives attachment to the tendo Achillis, which exerts a powerful influence in locomotion. When gouging fails to remove the diseased bone, excision becomes the final resort. A horse- Fig. 271.—Excision of os calcis. shoe-shaped incision is begun a little in front of the calcaneo-cuboid articulation and carried around the base of the os calcis along the side OPERATIONS ON BONES. 199 of the foot to a corresponding point on the opposite side. This flap, with the knife hugging the bone, is dissected up, exposing the entire under surface of the os calcis (Fig. 271). A second perpendicular in- cision about two inches in length is then made through the middle of the tendo Achillis down to the preceding one ; the resulting flaps are dissected off close to the bone, and the posterior articulation between the calcaneum and the astragalus opened, the ligamentous connections severed, together with those between it and the contiguous bones, the os calcis taken away, and any additional diseased bone removed. Results. — A large majority of these cases recover with useful limbs. Excision of the Astragalus.—This is accomplished through a semi- lunar opening, with the convexity downward, extending between the malleoli in front. The tendons of the extensor muscles must be care- fully pushed aside ; its ligamentous connections with the tibia, fibula, and os calcis are severed, finally, those with the scaphoid ; then, with the foot extended, the bone is pulled from its site and the calcaneum placed in the resulting gap between the malleoli. Results.—About seventy-five per cent of these cases recover with useful limbs. Excision of the Ankle-Joint.—This articulation is a hinge-joint, having no lateral movement, except the foot is well extended, and then it is very limited. The indications calling for the operation are numerous, and should be well considered before it is attempted. As in all excisions those incisions which best preserve the tendons, ves- sels, nerves, and periosteum are to be adhered to, consequently those of a longitudinal character are the best to be employed. Operation, Subperiosteal (Langenbeck).—Make an incision, about three inches in length, along the posterior border of the lower extrem- ity of the fibula down to the bone (Fig. 272), carrying it forward in a hooked shape around the lower end and then upward along its ante- rior border about an inch. The periosteum is reflected from the bone together with the tissues in contact with it, thereby exposing the lower extremity of the fibula without opening the tendinous grooves of the peronei muscles (Fig. 273). The fibula is then di- vided at the upper end of the in- Fig. 272.—Excision of ankle-joint. cision with a narrow saw, pulled outward, and the ligamentous attachments along its inner border and surfaces severed (Fig. 274), and the bone removed. An incision is then made about an inch and a half in length down to the bone, 200 OPERATIVE SURGERY. around the lower end of the inner malleolus (Fig. 275). A third and vertical one is next made about two inches in length, down to the bone through the center of the tibia, connecting with the semicircular one first made. The triangular flaps, in- cluding the perios- teum, are turned aside with the ele- vator, using care to raise the sheaths of all tendons from their grooves (Fig. 276), and, pushing them aside, the tibia is divided at the upper end of the cut with a chain-saw, the frag- ment pulled out- ward with the for- ceps, freed from the interosseous membrane, and re- moved. If it be ne- cessary to remove the articular sur- face of the astragalus, it can be done through either incision; the better, however, through the internal one, on account of the greater amount of room. If the excision is to be performed for chronic disease of the ankle and contiguous points, Vogt recommends, with the view of getting a more extended insight into the diseased portions, that an incision be made anteri- orly, midway between the tibia and fibula, beginning about two inches above the articulation of the ankle and extending downward to Fig. 274.—Removing lower end of fibula. Fig. 273.—Outer side of ankle, a. Tendo Achillis. b. Pe- roneus longus. c. Peroneus brevis. d. Peroneus tertius. e. External malleolus. /. Extensor longus digitorum. g. Crucial ligament, h. Extensor longus pollicis. OPERATIONS ON BONES. 201 the medio-tarsal joint on the dorsal surface of the foot. The long extensor tendons are carefully drawn to the inner side, the tendons of the short extensor are divided and drawn to the outer side ; the blood- vessels carefully tied between two ligatures and the capsule of the joint opened by a vertical incis- ion ; then detach the anterior liga- ment and expose the head and neck of the astragalus. If the Superior astragalo-SCaphoid liga- Fig. 275.—Internal incisions. ment be divided, the anterior and inner surfaces of this bone will be better exposed. A transverse in- cision is now made at right angles to the primary one, extending out- g Fig. 276.—Inner side of ankle-joint, a. Tibialis anticus muscle, b. Tendo Achillis. c. Tibialis posticus muscle, d. Flexor longus digitorum. e. Flexor longus pollicis. /. Posterior tibial artery, g. Tuberosity of scaphoid bone. ward to the tip of the external malleolus, leaving the tendons behind it intact. Divide the three fasciculi of the external lateral ligament close to the malleolus, also cut the interosseous or internal calcaneo- astragaloid ligament, force the articular surface of the astragalus out- ward, seize it with lion-tooth forceps, separate its remaining connec- tions, and remove it. All diseased portions can now be easily exam- ined and removed with a minimum degree of disturbance of the healthy tissues. The method recently practiced by Busch is a very ingenious one, serving as it does to remove the diseased joint without impairing its tendons or their sheaths. It is open to the objection, however, of 202 OPERATIVE SURGERY. weakening: the arch of the foot, on account of the division of the lon^ calcaneo-cuboid ligament and the plantar fascia. Busclt's Operation.—An incision is made down to the bone, across the sole of the foot, from one malleolus to the other; the sides of the joint are exposed by drawing the tissues forward. The os calcis is now sawn through from below upward and forward to the anterior margin of the calcaneo-astragaloid articulation, and pulled backward after the division of the opposing ligamentous structures. The entire astragalus can now be removed through the opening, and also the lower extremi- ties of the tibia and fibula. After the removal of the dead bone and the establishment of good drainage, the fragments of the os calcis are placed in position and held there by silver wire. The wound should be dressed antiseptically and no weight allowed upon the foot until the tissues are firmly united. The after-treatment for excision of the ankle-joint consists in ap- plying an immovable dressing around the joint under antiseptic pre- cautions. Results.—When done for disease, about ten per cent die ; for gun- shot wounds, about twenty-seven per cent ; for other injuries, about thirteen per cent. The results are better from complete than from partial excision. The prognosis for life is most favorable between one and fifteen years of age; most unfavorable between thirty and forty years. A large proportion of the recoveries from this operation results in a more or less useful limb ; about nine per cent being useless. Excision of the Bones of the Leg.—If it be desired to remove, by excision or otherwise, portions of either of the bones of the leg, the external incision is governed, as to its location and extent, by the situation and degree of the injury or disease of the bone. The bone should, however, be reached by the shortest course, which usually is between the individual muscles, rather than through their structures. After its removal, which should always be subperiosteal, the limb must be so confined as to permit the new structure, when completed, to ful- fill the functions of its predecessor. The patient must not be per- mitted to bear weight on the limb till the new bone becomes firm, else distortion or fracture will occur. Excision of the Knee-Joint.—This joint can be excised with com- parative safety to the patient, and with a fair prospect of recovery with a useful limb. As in the preceding, the nature of the cause de- manding the operation exercises a marked influence on the result. Results.—The mortality, when due to disease, is about thirty per cent ; when dependent upon injury, about forty per cent ; when done with all antiseptic precautions, the rate is less than fifteen per cent. OPERATIONS ON BONES. 203 If it be for a gun-shot injury, the mortality is increased to seventy- five per cent. The age of the patient is a consideration not to be un- derestimated ; the results are best from five to ten years of age, when due to injury or disease; fifteen to twenty per cent die when done for gun-shot wounds. Partial excision gives a higher rate than complete, when due to disease. The removal of about three inches of bone in- sures the best prognosis for life. A lesser or greater amount increases the percentage of deaths. The removal of the patella, wiien not dis- eased, increases the rate of mortality slightly. The usefulness of the limb after the operation can be briefly summed up as follows: When due to disease, fourteen per cent were perfect, forty-two were useful, and the remaining useless, of which eighteen per cent were amputated. For injuries, about eighteen per cent were perfect, about sixty-five per cent useful, and about twelve per cent were amputated. When due to gun-shot injuries, about sixty per cent were useful and twenty-four per cent were amputated, the remaining not accounted for. When done for deformity, nineteen and a half per cent of the results were perfect, and about sixty-eight per cent of the patients had useful limbs ; the remainder not reported. It appears that the degree of usefulness does not depend upon the amount of bone removed. The removal of the patella seemed to increase the degree of use- fulness of the limb. In excision of the knee-joint for all causes, before the growth of the patient is completed, great care should be taken to preserve intact, if, possible, the epiphyseal cartilage, especially of the lower end of the femur (Fig. 277). This precaution markedly lessens Fig. 277.—Epiphyseal cartilage and line of section in excision of knee-joint. the failure of the development of the length of the femur upon the diseased side thereafter, because this epiphyseal junction provides for much more than its proportionate share of the growth of the length of the femur normally. 204 OPERATIVE SURGERY. Contiguous Anatomy.—The articular vessels and those which oc- cupy the popliteal space are the ones to be preserved. The latter are removed from all danger by the dense and unyielding ligamentum posticum Winslowii. The former can be avoided by limiting the in- cisions to the space between the origin and insertion of the lateral ligaments. There are two well-known methods of excising this joint: 1, the non-subperiosteal, or the ordinary method; and 2, the sub- periosteal. The former is employed when the tissues are too exten- sively destroyed or diseased to admit of the saving of the periosteum. Non-subperiosteal Excision of the Knee-Joint (Mackenzie).—Flex Fig. 278.—Mackenzie's anterior curved incision. the leg to a right angle and make a curved incision, from the pos- terior border and upper portion of one condyle, around to the same point on the outer, with the convexity downward and correspond- ing to the insertion of the ligamentum patellae (Fig. 278). This in- cision divides the tissues down to and opens the anterior portion of the capsular ligament. The limb should now be still more strongly flexed and the lateral and crucial ligaments divided. A retractor is then passed between the ligamentum posticum Winslowii and the posterior surface of the femur, the bone pushed forward and cut off on a line parallel with the articular surface, provided the extent of the diseased bone will admit of it. The head of the tibia is then treated in the same manner, being careful to avoid the articulation of the fibula. In this operation it is better to remove the patella, since its means of attachment (the ligamentum patellae) has been severed. All in- flamed or degenerated synovial membrane should be dissected away. The bony surfaces should now be united by passing two annealed iron or silver wires anteriorly through to their posterior borders. The wound is then washed with the strong carbolic or a bichloride solu- OPERATIONS ON BONES. 205 Fig. 279.—Corresponding lines of division. tion and a drainage-tube passed from side to side through the joint behind the bones ; the whole enveloped in the antiseptic dressing, and the limb immovably fixed in a bracketed plaster splint, and properly suspended. In sawing through the exposed extremities of either bone, the line of incision can be made to include the whole of the diseased osseous tissue. If carious bone or an abscess cavity extend in an isolated manner into the sawn extremity of the femur or tibia, it can be scooped out and the resulting cavity drained by making an opening through its bottom with a bone-drill to the external surface of the limb, thereby saving the surrounding healthy bone-tissue and contributing to the length of the diseased limb. Deeply con- gested cancellous bone-tissue should be preserved if to remove it be to im- pair the epiphyseal cartilage, since it not infrequently makes a good recovery, but offers in addition thereto the only opportunity of preserving the nor- mal growth of the femur. The line of sec- tion through the bone last sawn must corre- spond in direction to, and be parallel with, the line of section through the bone to which its sawn surface is to be applied (Fig. 279), otherwise the union of the sawn sur- faces will cause an angular deformity. This applies more particularly to those cases where anchylosis in the straight position is sought. If for any reason it be thought better to an- chylose the limb with slight flexion, then the thicker portion should be taken from the pos- terior parts of the bones. Subperiosteal Excision of Knee-Joint (Langenbeck).—Extend the limb and make a curved incision on the inner side five or six inches in length, with the convexity down- ward, corresponding to the posterior border of the condyles, and its center to the line of the articulation, commencing at the inner border of the rectus femoris and terminating below at the crest of the tibia Fig. 280.—Langenbeck's in- cision. 206 OPERATIVE SURGERY. (Fig. 280). If the flap be now raised, the vastus internus muscle and the tendons of the adductor magnus and sartorius will be seen (Fig. 281), and should be carefully avoided. Divide the internal lateral ligament on a line with the articulation ; with the peri- osteal elevator, separate the cap- sular ligament and the perios- teum from the anterior and posterior surfaces of the inner condyle of the femur, and the tibia outward to the median line of the bones together with the internal semilunar cartilage; flex the leg, then extend it slowly, and at the same time dis- locate the patella outward by the thumb applied to the inner border; divide the crucial liga- ments, also the external lateral, and the corresponding portion of the capsular ligament by a semilunar incision carried a few lines below the tip of the external condyle. Bemove the periosteum and its associated tissues from the outer portion of tibia and femur, the same as at the inner side. Divide the posterior portion of the capsule and force the extremities of the femur and tibia successively through the wound, and saw them as before. The patella remains unmolested, except it be diseased, when the diseased portion is removed with a gouge, or the bone can be enucleated from the periosteal surroundings by the elevator and scalpel. A small opening should now be made at the outer and inner sides of the joint posteriorly, for the purpose of es- tablishing thorough drainage. A drainage-tube can be passed through the upper synovial pouch, or firm compression be made thereon to prevent the collection of inflammatory products within it. The sur- faces are then cleansed, all hemorrhage arrested, the flaps united, and the limb surrounded by antiseptic dressing, and immovably fixed till future dressings become necessary. The Subperiosteal Excision of Oilier is made through an incision commencing two inches above and to the outer side of the patella, carried down to its upper and outer angle, along the outer border to the apex and to the outer side of the ligamentum patellae, below its insertion, through the soft parts (Fig. 282). The outer condyle of the femur is denuded of its periosteum together with the lateral and cap- sular ligaments and the outer head of the gastrocnemius ; the anterior Fig. 281.—Tendons at inner side of knee- joint, a. Vortus internus muscle, b. Rec- tus femoris muscle, c. Sartorious muscle. d. Adductor magnus muscle, e. Gracilis muscle. /. Semi-membranosus muscle, g. Semi-tendonous muscle, h. Gastrocne- mius muscle. OPERATIONS ON BONES. 207 and internal surfaces of the femur are denuded, the crucial ligaments cut, patella displaced inward over the inner condyle, the leg is then flexed and carried inward, causing the femur to protrude, when it is isolated and sawn off. The upper end of the tibia is then denuded of its periosteum from above downward, pushed through the opening and likewise divided. If the patella be / diseased, remove it, leaving its periosteum behind. / Excision by a Transverse Incision.—Ascertain the line of junction of the articulation with the limb ex- tended, if the joint will permit; make a transverse ; incision from one condyle directly across to the other, \--\ passing across the middle of the patella or at its \ apex; if the former, saw the patella through in the \ line of the incision, remove the fragments, after which '■ the joint surfaces are exposed and removed as in the | preceding operations. This incision affords good j , drainage, and exposes the joint by a minimum injury j \ of the soft parts. In all instances the diseased syno- i i vial membrane should be carefully dissected away be- / i fore the wound is closed. In all forms of excision of this joint care must be taken to prevent the soft ' jnc parts posterior to the bones from being caught be- tween their sawn surfaces, since this will hinder union by preventing a proper contact of their surfaces. If the two wire sutures be carried through to the posterior borders of the bones, this accident can not occur. If the patella be permitted to remain, its severed ligament may be united by suturing, or, if the bone have been sawn across, the bony fragments may be united by strong catgut or silver wire. It is thought, in cases of imperfect union of the tibia and femur, that the presence of the patella gives greater stability to the limb. Excision of the Patella.—It may be necessary, on account of ne- crosis or injury, to remove the patella independently of the tibia and femur. In such cases the deep incisions must correspond in extent to the diseased bone, for if they be greater, the synovial cavity may be opened. The periosteum should be raised, and the dead bone care- fully removed, if possible, without entering the joint. When the joint is not involved, recovery will be speedy and satisfactory, if the limb be confined in the extended position till sufficient repair has taken place to warrant flexion without fracture of the bone. The results in eleven cases are two deaths and nine recoveries, of which eight were complete and three partial excisions. Excision of the Great Trochanter.—This is occasionally required on account of caries. A longitudinal or curved incision is made down upon the bone, and the diseased portion removed with the usual in- struments. The branches of the circumflex vessels and the capsular 208 OPERATIVE SURGERY. ligament are to be avoided. The periosteum should be saved when possible. Excisions of the Hip-Joint.—It is well before attempting this opera- tion to give a brief survey of the important ligamentous and muscular attachments to be respected. The extent of this book is too limited to describe them in detail, and even to do so would hardly be in keep- ing with the scope of the work. The ilio-femoral, capsular, cotyloid, and even the teres ligaments, should be carefully considered in connection with their origin and in- sertion, in order that their relations to the involucrum or periosteum may be maintained. Those muscles which are connected with the tro- chanters major and minor should likewise be preserved intact, in order that their association with the new bone-growth may give to the new joint, so far as possible, the normal functions of the old. The results of this operation are substantially as follows: When done for gun-shot injuries, about ninety-two and a half per cent die from the primary ; about ninety-one per cent from the intermediary, and ninety and a half from the secondary operation. When done for dis- ease, the mortality is reported variously from thirteen (Sayre) to forty- five per cent. The most favorable age is between five and ten years; the best results are said to occur when the disease has existed several months. The rate is about three per cent greater from complete than partial excisions. The rate of mortality is but little improved by the removal of the trochanter major, and the upper portion of the shaft; it is diminished, however, from the head of the femur downward, in proportion to the amount of diseased bone removed, and is increased in proportion to the extent of the disease of the ilium. About ninety- four per cent secure useful limbs, when excised for disease. Complete excision is followed by a more useful limb than partial excision. The hip-joint may be removed with or without the preservation of the periosteum, by two quite distinct methods of operating: 1. The simple, when no effort is made to save the periosteum, and the mus- cular and ligamentous attachments about the joint are freely sacri- ficed. This method is applicable for malignant disease of the bone, and for injuries causing extensive comminution and laceration. 2. The conservative, in which conscientious care will often be repaid in peeling off the periosteal tissue and muscular attachments worthy of preservation. Under all circumstances the acetabulum should be closely scrutinized for the presence of dead bone, which should, in all instances, be removed with care, otherwise the pelvic contents may be injured by the manipulation. Operation (White).—The simple method is performed by placing the patient on the healthy side, and making a deep curved incision (Fig. 283), commencing at a point midway between the anterior supe- rior spinous process of the ilium and the trochanter major, and pass- OPERATIONS ON BONES. 209 ing backward around the top of the trochanter major, down its pos- terior border about three or four inches, with a strong knife; then dividing the insertions of the muscles connected to the great trochan- ter (Fig. 284), drawing them Fig. 283.—White's posterior curved in- Fig. 284.—Sciatic nerve and external cision. rotator muscles. thigh be flexed and adducted, the head of the bone will be raised from the acetabulum sufficiently to admit of the division of the liga- mentum teres, when the complete escape of the head of the femur will take place. The soft parts are then protected by a spatula, the bone exposed the required extent, and sawn off (Fig. 285). Subperiosteal Excision of the Hip-Joint (Langenbeck).—Place the patient on the sound side with the thigh flexed at an angle of 45° ; make an incision five or six inches in length in the long axis of the great trochanter (Fig. 286) upward and backward toward the posterior superior spine of the ilium, through the fibers of the gluteus maxi- mus, fascia lata, and periosteum of the trochanter; separate the sur- faces of the wound with retractors, and with the elevator and knife raise the periosteum and the attachments of the muscles inserted into the trochanter major and the contiguous surfaces, being careful to 14 210 OPERATIVE SURGERY. Fig. 285.—Sawing off head of femur. preserve their connections with each other ; next make a longitudinal incision along the neck of the femur, through the capsular ligament and the periosteum. The periosteum of the neck is then separated in connec- tion with the attachments of the capsular ligament and the obturator externus in a careful manner. If an incision be now made through the cotyloid liga- ment, and the thigh be ro- tated outward and ad- ducted, the head of the bone will be elevated from the floor of the acetabulum sufficiently to admit of the division of the ligamentum teres, when the head of the bone can be pushed through the opening and sawn off. Fig. 286.—Langenbeck's longitudinal incisioa OPERATIONS ON BONES. 211 Sayre's Operation.—The following admirable method of excision is recommended by Professor Lewis A. Sayre. It is subperiosteal in all essential particulars, and possesses an advantage over the one just de- scribed in that the primary incision is better fitted for drainage. Place the patient on the sound side and make an incision with a strong knife down to the bone, commencing at a point midway be- tween the anterior superior spinous pro- cess of the ilium and top of the trochanter major ; carry it in a curved course upon the bone to the top of the great trochanter midway between its posterior border and center ; complete it by carrying the knife forward and inward, making the length of the incision from four to six or eight inches, depending upon the size of the thigh (Fig. 287). If it be not cer- tain that the periosteum of the trochan- ter has been divided by the first incis- ion, the knife should be carried along the same line a second, and even a third time if need be. The soft parts are now drawn apart, exposing the great tro- chanter, when, with a narrow, thick knife, a second incision is made through the periosteum only, at right angles with the first, about an inch or an inch and a half from the top of the trochanter. At the junction of the periosteal incisions introduce the blade of the elevator, and carefully peel the periosteum from either side as far as possible, together with the ligamentous attachments, un- til the digital fossa is reached. The insertions of the rotators into the trochanter major and digital fossa are so firm that it will be impossible to peel them off ; they must, therefore, be carefully separated by short parallel cuts, so directed as to remove the periosteum with which they are blended. After the separation of the tendinous insertions, con- tinue to elevate the periosteum upon either side of the neck, using great care not to rupture it. Its integrity is important to prevent in- filtration into the surrounding tissues, provide attachments for the important ligaments and muscles, also as the basis for the reproduc- tion of bone which it is hoped will take place, each of which will exert an important influence in the preservation of a useful joint. Having separated the periosteum as far as can be done safely, adduct the thigh carefully, raise the head of the bone from the acetabulum, and the remaining portion can be detached. Adduct and depress the femur slightly, being careful not to tear the periosteum, lift the head of the bone out far enough to admit of a division just above the tro- Fig. 287.—Sayre's line of incision. 212 OPERATIVE SURGERY. chanter minor. Care should be taken not to expose a greater surface than is necessary, since necrosis will follow and hinder recovery. It is better to remove the trochanter major, even though it be not dis- eased, since it will impede the escape of discharges, and is not essen- tial to a useful limb if its periosteal covering and muscular attach- ments have been preserved. In all cases after the operation, the wound should be well irrigated with a strong solution of carbolic acid, thoroughly smeared with balsam of Peru, and loosely filled with fine, well-shaken oakum ; good drainage provided, and extension applied to the limb either by the Buck's apparatus or the wire breeches. Excision of the Coccyx.—This is ofttimes done, though sometimes ineffectually, for the relief of coccydynia. The operation exposes the patient to no danger, and can but remove a comparatively useless appendage. Operation.—Place the patient on the side and expose the bone by a straight incision in the middle of its long axis ; isolate it carefully and remove it with bone-forceps. OSTEOTOMY. In a liberal acceptation, osteotomy may be defined as a section of bone. In a limited sense, however, it is applied to the divisions of bone that may be made for the relief of deformities dependent on anchylosis, rickets, badly united fractures, etc. It may be performed either with or without antiseptics. The former, however, is by far the safer plan. The Instruments employed consist of especially designed saws, chisels, osteotomes, mallets, scalpels and blunt hooks, and sand-pil- lows. There are variously formed saws employed, named usually after the one who designed them, as Langenbeck's (Fig. 288) and Adams' saws (Fig. 289). The blades are short and strong; one fourth of an inch in width and an inch and a half in length, connected to the handle by a strong shank three inches long. The deviations from OPERATIONS ON BONES. 213 these are to meet especial indications, rather than to abrogate their use. The objections to the use of the saw not only apply to the danger Fig. 289.—Adams' saw of lacerating the contiguous tissue, but more forcibly to the retention in the wound of the bone-dust, which, failing to be absorbed, is apt to be followed by suppuration. The saw devised by Dr. George F. Shrady, of this city, is the best, and is described by himself as follows : Figs. 290 and 291. " The instrument consists of a trocar (1) and a staff (2), with a handle and blunt extremity. A portion of this Fig. 290.—Shrady's saw. Bhaft at a short distance from the extremity is flattened, one edge (B) being made into a knife-blade, and the other (C) being provided with saw-teeth. This shaft is intended to replace the trocar in the canula after the latter is introduced. When in position (3) either the saw (C) or the knife-edge of the shaft, according to the way the latter is turned, corresponds with the opening of the canula. The saw or Fig. 291.—Shrady's modified saw. 214 OPERATIVE SURGERY. knife can then be worked to and fro within the canula by a piston- like movement, the canula being steadied by grasping the flange (D) at its base. If it be necessary to work the instrument as an ordinary blunt-pointed sheathed saw or knife, the shaft can be fixed in the canula, and made into one piece by a thumb-screw in the handle. The portion of the canula at the back of the opening is made extra strong, and is of the same thickness as the blade, so that in sawing there is no stoppage of the passage of the instrument through any thickness of the bone. The soft parts are protected from injury, no matter which way the instrument may be worked. The saw-blade is blunt at its extremity, and is guarded on all sides except in its limited cutting surface. The same may be said of the knife. The working of the saw to and fro in the canula is sufficient in sweep to insure the division of any7 bone having a diameter less than the cutting edge. Still, as this process is much slower than when the saw is used in the ordinary way, it is perhaps better to restrict its employment to opera- tions on the smaller bones, to cramped localities, and to situations where there is special danger of wounding some neighboring vessels. All that is necessary in using this saw is to thrust the trocar and canula into the limb, the fenestrum of the canula being alongside of the bone upon which the operation is to be performed. The trocar is then withdrawn, the staff introduced in its place, and worked as already described." Since the above description was written, the instrument has been slightly modified by lessening the size of the fenestrum through which the teeth of the saw are seen ; this strengthens the canula and facili- tates its progress through the bone (Fig. 291). The Chisel is like that of the carpenter in form, but differs from it in temper ; it has two parallel sides extending to its cutting edge. The cutting surface has one side straight and the other beveled, and should be one eighth of an inch thick at the base of the bevel; if thicker, it may splinter the bone. The breadth varies according to the size of the bone ; half an inch is suitable in the majority of cases. For narrow bones one fourth inch is better (Fig. 292). The width should always be less than the bone to be operated upon. The temper given to the tools of the hard-wood or ivory turner is best suited for the purpose, and its efficacy should be tested upon the thigh-bone of an ox or like animal before using the instrument. The chisel should be sharp, and leave a smoothly cut surface. This instrument is employed only to remove a wedge-shaped piece from the bone, since the shape of its cutting extremity will, like that of the carpenter's chisel, cause it to go awry if a straight section be at- tempted. The Osteotome.—This instrument is beveled on both edges, resem- bling a slender wedge ; the handle and the blade forming one piece. OPERATIONS ON BONES. 215 Fig. 292.—Chisels and osteotomes. The top should have a round head, against which the thumb is pressed to steady it. One border of the blade should be delicately marked in inches to determine the depth of the incision. The edge should be sharp enough to cut the finger-nails, and the temper of a character to withstand the strain required. It can be tested upon the thigh-bone of the ox, when, if it neither turn nor chip, it is calculated to with- stand the test of human bone. Osteotomes vary in thickness, in order that a section begun by one of a given thickness may be continued on its withdrawal, by the substitution of another of a less thickness. The Mallet is made of hard wood, and can be constructed for the purpose ; or, an extemporized one may be employed. The Scalpel is an ordinary one, with a sharp point suitable for penetrating at once to the bone. Blunt hooks are employed to draw the edges of the incision apart without force. The Sand-Pillow. — Its dimensions are usually about eighteen inches by twelve ; made of stout cloth, and filled with sufficient fine sand to permit its contents being moved from one part of the bag to another, without leaving any portion empty. It should be dampened before being used, covered with carbolized cloth, and the limb laid upon, or rather imbedded in it. It forms an efficient support, and prevents the force imparted to the bone by the mallet injuring the soft parts. The opening through the soft parts leading down to the point of proposed section should be limited in extent, and so located as to avoid the division of vess3ls, or injury to a joint. It should be made when practicable in the long axis of the fibers of the muscle through which it passes down to, but not through, the periosteum. The blade of the scalpel should remain in the incision till the danger of muscu- lar contraction ceases, and then the chisel or osteotome is passed into 216 OPERATIVE SURGERY. the incision by the side of it, as a guide, after which the blade can be withdrawn. It is better that the wound be large enough to admit the finger, or even to permit inspection of the bone, than that the tissues around a small incision be treated with violence, in the effort to accomplish the purpose. If chips of bone are to be removed, a larger incision is required than if a simple section be intended. The patient should in all in- stances be anaesthetized and the limb rendered bloodless by the elastic bandage of Esmarch or Martin. All cutting instruments employed must be rendered aseptic, and in all other respects the operation must be performed with antiseptic care. Subcutaneous Division of the Neck of the Femur (Adams).— Place the patient upon the side, with the bone to be operated upon upper- most. Introduce a long slender scalpel or tenotome above the top of the great trochanter, straight down to the neck of the femur ; divide the muscles and open the capsule freely on the anterior and upper sur- face ; pass the small saw by the side of the knife along the track down to the anterior surface of the neck, which is then sawed transversely through (Fig. 293) from before backward suf- ficiently to be easily broken. The limb is then placed in position, the wound irrigated with an antiseptic solution, to render it aseptic and to wash out the bone-dust ; hemorrhage is checked, a small drainage-tube introduced, the remaining portion of the incision closed, the whole enveloped in antiseptic dressing, and the limb placed in an immovable apparatus. The tendinous contractions, that prevent the limb being placed properly, should be divided subcutaneously. Results.—This operation has been success- ful in thirty-one out of thirty-four cases. Maunder, Billroth, and others have used the chisel for forcible fracture with good re- sults. Another method (Volkmann) consists in forming a false joint in the following manner : Make an incision along the posterior surface of the great trochan- ter four or five lines in length down to the bone. The femur is then cut through about an inch below the point of the great trochanter, with a chisel, the wall of the cervix femoris broken, and this portion of the bone removed. The thigh is then adducted to make the upper end of the femur more accessible then it is cut across and rounded off to fit the new socket which is made by chiseling out the head of the femur and increasing the area of the acetabulum by the same Fig. 293.—Sawing neck of femur. OPERATIONS ON BONES. 217 process, being careful not to open into the pelvic cavity. The upper end of the femur is placed in the newly-formed cavity, and extension is applied to the limb to keep the cut surfaces sufficiently separated to prevent bony union. Early passive motion should be made. Volk- mann has performed this operation several times, resulting in useful limbs in each instance. Inter-trochanteric Osteotomy.—This operation consists in exposing the anterior, outer, and posterior surfaces of the femur through an in- cision about six inches in length, beginning just above the tip of the trochanter major, and carried longitudinally through the center of its outer surface. A short, transverse incision is then joined to the cen- ter of the posterior lip of the first; the respective surfaces are then exposed with an elevator until the trochanter minor can be felt, when a chain-saw is passed around the bone immedi- ately above this process. The uppermost or curved section (Fig. 294) is made by first saw- ing upward and outward, until the bone is half severed, then changing the direction downward and outward and completing the section. The second section is made by sawing direct- ly through the bone in its transverse axis, re- moving a piece one eighth of an inch thick at its outer and posterior border, and three fourths of an inch of its central part. The upper end of the lower fragment is then rounded to fit the concavity above. The fig. 294.__Sayre's lines limb is straightened out and the wound treated of section. like a compound fracture. This method was practiced by Professor L. A. Sayre some time since with eminent success. The removal of a disk of bone in this situation has been quite fre- quently done, but with indifferent success. Out of the seventeen cases reported, seven died. While this method displayed great ingenu- ity and resource on the part of the originator, the fatality attending it, together with the introduction of the chisel and osteotome, render it at the present time impracticable. The modification introduced by Volkmann in 1873 consists in making an incision along the posterior surface of the great trochanter and removing the periosteum from two thirds of its circumference, when with chisels and gouges a triangular piece is taken from just below the trochanter (Fig. 295), the bone broken, straightened, and placed in proper position until union takes place. Results.—Of the twelve operations thus performed, all recovered. Osteotomy for Bony Anchylosis of Knee-Joint (supra-condyloid).— 218 OPERATIVE SURGERY. Fig. 295.—Volkmann's section. Make a longitudinal incision, sufficient to admit the osteotome, at the outer side of the rectus tendon, one finger's breadth above the upper portion of the outer condyle. The osteotome is introduced, and turned so that its cutting sur- face corresponds to the transverse axis of the bone at the point to be divided ; with the limb resting upon the sand-bag, the bone is two thirds divided and the remainder broken or bent. If performed from the inner aspect, the incision is made along the anterior border and half an inch in front of the tendon of the ad- ductor magnus, beginning one inch above its insertion. The remaining steps of the opera- tion are similar to the preceding. It may be necessary to supplement the section of the fe- mur with that of the tibia, in order to suffi- ciently correct the deformity. This is done by making an incision through the skin over the tibial crest just below the tuberosity. Through this opening, the subcutaneous and posterior surfaces of the tibia are divided sufficiently to admit of a fracture of the bone and the conse- quent correction of the deformity. The fibula, owing to its mobile asso- ciation with the tibia, does not require division at this situation. It is often necessary, how- ever, to cut the ham- string tendons before the deformity can be properly corrected. Supra - Condyloid Osteotomy for Genu Val- gum (Macewen) (Fig. 296).—In this operation care is taken to avoid the popliteal vessels, anastomotica magna, superior internal articu- lar arteries, and the syn- ovial pouch of the knee- joint on the anterior surface of the femur. The incision in the soft parts is made at the inner side of the limb, beginning a finger's breadth above the insertion of the tendon of the adductor magnus into Fig. 296.—Genu valgum. OPERATIONS ON BONES. 219 the spine at the upper portion of the internal condyle and half an inch in front of it, and carrying it up sufficiently to admit the osteo- tome ; or, its lowest limit is made to correspond to a line drawn trans- versely across the limb in front, beginning *an inch above the external condyle, which will, if the internal condyle be much elongated, pre- vent the osteotome being driven into the exter- nal condyle, instead of above it. The course of this incision avoids as far as possible any in- terference with the anastomotica magna and the articular arterial branches. The osteotome may be applied to the bone transversely at the point indicated by the faint transverse undotted line in Fig. 297, and so directed that its course will correspond to a line extending across the posterior surface of the femur to a point one finger's breadth above the external condyle. The extent of the osseous incision will depend upon the density of the bone ; if the subject be young, and if the bone be cut through two thirds of its diameter, it can be bent or broken. If it be dense, it will be necessary to carry the incision to the outer wall. The posterior and inner surfaces of the bone are first cut, when, if necessary, a thinner chisel is employed to Fig. 297.—Line of bone section. Fig. 298. Fig. 299. Fig. 300. Figs. 298, 299, 300.—Macewen's method. Fig. 301. Fig. 302. Figs. 301, 302.—Ogstcn's method. complete the operation. When the bone is sufficiently divided, the limb is straightened, all hemorrhage arrested, and the limb treated as before indicated. The above figures will aid in explaining the method. Fig. 298 shows a long internal condyle in genu valgum ; Fig. 299, a section through about three fifths of its diameter ; Fig. 300, the ap- pearance of the bone with the limb placed in position, showing the 220 OPERATIVE SURGERY. curvature rectified. The prognosis of this operation, with refereuce to usefulness of the limb, cure of the deformity, and danger to life, is most flattering. Results.—In about six hundred and fifty supra-condyloid osteoto- mies, but three fatal cases are reported that can be attributed to the operation; one each from septicaemia, hemorrhage, and carbolic-acid poisoning. All the patients were benefited, and many were able to take an active part in affairs from which they had been debarred. Osteo-Arthrotomy (Ogsten).—This method consists in dividing the elongated condyle of the femur by sawing (Ogsten), or cutting (Beeves), sufficiently to admit of the rectification of the deformity (Figs. 301, 302). Operation by Sawing.—Place the patient in the dorsal position ; administer an anaesthetic ; flex the leg upon the thigh, fully. At a point two or three inches above the tip of the inner condyle, introduce a tenotome upon the flat, carry it downward, forward, and outward until its point can be felt in the inter-condyloid space. The cutting edge is then turned downward and the tissues divided down to the bone as it is withdrawn. A small Adams' saw is then introduced along the course of the incision and the condyle is sawn, from above downward, through about three fourths of its thickness. If the limb be now straightened, the remaining portion is fractured and the de- formity is rectified. Results.—In forty-six operations two patients have died of septi- caemia. Operation by Cutting.—By this method the elongated condyle is divided or loosened with a chisel or osteotome ; the intention being to divide the condyle to the greatest depth without opening into the joint. Even though the cut be made to meet this indication, the joint is no doubt involved (except possibly in the very young) by the displacement upward of the fragment necessary to correct the de- formity. Chiene's Method.—Mr. Chiene, instead of sawing or cutting off the condyle, corrected the deformity by the removal of an oblique trans- verse wedge of bone from the body of the condyle which, when pressed upward by straightening the limb, remained attached by its apex to the shaft. Not infrequently, however, the fragment is detached by this manipulation, and the joint opened into. The details attending this method are omitted, since it can not be compared favorably with the much simpler and equally efficient one, supra-condyloid osteotomy. Osteotomy for Genu Varum.—In this deformity the operative pro- ceedings are directed to the outer instead of the inner side of the bones of the leg and thigh. The procedure, precautions, and treat- ment are similar. The division of the bones through a small external opening can be made almost indiscriminately in such as present this OPERATIONS ON BONES. 221 deformity, always remembering that thorough and complete antiseptic precautions should be taken. The results are most flattering, and commend it to the consideration and practice of the profession. Bow-Legs.—Genu varum may depend on an outward curvature of the bones of the leg, wholly or in part. In either instance the de- formity can be corrected by a subcutaneous osteotomy of the tibia. If the patient be young enough, a green-stick fracture of the fibula will obviate the use of the osteotome upon it. Operation.—Cleanse the part thoroughly with soap and brush ; apply the elastic bandage ; place the limb on the sand-bag, and at the point of the greatest curvature make a longitudinal incision down to the periosteum, midway between the borders of the subcutaneous bone at the point of proposed division, of ample length to admit the osteotome, which is then turned so as to divide the bone transversely, sufficiently to admit of its being fractured. Cut or bend the fibula, correct the deformity, close the wound in the soft parts with catgut, dress antiseptically, and confine the limb in a temporary dressing until all danger of hemorrhage, inflammation, etc., has subsided, when it may be placed in an immovable plaster-of-Paris dressing, and retained until union has taken place. If a double section is to be made at different points, an antiseptic sponge should be bound over the incision in the soft parts of the first while the second operation is being made. This affords an opportunity to determine the severity of the hemorrhage and the ease with which it can be controlled. If it be necessary to divide one bone in two situations to correct a deform- ity, the second division should be deferred until the former has healed, when it should be done at the remaining point of greatest convexity. If the bones be much curved, it may become necessary, in order that the deformity be properly corrected, to remove a wedge-shaped piece (cuneifom ostreotomy). For this purpose the chisel alone should be employed. In all instances when the bichloride gauze is to be applied, the skin must be protected from its irritant effects by smearing it with a mixture of glycerin and salicylic acid, or by placing between the bichloride gauze and the skin one or two thicknesses of carbolic- acid gauze ; the latter plan is the better. All osteotomies should be performed under strict antiseptic precau- tions, and the incision of the soft parts closed with a catgut suture. The limb must be immovably fixed and the patient kept quiet; in fact, the measures applicable to a compound fracture are in order, since it resembles that condition more nearly than any other. Results.—The results of all osteotomies performed with antiseptic precautions are extremely flattering. As yet, I have no personal knowledge of a death from the operation, and of fourteen hundred osteotomies but about one per cent are reported to have died in con- sequence of it. 222 OPERATIVE SURGERY. Hallux Valgus.—This deformity is practically limited to the great toe, and is usually caused by improperly fitted boots and shoes. Fig. 468 represents the condition more graphically than words can do it. The first phalanx (anatomical) articulates with the inner portion of the distal extremity of its metatarsal bone and is rotated inward on its long axis. The principal portion of the head of the metatarsal bone projects inward, and its extremity is surrounded by a sensitive bunion. The indication is to place the toe in its normal axis and retain it in that position. If the deformity be great, little else than an operation on the bone will be of any practical value. Two methods can be recommended: 1. The removal of the head of the metatarsal bone, with enough of the shaft to permit the great toe to be easily returned and held in its normal axis (Fig. 270). Under strict antiseptic precautions this operation results in quick recoveries and useful toes. 2. The deformity can be corrected by removing a V-shaped piece from the inner portion of the distal extremity of the metatarsal bone, as near the head as possible without involving the joint cavity. This, too, must be done under strict antiseptic precautions, and is accom- plished through an incision made along the inner side of the meta- tarsal bone. The soft parts are retracted and the V-shaped piece of the bone is removed, without dividing more than three fourths its diameter. The thickness of the base of the triangular piece to be removed is estimated by the degree of the deflection of the toe from its normal position; it should correspond as nearly as practicable to about one third the distance which the extremity of the toe will trav- erse to regain its normal relation to the foot. The wedge can be removed by means of a saw or chisel and the toe brought into position, which will fracture the inner undivided por- tions of the bone. Horse-hair drainage and immobility under anti- septic dressing will be followed by speedy union and a satisfactory recovery. Osteoplasty, or transplantation of bone, has not gained the promi- nence as a surgical expedient that the knowledge of the laws govern- ing the growth of bone bids fair to attain for it. Bone associated with its periosteal and fibrous connections, has been transferred, as in the case of the operation on the hard palate for the closure of the fissure, also the closure of the spaces between the ununited fragments of bone, by filling them with freshly sawn sections from the main shaft. The conditions necessary to a successful issue of this operation are exceedingly numerous and exacting, the chief one of which is a most rigid adherence to the antiseptic methods. The feasibility of bone transplantation as a practical measure is not, as yet, sufficiently established to warrant its being considered an accomplished fact. AMPUTATIONS. 223 CHAPTER IX. AMPUTA TIONS.—GENERAL CONS/DERA TION. Amputation consists in the removal of a limb either in its con- tinuity or at its articulation, although the latter is often termed dis- articulation. The aims sought to be gained by an amputation are : 1. The saving of the life of the patient. 2. The securing of a serviceable stump. If the prospects of recovery be annulled by the presence of a badly diseased or mangled limb, it is no opprobrium upon the art to remove it. If a limb be so badly injured or diseased as to require removal, it is entirely proper that the ability of the designer of compensative ap- pliances be considered, that the patient may reap the combined benefit of the art of the surgeon and the ingenuity of the mechanic. A stump, to be serviceable, should be sound, unirritable, with a good circulation and abundant leverage. The first three qualities depend, all things being equal, very largely upon the length, shape, and vascu- lar supply of the flaps; the last depends entirely upon the length of the bone. The flaps should be movable over the extremity of the stump after healing is completed, not tightly drawn and smooth like a base-ball cover. Flaps that are tightly drawn at the initial dressing soon become more so, on account of the inflammatory action. The increased tension causes pain, and early and rapid ulceration at the seat of the ligatures, followed by separation of the flaps, union by granulation, and finally a troublesome stump ; or, the normal shrink- age of the integument draws the flaps against the end of the bone, to which they, together with the cicatrix, become immovably united, and cause a similar difficulty. The proper length of the flaps, then, be- comes an important point in estimating the prospective usefulness of the limb and comfort of the patient. In cases where each flap can be made of a similar length, its extent should correspond to about one fourth the circumference of the limb at the point where the bone is to be divided. If one flap only be employed, it should be made double the length of each flap when two are employed. Any increase in the length of one flap should be accompanied by a proportionate decrease in the length of the other. The shape of the flaps largely controls the site of the cicatrix. It is advisable that the cicatrix be so placed as not to be subjected to pressure or friction. If, however, the flaps be made of sufficient length to admit of the formation of a non- adherent or movable cicatrix, its location is a matter of secondary importance. The length and location of the flaps also largely control their circulation. If they be too long, the circulation will be en- feebled ; if, on the contrary, they be too short, the tension will be- come an impediment, causing a blue, cold, and shiny surface, sensitive 224 OPERATIVE SURGERY. to the slightest injury. The circulation in the normal limb, or a por- tion of it, may be such as to predispose to a small and sluggish blood- supply in flaps constructed from it. Flaps are classified, according to the tissues entering into them, as the cutaneous, integumentary or skin flaps, musculo-cutaneous, and periosteal, either variety of which may be made either single or double. The integumentary variety is commonly employed in this country. Flaps are also classified, according to their shape, into circular, modified circular, oval, rectangular, hood, etc. The oval may be either unilateral, bilateral, anterior, or posterior. Many of the pre- ceding forms may be composed of integument alone, or combined with muscular tissue, and even with periosteum. Circular Method (Fig. 303).—This method is followed by an ad- Fig. 303.—Circular method. mirable stump, is easiest of performance, and consequently very fre- quently practiced. It is especially to be recommended in the field operations of military surgery, since the lightness of the flaps permits the transportation of the wounded with the minimum degree of dis- turbance of the seat of the amputation. It is done by making a circu- lar incision transversely around the long axis of the limb, through the integument and subcutaneous tissue down to the muscles, at a distance below the proposed division of the bone, corresponding to about one fourth the circumference of the limb at that point. The flap is then dissected up from the muscles with an ordinary scalpel; the edge of the knife being directed toward the muscles (Fig. 304) rather than AMPUTATIONS. parallel with them (Fig. 305), as the latter severs the capillary con- nection between the integument and the deeper tissues. The dissec- Fig. 304.—Dissecting up the flap. tion should be done by circular sweeps, rather than by mincing cuts, which hack the tissues and provoke suppuration. This careful man- Fig. 305.—How not to do it. ner of raising the flap applies equally to all the varieties which involve the separation of similar tissues. If the limb be conical, much difficulty will be experienced in turn- ing over the sleeve of integument; this, however, can be obviated by a longitudinal cut made usually at the most dependent portion of the flap. 15 226 OPERATIVE SURGERY. The flap should be turned upward to the point where the bone is to be divided; then with suitable knife make a circular division of the zj? Fig. 306.—Circular division of the muscles. muscles down to the bone, beginning far enough below the reflection of the flap to allow for the retraction of the divided muscles. No definite law can be assigned to this element, still they will contract according to their size, length, degree of irritability, etc. The suita- ble points of section will be stated in connection with the description of the special amputations. Not infrequently the muscles are cut just below the reflection of the flap, as in Fig. 306; this is not, however, as good a plan as the former, since sensitive stumps are more liable to result therefrom. The bone should be sawn at its highest point of exposure. The Modified Circular Method (Fig. 308). —This plan was suggested by Mr. Liston, who made semilunar flaps, which he dissected up to their point of junction with each other, at which point the muscles and bone were divided, as in the circular method. This method was Fig. 307.-StumP after afterward modified by Mr. Syme, who dissected the circular operation. a short distance above the point of juncture of the flaps, and divided the muscles and bone, as before. In either instance, however, it amounts to slitting up the cuff of a circular flap, and trimming off the angles caused thereby. AMPUTATIONS. 227 The Oval Method.—This is in reality a modified circular amputa- tion, the flap being slit up at one side and the angles trimmed off. It Fig. 308.—Modified circular flap. is employed principally in disarticulations, and will be described in i connection with those operations. The Single-Flap Method.—-This is adapted to those cases where the tissues of one side of the limb only are suitable for the purposes of a flap; as in the case of lacerations, ulcerations, etc. This flap may be composed of the muscular tissues and integument, or of in- tegument alone ; and can be made either by transfixion, or division from without. If possible, a short convex flap is made on the opposite surface of the limb. The Double-Flap Operation is performed by transfixion, and includes the muscles down to the bone on either side of the limb (Figs. 309 and 310). The tissues to be transfixed are raised slightly by the left hand of the operator, who then enters the point of the knife at the side nearest himself, pushing it through slowly, in close contact with the anterior surface of the bone, slightly raising the handle as it passes in front of the bone, thereby causing its point to emerge at the opposite side of the limb at a point exactly opposite to its entrance; the flap is then made by cutting obliquely upward with a sawing mo- tion. It is pulled backward by an assistant, and the knife is reinsert- ed at the original point of entrance, carried behind the bone, handle depressed to cause the point to emerge at the same situation as at the anterior transfixion, and the posterior flap made by cutting obliquely downward. Each flap should correspond in length to at least one half the diameter of the limb. The retractor is then applied, and all 228 OPERATIVE SURGERY. the soft tissues are drawn well upward ; the remaining fibers in con- tact with the bone are severed by a circular sweep of the knife, and Fig. 309. Fig. 310. Figs. 309, 310.—Flap by transfixion. the bone is carefully sawn through. If lateral flaps be made, the outer should be formed first. The flap containing tlae large vessels is to be divided afterward. The Mixed Double Flap is a modification of the preceding, and sometimes called Sedillot's method. The flaps are made by trans- fixion, as before, but are more superficial, the knife not being brought in contact with the bone. The remaining muscles and vessels are di- vided by a circular incision, and the amputation completed as before described. In this instance the flaps are thinner and shorter than in the preceding. Lange?ibeck's Method.—This differs from the last only in the man- ner of obtaining the result; the flaps being cut from the surface toward the center of the limb, which affords a better opportunity to shape them. Another modification of the method consist in cutting the anterior flap from the surface, and making the posterior flap by transfixion. The Rectangular Flap, or TeaWs Method (Figs. 311 and 312).— In this two rectangular flaps are employed, one being four times longer than the other; both flaps include the structures down to the bones. The longer flap is taken from the side of the limb, where the bone is most superficial. The shorter contains the important vessels. The length and breadth of the long flap correspond to half the circumfer- ence of the limb at the point of proposed amputation. The width of the short flap is a half, and its length an eighth, of the circumference of the limb. Both flaps should be carefully marked out before begin- AMPUTATIONS. 229 ning the operation. This method makes an admirable stump, but sacrifices fulcrumage, and brings the bone section nearer the body Fig- 311. Fig. 312. Figs. 311, 312.—Teale's method. than is consistent with the additional dangers incurred. Mr. Lister recommends that the longer flap be made a third and the shorter flap a sixth of the circumference of the limb, which brings the cicatrix at the edge of the stump. Also that the posterior flap shall consist of the integument and subcutaneous tissues alone. This, like Teale's, may be employed when the loss of tissues is greater upon one side than upon the other. The Hood Flap.—There is no substantial difference between this and the circular method, if the latter be slit up at the most dependent part, and the resulting corners rounded off. This method meets the indications requisite to form a good stump as well as any other variety of flap. Equilateral Flaps (Fig. 313) consist of equilateral skin-flaps, oval in outline, the posterior angle being made somewhat farther up the limb, to improve the drainage. The muscles are cut by a circular sweep at a suitable distance below the point of reflection of the integumentary flaps, and the bone is sawn above the anterior point of junction of the flaps. Periosteal Flap.—This is made by raising the pe- riosteum in conjunction with the tissues which rest upon, or are attached to it, sufficiently to cover the end of the divided bones, when it is allowed to fall into place. It is best adapted to those bones subcuta- neously located, like the tibia, and will be again re- ferred to in connection with amputations of the leg. A periosteal flap will, if it becomes adherent to the end of the bone, preserve it from atrophy, and lessen the danger of the formation of a conical stump ; it likewise prevents the adhesion of the cicatrix to the stump, thereby forming the basis for a movable cicatrix. Fig. 313—Equi- lateral flaps. 230 OPERATIVE SURGERY. If the patient be young, new bone may be developed; this lessens the sensibility and increases the usefulness of the stump. It is claimed by some that the bony spiculae often shoot into the soft tissues on the end of the stump, and require a second operation for their removal. It is my opinion, however, that if the periosteum be removed entire and in connection with its superimposed tissues, and be so placed that the force of gravity will aid in holding its bone-producing surface in contact with the divided extremity, this danger will be obviated. Comparative Merits of Different Forms of Flaps.—The ends sought to be gained in making flaps are : 1. To secure good drainage. 2. To make them of suitable length, that the circulation and movement of the integumentary cushion at the end may be unrestrained. 3. To place the cicatrix beyond the point of friction, and prevent its adhesion to the end of the bone. 4. To guard against any danger of undue sensibility, by making the flaps of proper length, and by drawing down and cutting off the cutaneous and other nerves of larger size that may exist in them. With these aims in view, it will be seen that the. old-fashioned cir- cular flap affords equal advantages to the others, and is further com- mendable for its simplicity. It is true that in this method the scar will fall on the end of the stump, but with proper precautions as to the length of the flaps and suitable surgical attentions, any danger from this source is reduced to a minimum. The Agents required for an Amputation may be classed as those for arresting hemorrhage ; for the division and trimming of the soft parts and the bone ; and those for uniting and dressing the wTound. The preparation of the patient for the operation ; the agents for con trolling and arresting hemorrhage, together with the various methods of secur- ing and maintaining the coaptation of the cut surfaces, drainage, and various forms of dressing, antiseptic and otherwise, have herein been previously considered; therefore, there remain to be enumerated, under this heading, only those instruments especially adapted to the requirements of the operation. Amputating Knives (Fig. 314).—The modern amputating knives can be used for making circular flaps, or, for those made by trans- fixion. They should be double-edged (catlin) entirely or for an inch or two from the point. The length of the knife selected will depend upon the size of the limb to be operated upon, and should be about one and a half times its diameter. It may be inconsistent with good taste, but it is entirely consistent with good judgment and economy, to amputate an arm or forearm with the knife intended for the thigh, and the result will be equally satisfactory. The Manner of grasping the Amputating Knife, prior to and during the division of the soft parts, adds much to the optical effect of an operation. It should be, at first, lightly grasped, with the edge for- AMPUTATIONS. 231 Fig. 314.—Amputating knives. ward, between the thumb and first two fingers, near enough to the shank to admit the upper end of the handle to play between the heads of the metacarpal bones of thumb and finger, when it is swung backward and forward (Fig. 315). There are two methods employed of carrying it entirely around the limb : 1. Stand with the leftside toward the patient, seize the limb above the point of intended operation with the left hand, an assistant holding its distal extremity; place the left foot forward, slightly bend the right knee, and with the catlin held by the right hand, as before described (Fig. 315), stoop downward and forward sufficiently to carry the knife and arm under, and the knife over the limb, placing its heel as near to the upper sur- face of the limb as is convenient, when, with a sawing motion, it is drawn toward the operator beneath the limb, then upward between it and the operator, and so on around, until it joins the beginning of the cut, making a complete circle (Fig. 316). If the knife be properly grasped, it will pass readily between the thumb and forefinger, as the hand passes around the limb ; enabling the sur- geon to make the section with perfect ease, and without the least manifestation of stiffness. 2. The method may be reversed by pass- ing the hand and knife over instead of under the limb (Fig. 317) ; otherwise the manipulations are the same. The latter, however, is less natural, besides which it exposes the arm of the operator, and the integument to be divided last, to the flow of blood. Still, either of these methods is far superior to the one commonly employed and fig- ured in text-books (Fig. 318). The Catlin (Fig. 321).—This is chiefly employed to divide the tis- sues in the interosseous space, in amputations of the leg and forearm. It can be readily supplemented for this purpose by the single-edged narrow knife, provided the latter be withdrawn to complete the divis- Fig. 315.—How to grasp the amputating knife. 232 OPERATIVE SURGERY. tf. T£. ^3 Fig. 316.—How to carry the knife around the limb. Fig. 317.—Another method. ry broad-bladed saw (Fig. 320) and the bow-backid (Fig. 322) are in common use. The first meets all requirements except in certain excisions, when either the chain-saw (Fig. 239) or Butcher's saw (Fig. 323) must be employed. The narrow, movable-backed saw ion of the interosseous tissues, instead of chang- ing the direction of the cutting edge, while it remains between the bones. The latter act will bruise and tear the interosseous tissues. Two or three ordina- ry scalpels should be added for raising the in- tegument, etc. A knife with a long, narrow blade is the bet- ter for amputating at the phalangeal articula- tions (Fig. 219). Saws.—The ordina- Fig. 318.—A common method. AMPUTATIONS. 233 Fig. 319.— Fig. 320.—Broad-bladed Fig. 322.—Common bow-saw. Metacarpal saw. knife. (Fig. 241) is of use in sawing small bones and removing spiculae. The Proper Method of using a Saw should be given some attention (Fig. 324). After the division of the soft parts, Fig. 321. —Catlin. Fig. 323.—Butcher's bow-saw. 234 OPERATIVE SURGERY. m ? •■ -M >s Fig. 326.—Fara- bcuf s forceps. —Sawing the bone. bleeding points. Fig. 325.—Ferguson's lion-jaw for- ceps. the surgeon grasps the saw firmly, places its heel close to the border of the re- tracted muscles, in a line made through the perios- teum by the knife, and, while guided by the thumb- nail, slowly and carefully draws it toward himself along the first four or five inches of its edge, raises it from the track, and places it as before; repeating the operation until a track of sufficient depth is made to re- tain it during the to-and-fro move- ments of sawing, which should be done by quick, sharp strokes, until the bone is nearly severed, when care must be taken, or the saw will be clamped and the remaining por- tion be broken off. If the handle of the saw be raised and the re- maining portion be divided at a different angle with the bone, the danger of breaking is lessened. When two bones are to be sawed off, AMPUTATIONS. 235 the saw should be started in the less movable bone, and then turned so as to include both. If the movable one clamp the saw, cut off the more solid one first, then complete the other. The proximal and distal portions of the limb should be supported and steadied during the sawing of the bone. Bone-Forceps.—Liston's cutting forceps (Fig. 227) are used for trimming off rough prominences. Ferguson's lion-jawed (Fig. 325) and Farabceuf s forceps (Fig. 326) are excellent instruments for grasp- ing the bone to steady the part. They are also used for removing bone by twisting, when great force is required. How to operate.—Before beginning an amputation, the operator should rehearse in his mind, at least, the entire procedure as he con- templates it; by doing this he will be confident, and be certain to anticipate the unimportant as well as the important details. The preparation of the patient and administration of the anaesthetic, and methods of dressing, are given on the pages in the fore part of this work. The surgeon should always plan his work with careful precis- ion, even to marking out upon the limb the outlines of the flaps, and such other incisions as may be required. I am aware that this is sel- dom practiced, even by the most experienced surgeons; but, within my own observations, had it been done more frequently better results might have been secured. The young surgeon, too, often fancies that to do this announces him as ignorant and inexperienced ; such, however, is not always the case ; it rather serves to emphasize his cautious and painstaking qualities. An operation should be done without haste, when the safety of the patient will permit, remembering that it is done quickly when done well. The operator should stand in such a relation to the patient that the left hand can readily control any undue hemorrhage by compressing the artery, or otherwise. The primary incision should be so located, if possible, that the escaping blood will not obscure the course of the incisions to be subse- quently made. The incision which will divide the important vessels should be made last when practicable. In circular amputations the tissues should not be retracted until after the division of the integument. In flaps by transfixion, the tissues to constitute the flap can be raised or depressed, according to the aspect of the limb from which they are to be made. After the limb is removed, the open mouths of the vessels should be caught by serrefines, forceps, etc. The tourniquet, or Esmarch's band, is then loosened slowly, and all bleeding points controlled by suitable means (Fig. 327). The surgeon can then proceed carefully to ligature the vessels thus secured. 236 OPERATIVE SURGERY. _ . La,-"*? Fig. 328.—Retractor for two bones. Fig. 329.—Retractor for one bone. The Retractor is made of linen, or ordinary muslin, torn according to the size and anatomical arrangement of the limb to which it is to be applied. If for two bones, one extremity of the retractor should be torn into three strips (Fig. 328), the middle one to pass between the bones (Fig. 330). If for one bone, the re- tractor is torn partial- ly through the middle (Fig. 329), and applied as shown in Fig. 331. AMPUTATIONS OF UP- PER EXTREMITIES. Fig. 330.—Three-tailed retractor applied. General Remarks.— In all the amputations of the hand and fingers, it is important to remember that usefulness and symmetry are the ends to be attained. If strength and usefulness be desiderata, all those points should be preserved into which the muscles and ligaments are inserted, which endow the part with impor- tant functions. AMPUTATIONS. 237 It therefore be- comes imperative for the surgeon to careful- ly study the functions of the muscles associ- ated with the hand, and to preserve as care- fully as possible their points of insertion. It is a well - established principle that every portion of the hand of a laboring man which possesses motion and can become of service to him should be saved. In the case of one whose circumstances or avocation will permit, the sacrifice of useful- Fig. 331.—Two-tailed retractor applied. ness to symmetry may be made with the concurrence of the patient. Amputation at the Phalangeal Articulations.—Surgical Anatomy. —The first row of surgical phalanges is flexed by the terminal inser- tions of the flexor profundus digitorum; the second, by the flexor sub- Fir,. 332.—Attachments of tendons to phalanges. 1. Extensor communis digitorum. 2. First surgical phalanx. 3. Fibrous bands between common flexor tendons and distal extremity of the third surgical phalanx. 4. Tendons of flexor sublimus digitorum. 5. Tendon of flexor profundus digatorum. 6. Vincula accessoria tendinum. 7. Head of metacarpal bone. 8. Joint between second and third surgical phalanges. 9. Joint between first and second surgical phalanges. 238 OPERATIVE SURGERY. limis digitorum ; the third, by the flexor sublimis, through the vincula accessoria tendinum ; by dense fibrous bands connecting the tendons of the flexor sublimis with the distal extremity of that phalanx as it passes across it; also by the secondary action of the lumbrical mus- cles (Fig. 332). The Terminal Phalanx is amputated by seizing and flexing it to a right angle with the second (Fig. 333) ; a transverse incision is then Fig. 333.—Flexed phalanx. Fig. 334.—Making flap. Fig. 335.—Flap completed. made on its dorsal surface, on a line corresponding to the center of the long axis of the second phalanx, which will open the joint; divide the lateral ligaments with the point of the knife, separate the articular surfaces, and pass the blade between them, then cut along the under surface of the phalanx to be removed, close to the bone (Fig. 334), far enough to make a palmar flap of sufficient length to easily cover the end of the bone (Fig. 335). The rule previously given regarding the length of flaps will enable the operator to meet this requirement. If the at- tached extremity of the flap be commenced by dividing the tissues at each side of the phalanx, for three or four lines, down to the bone, the knife can follow its under surface without the danger of making the attached end of the flap too narrow, owing to the extremities of the phalanges being thicker than their bodies. If any of the tissue of the flexor tendon be in the flap, it should be re- moved. Tie the vessels, place and retain the flap in position by two or three fine sutures and adhesive strips ; or dress antiseptically. Amputation of the Second Row can be done in precisely the same manner as at the first, or, with the finger extended, by making a palmar flap first by transfixion through the palmar surface opposite the joint, and cutting downward until a well-rounded flap is formed (Fig. Fig. 336—Flap by trans- Fig. 337.—Opening joint fixion. AMPUTATIONS. 239 336). Then carry the knife upward between the articular surfaces and through the soft parts on the dorsum (Fig. 337). Either of the phalanges may be amputated at the center by a short posterior and a long inferior or palmar flap. If the third surgical (first ana- tomical) phalanges be amputated at the center, the power of flexion is limited to the lumbrical mus- cle, and the vincular tendons connecting them with the flex- or sublimis digi- torum (Fig. 332). When symmetry is a secondary consider- ation, this amputa- tion may be made. In the case of the thumb, the index and little fingers, everything possible adding to the length of the digit should be saved, as the range of motion of the thumb and little finger is more extensive than the others, and the presence of the index-finger or its stump greatly aids the crippled thumb in the performance of its functions. Amputation at the Metacarpophalangeal Articulation.—It is recom- mended by some that this operation be practiced in lieu of amputation at the middle of the third phalanges (surgical) of the second and third fingers, or even disarticulation between their second and third pha- langes. I am satisfied, however, that the hand will be far stronger if the stumps be allowed to remain, since they soon become easily flexed and extended, and the continuance of these motions serves to stimu- late and nourish the common muscles engaged in them, and thereby strengthens the power of the remaining fingers. Amputation of the Second or Third Finger.—This is done by the oval flap, which should be marked out before the operation is com- Fig. 338.—Amputating middle finger, oval flap. 240 OPERATIVE SURGERY. menced (Fi°- 338). The flaps must be taken from the finger to be removed, and should be of generous dimensions. The limit of the in- cision above corresponds to the head of the metacarpal bone, the lower limit to the transverse line of the palm joining the fingers to the web Separating widely the contiguous fingers, the surgeon seizes the condemned finger, extends it well, and carries the incision trans- versely along the line beneath, then in a curved direction upward, along the side of the finger to the head of the metacarpal bone. This incision is repeated on the opposite side ; the tissue carefully divided, and the finger removed (Figs. 338, 339). Better drainage will be se- cured if this flap be reversed by forming its retiring angle on the palmar instead of the dorsal surface of the hand (Fig. 340). Lateral-Flap Operation.—-This is best adapted to the thumb, in- dex, and little fingers (Fig. 340) ; it can, however, be employed at the ring and middle fingers. The limit of the dorsal incision is the same as in the preceding. The lower limit, after crossing the trans- Fig. 339.—Finger removed. Fig. 340.—Lateral-flap method. Fig. 341 .—Oval method. verse line of the web, extends toward the palm about a third of an inch. The flaps are taken from the sides of the finger to be removed. In the case of the middle and ring fingers the flaps should be equi- lateral. For the thumb, index, and little finger, that portion of each against which pressure is most liable to be brought should be covered by a longer flap, which is taken from the outer surface of the index- finger, from the inner surface of the little finger, and from the palmar aspect of the thumb, the base of the flap being on a level with tne joint. The longer one is dissected off, after which the smaller one is made. Divide the ligaments and tendons, and remove the member. Amputation of the Thumb at the Carpo-metacarpal Articulation. —Oval Method.—-This can be employed equally well upon the thumD, AMPUTATIONS. 241 index, and little fingers. The limit of the dorsal incision in either in- stance is the proximal extremity of the metacarpal bone to be removed. Its palmar limit is the transverse line at the junction of the finger with the palm. Begin the first incision at the base of the metacarpal bone of the thumb (Fig. 341), carrying it along in a slightly curved direction to the outer side of the metacarpophalangeal articulation ; then inward through the line of the web. The second one joins the first near the base of the metacarpal bone, and takes a corresponding course along the inner side, meeting the former at the inner extremity of the transverse line of the web. The flaps are dissected off, and the artic- ulation between the metacarpal bone and the trapezium is opened from the ulnar side, to avoid injuring con- tiguous joints (Fig. 342). The union of the flaps leaves a linear cicatrix (Fig. 343). The Lateral-Flap Method (Fig. 344).—This method can be more quickly and easily performed than the former, but leaves the cicatrix in a less advantageous situation. Abduct the thumb and enter the knife between the first and second metacarpal bones ; carry it up be- tween them with a sawing motion, till the head of the first is reached. Cautiously disarticulate it from within outward; increase the abduction, and carry the blade through the joint and along the outer side of the metacarpal Fig. 342.—Opening joint. Fig. 343.—Flaps united. Fig. 344.—Lateral-flap method. 16 Fig. 345.—Making outer flap. 342 OPERATIVE SURGERY. bone, making the outer flap, which should terminate opposite the web of the thumb (Fig. 345). The bases of the metacarpal bones of the index, middle, and little fingers should be preserved in all possible instances, as they afford attachment to the important extensor and flexor muscles of the carpus. Amputation through the Metacarpal Bones. — In amputation through two or more of these bones, the principal flap should be taken from the palmar surface, although it may be taken from the border and palm of the hand (Fig. 346). If through but one bone, the Fig. 346—Amputation through fourth Fig. 347.—Amputation through one metacarpal and fifth metacarpal bones. bone. incisions are the same as those for amputation at the metacarpo-pha- langeal articulation by the oval method, the only difference being that their upper limit will correspond to the point of proposed section of the bone (Fig. 347). The bone is exposed by reflection of the soft parts upon the point of proposed section, after which it is sawn through with either a chain- or metacarpal bone-saw, separated from its palmar connections and removed with the finger attched. If a saw be not convenient, the cutting bone-forceps (Liston) can be used, al- though with some risk of splintering the bone. This operation is often performed in preference to disarticulation at its head, in order to give symmetry to the hand (Fig. 348). The division of the transverse ligament, which extends between the heads of the metacarpal bones, lessens the strength of the grip. AMPUTATIONS. 243 This operation is, therefore, not to be recommended except in those of sedentary habits. Amputation of the Last Four Metacarpal Bones {Disarticulation). (Fig. 349).—Make a semilunar flap from the palm by a curved incis- ion, beginning at the web of the thumb and terminating at the ulnar border of the fifth metacarpal bone. This flap can be made by trans- fixion, if desired (Fig. 350). The dorsal incision (Fig. 351) begins at the same point of the web of the thumb, and is carried to the upper third of the metacarpal bone of the index - finger, and Fig. 348.—Appearance of hand Fig. 349.—Line of palmar Fig. 350.—By transfixion. after amputation through flap. tliird metacarpal bone. from there transversely across until it meets the ulnar extremity of the first incision. The flaps are now reflected up to the carpo-meta- carpal joint, the hand strongly abducted, and the carpo - metacarpal joint opened from the ulnar side, using great caution not to injure the trapezium and the meta- carpal bone of the thumb. Without the thumb this operation would be of lit- tle avail in securing a use- ful stump. Unite the flaps with interrupted su- tures, introduce a drain- age-tube (Fig. 352), and treat antiseptically. The results oi ampu- FlG. 351.-Line of dorsal tations of the thumb and flap. Fig. 352.—Appear- ance of stump. 244 OPERATIVE SURGERY. fingers are favorable ; only three to six per cent, and even less, with antiseptic precautions, die. Amputation at the Wrist (Disarticulation).—The bones enter- ing directly into this articulation are the radius, scaphoid, and semi- lunar. The location of the joint can be determined, 1, by forcibly bending the carpus backward, when the summit of the angle on the dorsal surface formed by the hand and forearm indicates the radio- . carpal joint; 2, by drawing a line transversely from one styloid pro- cess to the other—the joint is about one fourth of an inch above it. This operation can be done by either the circular, single palmar or radial flap, or by the double-flap method. The Circular Method.—Ascertain one fourth of the circumference Fig. 353.—Circular method. Fig. 354.—Flaps united. at the articulation. Measure this distance downward from the articu- lation, and divide the soft tissues at that point by a circular incision ; dissect up the sleeve of integument until opposite the joint; pronate and forcibly flex the carpus, and open the wrist-joint on the dorsal surface by an incision extending between the styloid processes ; divide the lateral ligaments, pass the blade through the articulation, and sever the remaining structures (Fig. 353). Unite the flaps in the long axis of the joint, introduce drainage-tubes and sutures, and dress anti- septically (Fig. 354). Double-Flap Method (Euysch).—Mark out the distal limits of the flaps as in the circular method ; flex and pronate the hand; carry a semilunar incision over its dorsum, beginning at the styloid process of the ulna and extending to the circular line indicating the dorsal ex- tent of the flap, terminating at the radial styloid process (Fig. 355). AMPUTATIONS. 245 Making dorsal flap. Fir,. 356.—Making anterior flap. Dissect up the flap, allowing the tendons to remain ; flex the carpus firmly, and open the articulation, as in the circular method ; carry the blade of the knife through the articulation (Fig. 356) and make the anterior flap by cutting outward. Single Palmar Flap.—This method is easily performed, and makes as serviceable a stump as any. Mark out a flap on the palmar surface, semilunar in shape, and about three inches and a half in length, its base being located just below the apices of the styloid processes (Fig. 357); reflect it upward ; divide the remain- ing tissues in front of the articulation ; open it. passing the knife through, and making a short dorsal flap. The dorsal flap can be made first, the joint opened from behind, and the long anterior flap cut from Fig. 357.- the joint outward. Radial Flap (Dubrueil).—Mark out a flap, semilunar in shape, the base of which shall embrace the radial third of the carpus, corre- sponding to the base of the second phalanx of the thumb (Fig. 358). Separate the thumb-flap, then connect the extremities by an incision carried transversely around the ulnar side, draw the skin upward, open the joint as before, remove the carpus, and properly adjust the flaps and drainage-tube (Fig. 359). Results.—The rate of mortality in amputation at the wrist-joint is from fifteen to thirty per cent for gun-shot wounds, being about eight per cent greater than for amputation through the forearm. ■rtU -Single palmar flap. 24G OPERATIVE SURGERY. Fig. 358.—Radial flap. Fig. 359.—Ap- pearance of stump. It therefore follows that amputation at the wrist-joint can not be recommended, on the ground of safety to the patient. There are other objections of less importance, which, with the one just stated, should place the operation in disfavor with the surgeon. It makes a stump which, owing to the feebleness of the circulation in the flaps, becomes cold and even chilblained ; in addi- tion, its extremity is bulbous, thereby interfering with the application of the properly fitting sockets connected with artificial appliances. Amputation of the Forearm.—The forearm is best amputated by the circular-flap method ; although the equilateral skin, and musculo- cutaneous flaps are often employed. Circular Amputation.—Carefully lay out the length of the pro- posed flap, based on a fourth of the circumference. Divide the tissues by a circular incision down to the fascia surrounding the muscles ; the integumentary cuff is then dissected upward by repeated incisions directed toward the fascia surrounding the mus- cles. If the cuff be too small to be turned up readily, its most dependent part Avhen dressed can be slit up. After the flap is reflected suffi- ciently, the muscles are divided half an inch or so below the line of its reflection by a circular sweep of the knife down to the bone, the bone sawn off, and the wound dressed in the usual manner. The in- terosseous membrane and its vessels should be divided a short distance below the point of proposed bone section and its borders separated from those of the contiguous bones up to the point of section. This avoids the risk of cutting the vessels too short, as when they are divided at a level with the bones, which permits them to retract above the point of easy access. These remarks apply with equal force to amputation of the leg. The Er/uilateral Skin-Flaps are raised from the anterior and pos- terior, or internal and external surfaces of the forearm ; the latter be- ing by far the most frequently adopted. Their length is determined in the same manner as in the circular ; in fact, if the circular be first done, and the angles of the cuff trimmed off down to near the site of the muscular section, the lateral flaps will be formed. It is better, however, to mark out their outlines before beginning them ; since, to make each with the same curve and same breadth of base is not an AMPUTATIONS. 247 easy task without this precaution. The remaining procedures are the same as those of the circular method. The Musculo-Cutaneous Flaps are made by transfixion and cutting outward ; in other respects the steps do not differ from the preceding operation. Results.—The rate of mortality in amputation of the forearm is about fifteen per cent for all causes. Amputation at the Elbow-Joint (Disarticulation).—The methods commonly employed are the circular and the single flap. Before op- erating, carefully define the most prominent portions of the condyles. Just below the outer, is felt the movable head of the radius ; about an inch below the inner, the ulna joins the inner, condyle ; the articula- tion is therefore oblique, the inner portion being about half an inch the lower, owing to the inner condyle being that much longer than the outer. Circular Method.—Lay out the flaps in the usual manner, measur- ing around the condyles. Divide the superficial tissues down to the fascia surrounding the muscles, as be- fore ; dissect the flap upward to a level with the joint, ^, Fig. 360.—Amputation at elbow-joint. Fig. 361.—Circular ampu- tation at elbow. the bony indications to which should be carefully determined. For- cibly extend the arm and make an incision on the line of the articula- tion (oblique) down to and into it; sever the internal and external lateral ligaments, and press the arm still farther backward ; draw the 248 OPERATIVE SURGERY. olecranon process forward into the wound, and sever its connection to the triceps (Fig. 360). Unite the borders of the flap as indicated in the figure (Fig. 361). The flaps can also be united from before back- ward, which causes the cicatrix to fall between the condyles, and like- wise increases the drainage facilities—two very important indica- tions. The Single-Flap Method.—This flap can be made either of integu- ment and subcutaneous tissue alone, or be musculo-cutaneous, and formed by transfixion. In either instance it should be taken from the anterior surface of the forearm. If made by transfixion (Fig. 362), supinate and flex the forearm slightly, raise the soft parts in front of the joint, and enter the knife an inch below the inner condyle, pass it in front of the bones obliquely outward, causing it to escape about one inch and a half below the outer condyle. Cut the anterior flap downward and outward, making it about three inches and a half in length ; dissect and draw the flap up to a level with the joint in front. Make the posterior flap by connecting the ex- tremities of the first incision by a trans- verse one (Fig. 363), and dissect this up, after which the joint is opened in front; the lateral ligaments divided, olecranon Fig. 362.—Flap by transfixion. process displaced forward, and the tri- ceps cut off. It is advisable, when pos- sible, to saw off the olecranon, allowing it to remain with the triceps attached. The stump will be stronger if it be pos- sible to sever the ulna below the inser- tion of the brachialis anticus, allowing the fragment to remain along with its muscular attachments. In amputations near the elbow, the tubercle of the ra- dius, together with the biceps tendon Fig. 363.—Making posterior flap. inserted into it, should be carefully pre- served. Results.—The deaths from this amputation vary from thirteen to twenty per cent without antiseptic treatment. Amputation of the Arm.—Either the circular, double flap, or the single circular incision method of Celsus can be employed. The former is usually preferred. In the second, the flaps may be antero-posterior, or lateral; integumentary alone, or combined with muscular tissue. The single circular operation is seldom employed at the arm. Circular-Flap Method.—Plan the length of the flap upon the cir- A r& AMPUTATIONS. 249 cumference of the limb at the point of proposed section. Divide the superficial tissues down to the muscular fascia, and turn the flap up as elsewhere ; then divide the muscles down to the bone, about an inch below the reflection of the flaps. Apply the two-tailed retractor, saw through the bone opposite the point of reflection of the flap, and unite the flaps m the direction best calculated to provide dependent drainage. Unequal Double-Flap Method.-!! skin alone be used, the flaps should be carefully mapped out upon the integument of the arm in the general manner before described. Dissect them up, and make a circular section of the muscles down to the bone ; unite the flaps, and dress the stump as before. !f Musculocutaneous Flaps (Langenbeck) be desired, they can be made by transfixion from within outward, or with a scalpel from with- out inward. The latter plan secures the more uniformity of outline in the flap. If they are to be i / made from without inward, / first mark them out carefully, then with a sharp scalpel form them as planned (Fig. 364) ; when dissected up the desired Fig. 364.—Langenbeck's method. Fig. 365.—Unequal skin-flaps. 250 OPERATIVE SURGERY. distance, complete the operation by dividing the muscles as be- fore. Large Anterior and Small Posterior Skin-Flaps are sometimes made (Fig. 365), also a large anterior one, with a posterior circular in- cision (Fig. 366). They possess the advantage of good drainage, and of placing the cicatrix where it is well removed from irritation. The outline of these flaps can be easi- ly estimated on the same — basis as if they were to be equal in length—viz., if one be proportionately increased in length, the other is to be shortened. Results.—The death- rate from amputation of the arm varies somewhat according to the seat of the operation. It is about eighteen per cent when done in the upper third, sixteen per cent at the middle third, and about twenty-six per cent at the lower third—the greater per cent in this situation being due, no doubt, to the greater degree of injury calling for it at this point. If done for disease, the percentage would no doubt be reversed. Amputation at the Shoulder-Joint (Disarticulation).—There are various methods recommended for amputation at this joint. It is hardly necessary to enter into the details of more than two or three of those commonly recognized and employed. The remainder, while ingenious in many instances, do not present differences of enough practical worth to be introduced into a hand-book of operative surgery. Amputation by Internal and External Flaps (Dupuytren).—Place the patient on the edge of the table, partially upon the healthy side, with the body raised. An external oval flap is made by an incision extending from the coracoid process downward and outward to the insertion of the deltoid ; then upward and backward, terminating at the junction of the acromion process with the spine of the scapula (Fig. 367). The flap, including the deltoid muscle, is now raised as far as the acromion, turned back, and the capsule of the joint exposed, Fig. 366.—Long anterior flap. AMPUTATIONS. 251 the head of the humerus pushed upward, capsule divided above ; then the arm is rotated outward and the subscapularis severed ; then in- ward, followed by the rapid di- vision of the ex- ternal rotators attached to tho greater tuberos- ity. While the arm is rotated internally, the capsule is still further divided, together with the tendon of the long head of the biceps, the head of the hu- merus tilted out- ward, and the blade of the knife passed be- neath it (Fig. 368) ; the head of the bone is then seized and drawn outward, and the knife carried along its inner surface until within about four inch- es below the ax- illary fold, when its edge is turned inward and the flap completed. The last sweep of the knife sev- ers the principal vessels, and this flap should be seized by an assistant and tightly grasped before it is completed. The vessels in this operation are controlled by either pressure upon the third portion of the subclavian, or by the elastic band arranged as Fig. 367.—Disarticulation of shoulder-joint. 252 OPERATIVE SURGERY. Fig. 368.—Making inner flap. Fig. 369.—Flaps united. the bone and ligature the vessels. Make a second incision longitudi- nally, from the anterior border of the acromion, the whole length of the stump, down to the bone. The bone is then held firmly and the soft parts separated from it (Fig. 370), after which it is rotated outward, then inward, to admit of the division of the muscular and fibrous at- tachments to its head, when it can be removed. This is a good oper- ation and well calculated to provide favorable drainage (Fig. 371), and is done with a minimum amount of injury to the soft parts. If the periosteum be separated from the bone without disturbing the sur- rounding soft parts, there will be less danger of the extension of in- flammatory action beyond the line of the longitudinal incision ; more- over, a greater degree of firmness will be given the stump, even though new bone be not produced. Oval Method (Larrey).—This method is well thought of, and is performed by making a vertical incision from the extremity of the acromion process, with the arm extended, about three inches in AMPUTATIONS. 253 Fig. 370.—Removing the bone. length down to the bone; this incision should terminate about one inch below the head of the humerus. Two oblique incisions are then made, each beginning near the middle of the vertical cut, one on the anterior and the other on the posterior aspect of the limb ; these, when carried through the structures composing the anterior and posterior walls of the axilla, to the lower border of each, divide their attachments to the humerus (Fig. 372). The soft parts at the inner side of the humerus still remain undivided. The borders of the wound are now drawn apart, the joint exposed and opened above; the bone drawn downward to separate the joint surfaces, and the blade of the knife passed between them, behind the luxated bone, and the operation completed by cutting the remaining tissues at the inner side of the humerus intervening between the lower extremities of the incisions previously made (Fig. 373). Spence's Method has attracted considerable attention, and is cer- tainly entitled to additional consideration. It does not possess any practical advantages over the method by circular incision. It is done in the following manner : Abduct the 254 OPERATIVE SURGERY. arm slightly; rotate the humerus outward ; cut down upon the head of the bone, beginning im- mediately external to the coracoid process, thence directly downward through the fibers of the deltoid and pectoralis ma- jor to the lower border of the latter, which is di- vided ; carry the incision with a gentle curve out- ward across and through the lower fibers of the del- toid, to, but not through, the posterior border of the axilla (Fig. 374). Be- gin the inner incision at the lower extremity of the vertical one, carry it around the inner side of the arm, through the Fig. 371.—Flaps united. skin and fat only, to meet the one made at the outer side. If the fibers of the deltoid have been thoroughly divided, Fig. 372.—Larrey's method. Fig. 373.—Forming inner flap. Fig. 374.—Spence'fl method. the flap, together with the posterior circumflex artery, can be easily separated by the finger from the bone and joint, and drawn upward J AMPUTATIONS OF THE LOWER EXTREMITY. 255 and backward until the head of the bone is exposed ; then the liga- ments and muscular attachments are divided, disarticulation accom- plished, and the limb removed by dividing the remaining soft parts at the axillary aspect. In very muscular subjects, a redundancy of that tissue in the flap can be avoided by dissecting the integument and subcutaneous tis- sues a short distance upward over the deltoid, and dividing its fibers high up. Results.—The rate of mortality varies from twenty-five to thirty- eight per cent for gun-shot injuries. Amputation above the Shoulder-Joint.—It may become necessary, on account of malignant growths and severe injuries, to amputate the scapula together with a portion or the whole of the clavicle. The operation is often tedious and attended with great loss of blood. Inasmuch as the situation of the disease or injury calling for it will modify the location and direction of the incisions, no definite plan can be prescribed. However, the aim should be always to save enough healthy integument to cover the wound and to avoid hemor- rhage. Results.—Fifty-one cases are reported, with a mortality of twenty- five and a half per cent. CHAPTER X. AMPUTATIONS OF THE LOWER EXTREMITY. No better or more comprehensive statement can be made bearing on the duty of the surgeon in amputations of the lower extremity, than that "under all circumstances, except where poverty, advanced age, and confirmed dissolute habits so combine in the individual as to render it certain that mechanical appliances would be of little service, give the patient the stump best adapted to the most useful artificial limbs. In all amputations of the lower extremity, the surgeon should be governed in the selection of the point of operation and the method to be adopted by the mortality of the operation in question ; by the adaptability of the stump to the most serviceable artificial limb for locomotion."* Amputation of the Phalanges in their Continuity, or through the articulations, is done by the same rules as those applied to amputation of the fingers. In the case of the toes, however, it is often difficult * From report of Drs. Valentine Mott, Gurdon Buck, John Watson, A. C. Post, Wil- lard Parker, Ernst Krackowizer, W. H. Van Buren, and Stephen Smith. 256 OPERATIVE SURGERY. to open the joints on account of the changes induced in them, and in the contour of the bones, by the pernicious influence of illy fitting boots and shoes. The flaps are made from the plantar surface. In amputation at the metatarso-phalangeal articulations, remember the relation of the web to the joints in question, the former being a con- siderable distance below the latter (Fig. 375). Amputation of Single Toes (Disarticulation).—They can be re- moved by the oval or by the lateral-flap method. | j ; j i I The former is the better, and is done by first I j !/ \\ grasping the condemned toe, while the assistant s fellows. Commence the incision on >ver the joint, carry it downward along the phalanx to be removed, beneath Fig. 375.—Incision for Fig. 376.—Removal of Fig. 377.—Lateral-flap amputation at meta- single toe. method. tarso-phalangeal ar- ticulation. the toe through the line of the web to the sole of the foot. A second incision is then made of a similar extent and outline on the opposite side of the toe, down to the bone (Fig. 376). The ligaments are di- vided, the tendons are cut off, and the bone removed by cutting from below. If the extremities of the divided tendons remain exposed, they are pulled down and severed on a level with the divided border of the soft parts. The removal of either the second, third, or fourth toes can be effected by making a transverse incision on the dorsum over the joint, and passing the knife through it and along the under surface of the bone a sufficient distance to make the necessary plantar flap, which is turned upward and united. If it be required to remove the whole or part of the metatarsal bone of either of these toes, the dorsal incisions of the oval flap for disarticulation have only to be extended upward on the dorsal surface of the bone to be removed, to the point of in- tended section (Fig. 376). The lateral flap is better for the disarticulation of the great and AMPUTATIONS OF THE LOWER EXTREMITY. 257 ,v„ Fig. 378 Fig. 379.—Square-flap method. little toes (Fig. 377), and is made by abducting the toe and entering the knife vertically between it and the contiguous toe, and cutting through the web till the line of articulation is reached, when the knife is turned outward from the median line of the foot, joint opened, blade pa ssed through it, and the lateral flap made of sufficient length by cutting along the opposite side of the toe (Fig. 378) to be removed. The importance of the great toe as a lever in propelling the body, requires that am- putation through its phalanges be practiced when possible. With the remaining toes, however, it is not a matter of so much importance. The prominent head of the metatarsal bone of the great toe, which remains after disarticulation, has so frequently become the seat of painful bunions, that many surgeons of prominence advise that the bone be amputated behind its head by either a transverse or oblique section of its shaft. Of one fact there can be no doubt : if that por- tion of the boot or shoe in contact with this stump be not fitted to it and kept elevated by some means, the leather will in a short time press upon it, cause great annoyance, and cripple the patient unnecessarily. The great toe can be amputated by a large square internal flap (Fig. 379) and by the oval method (Fig. 375). Begin the longitudinal in- cision at the outer side of the extensor tendon a little below the joint; carry it through the tissues down to the first phalanx (surgical); make a transverse incision from the termination of this one around the inner side of the toe to a point opposite, on the plantar surface ; extend the toe and make another incision from the termination of the last toward the foot along the outer side of the tendon of the flexor longus pollicis to the web ; connect this with the center of the dorsal one by a trans- verse cut carried around the outer side of the base of the toe ; dissect off the flaps and divide the ligaments and the remaining soft parts from within outward. The oval method is performed in a similar manner to the same method when applied to the fingers. Amputation of Two Adjoining Toes.—Begin the dorsal incision between the metatarsal bones of the toes to be removed, just below 17 258 OPERATIVE SURGERY. the joint, where the bones are to be divided ; carry it to the outer side of one of the toes to be removed, taking a good-sized flap from it, thence through the digito-plantar fold to the outer side of the remain- ing toe, back to the point of starting. Remove each toe separately in the usual manner, and close the wound. Amputation of all the Toes at the Metatarso-phalangeal Joint (Disarticulation). — Forcibly ex- tend the toes with the left hand, and make a curved incision on the plantar surface from the inner side of the articulation of the great toe, to the outer side of the corre- sponding joint of the little toe, carrying it through the groove be- tween the sole of the foot and the base of the toes (Fig. 380). Flex the toes and join the first incision by a similar one across the dorsum (Fig. 381). Dissect up the flaps, expose the joints, and remove each toe separately, allowing the sesa- moid bones of the great toe to re- main. If the flaps be too short, the heads of the metatarsal bones should be cut off sufficiently to permit proper adjustment, and the Fig. 380.—Plantar incision. Fig. 381.—Dorsal incision. divided surfaces united. When recovery takes place, the foot presents the following appearance (Fig. 382). Amputation through all the Metatarsal Bones.— This is best done by a short dorsal and a long plantar flap. Make the plantar flap first, dissecting the tissues backward down to the bones, from the junction of the toes with the sole, to the point of amputation. A short dorsal flap is then made with the convexity downward, its extremities being united to those of the preceding. Divide the interosseous tissues with AMPUTATIONS OF THE LOWER EXTREMITY. 259 a sharp, narrow-bladed knife; introduce a carbolized six-tailed re- tractor (Fig. 383), draw the soft parts upward, and divide the bones Fig. 382.—Appearance of stump. Fig. 383.—Sawing the bones. with a fine saw, and turn the plantar flap upward and unite it in the usual manner. Amputation of the Great Toe with its Metatarsal Bone.—This is best done by the oval method (Fig. 384), which is similar to f ,-• that for removal of the thumb. It is recommended, on account of the width of the base of the metatarsal bone, to make a short transverse incision across it at the joint ; remove the flap, thereby exposing the whole length of the bone; open the joint on the dorsal aspect, sep- arate its remaining connections, and remove it. Amputation of the Fifth Toe, with the Metatarsal Bone.—This can be done by either the oval or later- al-flap method ; the steps of the former being in all respects substantially simi- lar to those for the removal of the great toe. The lateral-flap method is done by separating the Fig. 384.—Amputation at proximal end of metatarsal bone. Fig. 385.—Amputation of little toe and metatarsal bone. 260 OPERATIVE SURGERY. Fig. 386.—a, a. Line of Lisfranc's amputation, b. Line of Hey's modification of Lisfranc's amputa- tion, c. Line of Skey's modification of Lisfranc's amputation, d. Line of Baudens' modification of Lisfranc's amputation, e, e. Line of Forbes' amputation. /, /; /,/. Lines of Miculicz[s am- putation. g, g. Lines of Chopart's amputation. fifth from the fourth toe, at the same time carrying a narrow-bladed knife up- ward between the meta- tarsal bones from the web, until it is obstructed, when the knife is with- drawn and the incision prolonged upward on the dorsal and plantar sur- faces in a straight line about one inch. Strongly abduct the metatarsal bone to be removed, sepa- rating it from its fellow and from the cuboid ; carry the knife around the base to the outer side, and so on downward to the metatarso-phalangeal articulation (Fig. 385) ; remove the bone, and the tongue - shaped flap just made will fit the inter- na etatarsal incision. Amputation at the Tarso - metatarsal Joints (Lisfranc's).—It will very much expedite matters, save considerable annoy- ance to the operator, and preserve the edge of his knife, if the relations of the bones entering into the joints be fully noted before attempting to open them (Fig. 386). The ar- ticulation between the cu- boid and the fifth meta- tarsal is seen to be to the inner side of its tuberosity. The joint of the inter- nal cuneiform and the metatarsal bone of the great toe is about an inch AMPUTATIONS OF THE LOWER EXTREMITY. 261 and a half in front of the tuberosity of the scaphoid, and the head of the second metatarsal bone is lodged between the three cuneiform bones. In every instance these joints must be carefully located. Operation.— Raise the foot and mark out a large semilunar flap on the plantar surface, the base of which shall correspond to the distance between the joints just indicated, and its distal extremity to the heads of the metatarsal bones. Ex- tend the foot, and make a short dorsal flap with the convexity forward, and its base corresponding to that of the plantar flap (Fig. 387). Draw the small dorsal flap upward, and commence the disar- ticulation at the outer side of the tarsus ; strong- ly extend and adduct the bones, which will better mark the outlines of the articulation; separate the fifth, fourth, and third articulations; skip the second and open the first. The articulation of the second with the cuneiform bones is peculiar, in that it is about two fifths of an inch higher (Fig. 388); however, with the bones depressed, a short transverse in- cision liberates its dorsal connections with the middle cu- neiform, after which it is disconnected from the internal and external cunei- form bones, as well as its contiguous Open the joint well, divide Fig. 3S7.— Dorsal flap. Fig. 388.—Articulation of second metatarsal. Fig. 389.—Separating second metatarsal. metatarsal, by cutting upward (Fig. 389). the ligaments on the side and plantar surface, carry the knife along the sole, and make the plantar flap as previously laid out (Fig. 390). If all the muscular tissues of the sole be removed, it will be too bulky; a part should therefore be omitted from it. 262 OPERATIVE SURGERY. The plantar flap may be made by transfixion, before the articula- tions are opened ; this method can not be recommended, however, as the flaps thus formed must await the completion of the operation without facilitating it. Moreover, if the plan- tar flap be made by transfixion, before disarticulation, the transverse arch of the foot will be intact, causing the center of the flap to be made thin, since the knife can not come suffi- ciently close to other than the first and fifth metatarsal bones. After the removal of the part, the flap appears as seen in Fig. 391. This method has been variously modified, the mod- ifications, in some instances, becom- ing confused with the original meth- od. Hey sawed off the projecting portion of the internal cuneiform ; this, however, is not expedient, as it lessens the attachment of the tibialis anticus and shortens the lever- age of the foot. Skey sawed off the base of the second metatarsal, leaving it in the mortise. This adds nothing to the usefulness of the stump, and ex- poses the remaining fragment to the danger of necrosis. Baudens proposed that the first metatarsal bone only should be disarticulated, and the remaining ones sawn off transversely on a level with the internal cuneiform. Reported as Results.—The rate of mortality in amputation of the toes is about six per cent. Amputation through the Medio-tarsal Joint (Chopart's).—The me- Fig. 390.—Making plantar flap. Fig. 391.—Appearance of flap (after Lisfranc's amputation). Fig. 392.—Inner dio-tarsal joint is formed by the astragalus and os calcis behind, and the scaphoid and cuboid bones in front. This articulation can be located by drawing a transverse line across AMPUTATIONS OF THE LOWER EXTREMITY. 263 Fig. 393.—Inferior aspect. the dorsum of the foot, beginning just behind the tuberosity of the scaphoid ; the outer extremity will be about one inch behind the tu- berosity of the fifth metatarsal bone. The foot is raised and a curved incision is carried over the sole, extending from the articulation of the scaphoid with the astragalus (Fig. 392), forward to within a thumb's breadth of the heads of the metatarsal bones (Fig. 393), then across the sole and backward to the outer extremity of the articulation of the cuboid and os calcis (Fig. 394). Forcibly extend the foot and make a slightly curved incision, through the skin only, the convexity downward, across the dorsum, connecting the upper extremities of the plantar incision (Fig. 395). Turn the dorsal flap up- ward, open the joint on the dorsal surface ; beginning from within, bend the met- atarsal bones toward the heel, and sever the ligamen- tous connections thus made tense. Finally, pass the knife through the articula- tion to the plantar surface, turn the edge toward the toes, and complete the plan- tar flap (Fig. 396). Fig. 397 represents the stump after the flaps are united. This operation is objected to on account of the liability of the stump to become extended, causing the patient to walk on the cicatrix at its anterior extrem- ity. The division of the tendo Achillis at, or subsequent to, the operation is made to counteract this tenden- cy ; but frequently, however, without suc- cess. If the foot-stump be confined in a flexed position during the healing, and danger of its becoming extended Fig. 394.—Outer aspect. Fig. 395.—Dorsal aspect. for a time afterward, there is less This operation can not be recom- 264 OPERATIVE SURGERY. mended as a substitute for those that are to follow, in point of com- fort and usefulness. Better execution is done with an artificial limb- appliance after the Syme's amputation than after this ') operation. Results.—The mortali- ty is about eight per cent. Forbes' Modification.— This is made through the same incisions as Chopart's. After the cuneiform bones have been separated from the scaphoid, the cuboid is sawn through on a line with '"....."N\ them. Inasmuch as this Fig. 396.—Removing the foot. Fig. 397.—Appearance of stump. operation offers no additional power of flexion by reason of its muscu- lar attachments, its stump may become subjected to the same annoy- ance as the former. In this, as in the medio-tarsal amputation, the after-treatment ex- ercises a most important influence upon the results. Sub-astragaloid Disar- ticulation (De Lignerolles). —Make two lateral flaps by an incision beginning im- mediately above the tuber- osity of the os calcis on the outer side, which divides the tendo Achillis, and is carried along the outer side Fig. 398.—External incision. AMPUTATIONS OF THE LOWER EXTREMITY. 265 of the os calcis in a curved manner, convexity downward, below the external malleolus, thence extending obliquely upward across the mid- dle of the cuboid to the dorsum of the foot (Fig. 398) ; then vertically downward across the inner border of the scaphoid (Fig. 399) till it reaches the center of the sole of the foot; it is then turned directly backward at a right an- gle with the preceding cut, and joins the begin- ning of the incision at the inner border of the tendo Achillis (Fig. 400). Dissect up both flaps till the lateral surface of the os calcis and the talo- scaphoid joints are ex- posed, being careful not to injure the tibio-tarsal joint; remove the bones in front of the medio-tarsal junction ; seize the anterior extremity of the os calcis with bone-forceps, depress and turn it inward, and divide the external lateral ligaments with a narrow knife about a third of an inch below the tip of the malleolus ; then divide the interosseous Fig. 399.—Internal incision. \ < ill Ihi '■■) Fig. 400.—Plantar incision. Fig. 401.—Internal ligaments. ligament between the os calcis and astragalus ; finally, the talo-calcane- an ligament is divided an inch below the internal malleolus (Fig. 401). The os calcis is then removed (Fig. 402), and the flap united in its proper position. Fig. 403 shows the appearance of the stump after union of the flaps. 266 OPERATIVE SURGERY. Fig. 402.—The bones separated. Results.__Over twelve per cent are reported to have died from the operation alone. Hancock's Amputation.—This may be considered a combination of the sub-astragaloid and Piro- goff s method. The operation can be done through incisions similar to the latter ; the flaps, however, should be made somewhat longer. Saw the os calcis as in Pirogoff's method. Make a transverse sec- tion of the astragalus (Fig. 402); remove it, together with the asso- ciated fragment of the os calcis, and bring the sawn surfaces of the remaining portions of the os calcis in contact with the under surface of the articulated portion of the astragalus. Tripier's Method.—By this method it is thought possible to prevent the retraction of the flap and extension of the stump by the powerful muscles attached to the heel. The os calcis is divided on a level with the sustentaculum tali and at a right angle with the long axis of the tibia, which makes the cut surface of the bone parallel with the ground. Operation.—Begin the incision of the soft parts at the outer border of the tendo Achillis, on a level with the outer malleolus, carry it along the outer border of the foot to the base of the meta- tarsal bone of the little toe, thence directly across the dorsum of the foot to the base of the metatar- sal bone of the great toe; from this, it passes across the sole of the foot, forming a convex flap at least one inch longer than the dorsal one, join- ing the outer incision at an oblique angle. The flaps are dissected up sufficiently to admit of the disarticulation of the astragalo-scaphoid joint and the horizontal section of the os calcis just below the susten- taculum tali. If the bone be divided from without inward, the pos- terior tibial artery is less likely to be injured. The wound is drained, and the flaps united and surrounded by antiseptic dressing. The results from some sources, in all forms of amputation through the foot, show a death-rate of about twenty-three per cent. How- ever, in this respect, the records of American surgery in these opera- tions are but little in excess of ten per cent. Irregular Tarsal Amputations (Molliere).—In view of the great ad- Fig. 403.—Appear- ance of stump. AMPUTATIONS OF THE LOWER EXTREMITY. 267 vantages to be gained by a strict use of antiseptic measures, in pro- moting union by first intention, limiting suppuration, and lessening the danger of necrosis, it is suggested that amputations across the foot be made irrespective of the articulations of the tarsal bones ; in other words, that the foot be treated as if it contained but one bone. Heretofore, such measures have been followed frequently by necrosis of the fractional portions of the tarsal bones remaining in the stump. Amputation at the Ankle—Removal of the Entire Foot (Syme).— This may be considered one of the most practical of the operations on the foot and ankle. It is followed not only by a low rate of mortality, but also by a most servicea- ble stump, either with or without an artificial appli- ance. The patient is placed upon a table, with the leg overhanging it; the thigh raised by an assistant, who at the same time flexes the condemned foot upon the leg, by seizing and pulling upward on its anterior por- tion. The outlines of the respective flaps should now be carefully drawn before the incisions are commenced. The line indicating the proper course of the plantar incision begins at the apex of the external malleolus— for left side—and, with a slight backward inclination, passes around the foot (Fig. 404) to a point opposite to its begin- ning, which is about a fin- ger's breadth below the apex of the internal malle- olus (Fig. 405). The second or dorsal line is drawn directly across the instep, and con- nects the extremities of the plantar incision. Operation.—The sur- geon selects a scalpel of large size and with a strong shank, and inserts the point at the com- mencement of the incision down to the bone at a right angle to its outer surface, with the edge undermost; carries it along the guiding line in contact with the bone to its inner extremity ; places the fin- gers on the heel and the thumb within the cut, and draws firmly Fig. 404.—Outer incision. Fig. 405.—Inner incision. 2gg OPERATIVE SURGERY. backward on the posterior flap, at the same time liberating it from the outer surface and sides of the os calcis, back to near the insertion of the tendo Achillis. An incision is now made down to the bone on the anterior line, and the joint opened in front; the foot well ex- tended, lateral ligaments divided, and foot removed by liberating the remaining tissues attached to the posterior surface of the os calcis, in- cluding the tendo Achillis ; always remembering to closely hug the bone, else the flap may be perforated and its integrity impaired. After the removal of the foot, dissect up the soft parts around the malleoli a suf- ficient distance to permit the articular ends of the bones to be sawn off (Figs. Fig. 406.—Bones of leg sawn through. 406 and 407) ; cut off the extremities of the tendons even with the cut surface of the soft parts, bring the flap into position, unite it in front (Fig. 408), and dress with antiseptic precautions. Fig. 407.—Heel flap. Fig. 408.—Flaps united. Fig. 4C9.—Side view. Modifications.— Sawing the malleoli obliquely (Fig. 410)—instead of removing them together with a thin transverse section, that includes the articular surface of the tibia, as recommended by Mr. Syme—is a modification which has been long and somewhat extensively practiced. It is believed to give a better-shaped stump, and to be attended with AMPUTATIONS OF THE LOWER EXTREMITY. 269 less danger to life, than if the bony canals of the tibia be extensively opened, as in the case of transverse section. Many surgeons, after making the plantar incision, open the joint in front, as before described, disarticulate, and dissect the heel-flap from behind for- ward. This affords more room and leverage to aid in the removal of this flap, but increases the danger of cutting it. The removal of the periosteum from the sides and the posterior surface of the os calcis, including the insertion of the tendo Achillis, has been practiced. If it can be done without too much lacer- ation of its structure, it is a commend- able modification. By some, the articular cartilage re- maining on the extremity of the tibia is scraped off; this procedure is thought to hasten the healing process. Many methods, adapted to various forms of injury to the soft parts, have been de- vised to modify the construction of the flaps to cover the end of the stump. When the heel-flap is impossible, tissues can be taken from all or either of the three remaining aspects of the foot to supply it; being ever cautious to avoid injuring the posterior tibial artery, as it lies below the inner malleolus. Fallacies.—The incision across the instep lies below the line of articulation between the astragalus and the tibia ; therefore, unless care be taken to locate the joint, the operator will cut down upon the neck of the astragalus, and, not finding the joint, will become much confused ; or he may even open the articulation between the scaphoid and astragalus. If the plantar flap be made too long, it will be im- possible to carry it over the point of the heel ; therefore, if it be neces- sary to make a long heel-flap, the joint should be opened at once from before backward, and the heel-flap dissected off from above downward. Results.— The rate of mortality from Syme's operation is from five to nine per cent. Roux's Operation.—Begin the incision tendo Achillis, a little above the insertion Fig. 410.—Oblique division of malleoli. at the outer side of the ; carry it straight forward beneath the outer malleolus (Fig. 411), then in a curved line across 270 OPERATIVE SURGERY. the instep half an inch in front of the articular edge of the tibia back- ward and downward, in front of the inner malleolus, to the sole (Fig. 412) ; then obliquely backward to near its outer border; then Fig. 411.—Outer incision. Fig. 412.—Inner incision. backward and upward over the heel to the point of beginning. Dis- sect up the edges of the flaps, open the joint at the outer side, and complete the internal flap after disarticulation of the foot. The bones should then be divided, as in Syme's method ; flaps united and dressed antiseptically. Pirogoff s Amputation.—This is osteo-plastic in character, and con- sists in the application of the sawn surfaces of the posterior portion of the os calcis (Fig. 416) to the sawn surfaces of the bones of the leg. The length of the limb is well preserved, and, without the use of an artificial appliance, the stump is often superior to that of Syme's operation. Operation.—Flex the foot at a right angle with the leg ; make an incision down upon the bone, from the tip of the internal malleolus directly across the sole, its lowermost portion being a little in front of the long axis of the tibia (Fig. 413), around the foot to a point in front of the apex of the external malleolus (Fig. 414). The extremities of this are connected by another carried down to the bone, half an inch in front of the lower extrem- ity of the tibia. Open the joint in front, divide the lateral ligaments, disarticulate the Fig. 414.—Outer ii AMPUTATIONS OF THE LOWER EXTREMITY. 271 head of the astragalus (Fig. 415), and with a narrow saw divide the os calcis obliquely downward and forward in the line of the plantar incision. Eaise the anterior flap, dissect up the tissues around the lower ends of the bones, and saw Fig. 415.—Separating articular surfaces. Fig. 416.—Lines of section of os calcis. through the lower extremities of the tibia and fibula, just above their articular surfaces. If any of the divided tendons be below the edge of the wound, cut them off on a level with it. The cut surface of the os calcis is then brought forward and placed in contact with that of the tibia; the wound united and dressed anti- septically. Fallacies.—If the posterior border of the os calcis be cut too long, the divided bone surfaces can not be properly apposed without force which will cause the fragment to tilt backward. This can be reme- died by removing more bone from this border, or by dividing the tendo Achillis. Whenever this tendon inclines to tilt the bone, it should be divided. The fragment can be united to the tibia by silver wire to retain the sawn sur- faces in apposition. The os calcis has been sawn at different angles to that bone (Fig. 416), | but the one just considered has given the most [ : , \ satisfactory results. Fig. 417 shows the ap- f. } pearance of the stump after Pirogoff's operation. | ^ K Results.—The death-rate from this opera- | I tion is about ten per cent. p * ^J Modifications of Pirogoff's Operation.— V. # Pergusson's modification consists in not remov- ^-jf 0" |ng the malleoli, unless they are diseased, but FlG. 4n._Appearailce of m dividing the tendo Achillis, and placing the stump. 272 OPERATIVE SURGERY. sawn end of the os calcis between them. Dr. Turnipseed and others have practiced this modification and recommend it. Le Fort's Modification.—The incisions for the flaps are similar to those in Roux's modification of Syme's amputation. The ankle-joint is exposed by raising the dorsal flap, keeping close to the bone so as not to injure the posterior tibial artery. Divide the external lateral ligament, and the ligaments between the astragalus and os calcis. Turn the foot inward, and remove the anterior portion of the foot at the medio-tarsal joint. Seize the astragalus with strong forceps, make tense the ligaments connecting it with the bones above, which should then be cut and the bone removed. Push down the os calcis, and with a narrow saw remove its upper third from behind forward, beginning just |V> 1 above the insertion of the tendo Achillis. I ^ ■"] Saw off the malleoli and the articular I | if '/ surface of the tibia, as in Pirogoff's opera- | I |§f / Fig. 418.—Sawn bones in Le Fort's method. Fig. 419. —Appearance of stump in Le Fort. tion (Fig. 418) ; place the sawn surfaces in apposition, and dress in the usual manner. This modification permits the reserved fragment of the os calcis, when placed in position, to maintain the same rel- ative axis to the end of the stump that it held to the foot; conse- quently the direct pressure is re- ceived upon the integumentary covering already adapted to the purpose (Fig. 419). Bruns recommended that the sawn surfaces of the os calcis be made concave, and the tibia con- Fig. 420.—Bruns' modification. vex (Fig. 420). AMPUTATIONS OF THE LOWER EXTREMITY. 273 Fig. 421.—Outer incision, Esmarch's Modification of Le Fort's operation consists of two in- cisions : one across the sole, the other across the dorsum of the foot. The former commences about four fifths of an inch below the tip of the external malleolus, and with the convexity ^ forward (Fig. 421), runs under the cuboid and scaphoid bones (Fig. 422), ending at the inner side, one inch below and in front of the internal malleolus (Fig. 423). The curved dorsal incis- ion (Fig. 424), with its concavity forward to the tuberosity of the scaph- oid, connects the ex- tremes of the plantar one. Dissect up the dorsal flap to the tibio-tarsal joint, which should be opened, the foot bent downward, and the upper surface of the os calcis exposed suf- ficiently to apply a small saw behind the upper margin of the tuber- osity of the os calcis and the bone sawn, as before described (Fig. 418). The flaps are then united, drained, and dressed antiseptically. Osteoplastic Am- putation of Heel and Ankle (Mikulicz).— This operation is spe- cially indicated in cases in which the tis- sues composing the posterior part of the foot have been de- stroyed. Operation.—Select a strong scalpel and make an incision from just in front of the tubercle of the scaph- oid directly across the Fig. 422.—Plantar incision. Fig. 424.—Dorsal incision. 18 274 OPERATIVE SURGERY. sole of the foot, down to the bone, terminating just behind the base of the fifth metatarsal bone. From each extremity of the plantar incis- ion, one is carried upward and backward to the bone of the corre- sponding malleolus, and the upper extremities of these incisions are connected by a fourth, passing directly transversely behind the limb and carried through the tendo Achillis. The lateral ligaments of the joint are divided, the joint opened from behind, and the calcaneum and the astragalus are carefully dissected out and removed by disar- ticulation at the medio-tarsal joint. The malleoli, including the articular surface of the tibia, are sawn off transversely, and also the cuboid and scaphoid bones are sawn transversely through on a line corresponding to the middle of the latter bone. The sawn surfaces of bone are then placed in contact with each other, and wired or pegged in position. AMPUTATIONS OF THE LEG. Supra-malleolar Amputation.—This operation resembles more near- ly a Syme, in location, than any other that can be performed upon the leg ; but, owing to the comparatively high rate of mortality resulting, it is not to be recommended in preference to a higher amputation. The flaps must always be made from the firmest and best-nourished tissues accessible. Operation.—Two semilunar incisions, one external and one inter- nal, are made, each beginning posteriorly at the posterior border of the malleoli, and passing forward beneath them, then around upon the dorsum of the foot, an inch in front of the ankle-joint, where they join each other. Their posterior extremities are then united by a curved transverse incision, with the convexity downward. The flaps are dissected upward, and the bones of the leg divided transversely about an inch above the articular surfaces. Amputation of the Leg at the Lower Third.—When possible, the leg must always be amputated at this situation. It gives a long ful- crumage for an artificial limb, and admits of the formation of a sym- metrically tapering stump, which can be closely adjusted to the socket of the artificial appliance. Three methods can be employed : the circular, the bilateral, and the hood flaps, embracing only the integument and subcutaneous tis- sues, or combined with the periosteum covering the subcutaneous sur- face of the tibia. Circular Method ivith Periosteal Reflection.—If the situation can be selected for the site of the operation, it should be three or three inches and a half from the lower extremity of the tibia; or, more definitely, at the point where the tapering of the limb from above downward ceases. The length of the flap should be equal to a fourth of the circumference of the limb at the proposed point of section. Operation.—Prepare the patient in the usual manner; make a cir- AMPUTATIONS OF THE LOWER EXTREMITY. 275 cular incision through the integument and subcutaneous tissue down to the muscular fascia and the subcutaneous surface of the tibia. Dissect the sleeve for about an inch all around, then divide the perios- teum on the subcutaneous surface of the tibia, by a transverse incis- ion at the point of reflection of the flap ; divide it also longitudi- nally at the outer and inner borders of the surface of the tibia a suffi- cient distance—one fourth of an inch—to allow the periosteum to be reflected upward while attached to the inner surface of the flap. These longitudinal incisions are repeated as often as it becomes neces- sary to detach the periosteum and keep pace with the turning up of the flap at the remaining portions of its circumference. That is, in- stead of dissecting the flap from the tibia, its periosteum is detached from its subcutaneous surface, and pushed up to the point of proposed section while still adherent to, and forming a limited lining to the flap. Fig. 425 shows the extent of the reflection of the periosteum, which, however, in the operation, remains attached to the inner surface of the corre- sponding portion of the flap. The tibia is sawn carefully through at the highest point of the periosteal reflection, the fibula Line indicating antero-posterior coaptation of Haps. Line indicating direction of sub- cutaneous surface of tibia. Line indicating oblique coapta- tion of flaps. Pig. 425.—Reflection of the peri- osteum. Fig. 426.—Oblique coaptation. exposed one fourth of an inch higher and divided separately by sawing toward the tibia. The flaps are then united obliquely, so that not only will the line of union fall between the two bones, but that—which is more important—the periosteal lining of the inner portion of the flap will fall and lie smoothly across the divided extremity of the tibia, since the subcutaneous surface of the tibia lies parallel with the hue of oblique coaptation (Fig. 426). It will be necessary, in order 276 OPERATIVE SURGERY. to reflect the sleeve-flap, that it be divided longitudinally; this is done at such a point as will become lowermost when the flaps are obliquely joined. The limb should be dressed antiseptically, using cau- tion to maintain the oblique direction of the flaps till the healing process is complete. i The periosteal flap grows to the end of the V bone, preventing it from becoming atro- \ phied, and likewise preventing the adhesion \ Fig. 427.—Dissected specimen showing the relation Fig. 428.—Bilateral flaps. of parts. of the cicatrix to the end of the tibia. Fig. 427 shows a longitudinal section through the flap three months after this operation had been done. Results.—Of the eight cases done by myself all have resulted in ex- ceptionally serviceable stumps. In no instance have bony spiculae ap- peared, and in each the stump has given entire satisfaction to the patient. The Bilateral Flap Method (Fig. 428, a) consists of equilateral flaps constructed from the integument and subcutaneous tissue at the outer and inner surface of the limb. The operation may be performed by this method either with or without the periosteal lining. The cir- cular, with oblique coaptation, is by far the better method if the peri- osteum be raised ; since in antero-posterior coaptation, the periosteal flap will be tilted, and become more liable to eversion and the produc- tion of bony spicular growths. AMPUTATIONS OF THE LOWER EXTREMITY. 277 The bilateral flaps are made by first ascertaining the circumfer- ence of the limb at the point of the proposed amputation. The base of each flap is then made equal to half, and the length to one fourth of this circumference. Each one is nearly semicircular, and their points of junction should be at the center of the limb, anteriorly and posteriorly, which will bring the anterior point of union to the inner side of the crest of the tibia ; it should also be a little below the point of the proposed section of the tibia. The posterior point of junction is made above that of the anterior, to provide for suitable drainage (Fig. 428, a). When properly outlined, each flap is dissected upward to near the point where the bone is to be divided ; the muscles are divided by a circular incision, then pushed upward above the anterior point of union of the flaps, and the bones sawn off—the fibula'a fourth of an inch the shorter—on a line corresponding to the junction of the flaps posteriorly. If there be an undue amount of muscular tissue be- hind, it can be trimmed off until it admits of the ready union of the divided borders of the flaps. Suitable drainage, antero-posterior co- aptation, and an antiseptic dressing, comprise the immediate atten- tion to the case. The Hood, or Oval Flap Method is a modification of the circular, the skin-cuff being slit up posteriorly to the point at which the bone is to be divided, and the corners trimmed off to resemble the outlines of the lower portions of the bilateral flap. This flap is then reflected upward, and the muscles and bones divided as before. The line of union is made antero-posteriorly. The advantages claimed for this method are : its perfect drainage ; the location of the cicatrix on the posterior surface ; and the carrying of the integument over the end of the bone, thus preventing the adhe- sion of the cicatrix to it. Like the bilateral, it can be employed in con- nection with the periosteal flap ; still, as it is joined to form an antero- posterior line of union, it is open to the same objections as the former with reference to the periosteum. Results.—The rate of mortality from amputation in the lower third is variously estimated at from thirteen to twenty-two per cent; this being, however, less than at any other part of the limb. Amputation through the Middle Third.—The limb can be ampu- tated at this point by the same methods employed at the lower third of the leg. The principles applicable to the lower third have an equal force at this situation. The presence of the calf offers an additional difficulty in obtaining the oblique coaptation, but does not interpose an insurmountable obstacle to it. Care in dressing the stump will maintain the obliquity of the line of coaptation in the periosteal flap method. The bilateral and hood flap methods, either with or without the periosteal lining, present to the surgeon the means of making a most serviceable stump. If other than the preceding be desired, the 278 OPERATIVE SURGERY. long external and short internal flaps are to be preferred, instead of either the long anterior or the long posterior, since either of these im- pede drainage, and both by their weight exert undue traction across the crest of the tibia. The Unilateral Flap Method, combined with a semicircular in- cision on the opposite side, offers good drainage, and carries the cicatrix be- yond the point of pressure. These flaps may be muscular or in- tegumentary ; the former are made by transfixion, the latter by external in- cision with the ordinary scalpel, and circular section of the muscles with the long knife. The principles con- trolling the length of the flaps are the same as previously stated. The long flap should be made from the outer side of the leg, having a base some- what less than one half the circumfer- Fig. 429.—Long external flap. ence of the limb. The inner, or short flap, is semicircular in shape (Fig. 429). The bones are sawn off just above the anterior point of junction of the flaps, which are then to be united, and the wound dressed as before. Results.—The rate of mortality of amputations in this portion of the limb is about twenty-seven per cent. Amputation at the Upper Third.—Either of the methods em- ployed in the middle third is applicable at this situation. The fibula should not be removed, as the superior tibio-fibular articulation some- times communicates with the knee-joint. The tibia is sawn below the insertion of the ligamentum patella?. Results.—The mortality is about forty-three per cent. Amputation at the Knee-Joint (Disarticulation).—The bilateral, the circular, the long anterior, and the hood flaps are the ones best constituted to meet the indications. The stump resulting from either has an early sustaining power with a broad point of support, which, however, later in life becomes somewhat lessened in size. The joint surface is not to be molested in any other way than by scraping off the articular cartilage. The patella, unless diseased, should be allowed to remain. It will be found to rest just above the condyles, where it affords a good point of attachment for the quadriceps extensor. The ligaments should be divided close to the femur, the semilunar cartilages remaining attached to the tibia. The popliteal artery is tied, only after sufficient isolation to admit of the application of the ligature above the articular branch- es. The popliteal vein also should be isolated and tied. AMPUTATIONS OF THE LOWER EXTREMITY. 279 Bilateral Method.—This, without doubt, is the best method. It provides two well-nourished flaps, which, when united, locate the cicatrix between the condyles posteriorly, thereby affording admirable drainage. Operation.— With the thigh elevated and the leg extended, begin the anterior incision of either flap, one inch below the tuberosity of the tibia, cutting through the skin and subcutaneous tissues and mus- cles. Carry it downward and forward below the curve of the leg, thence inward and backward to the middle of the under surface of the leg, then directly upward to the middle of the popliteal space (Fig. 428, b). The opposite flap is made in a similar manner ; remembering, how- ever, that the flap at the inner side must be made the longer, on ac- count of the greater length and size of the inner condyle. Eaise the flaps until the articulation and the apex of the patella are reached; divide the ligamentum patella?; open the joint in front; divide the crucial ligaments ; draw the head of the tibia forward, and pass a long knife behind it; extend the leg somewhat and cut the remaining tis- sues directly downward. Before severing these tissues be careful to ascertain if perfect control be had of the femoral artery. After re- moval of the leg the flaps present the appearance shown in Fig. 430. The flaps are united and suitable drainage provided. A not in- Fig. 430.—Appearance of the flaps. Fig. 431.—Appearance of the stump. frequent sequel to this operation is the formation of an abscess beneath the quadriceps extensor, due to the collection of pus at the upper end of the synovial pouch of the joint; the elevation of the stump causing it to gravitate to that point. This can be avoided by the division of the lateral synovial bands commanding the entrance to it, and the in- troduction of a drainage-tube to the uppermost portion ; or by carrying the tube through the uppermost extremity to the anterior surface of the thigh. Sometimes compression firmly and continuously applied over the pouch will answer the purpose. When healed the stump presents the appearance shown in Fig. 431. If care be not taken in the applica- tion of the dressings, undue pressure will be made on the tissues cover- •ng the condyles of the femur, causing ulceration and even sloughing. 280 OPERATIVE SURGERY. Fallacy.—It has, however, one fallacy, which has been the cause of much chagrin to surgeons on rare occasions—the danger of mak- ing the flaps too short, followed by the necessity of removing the patella, or sawing off the condyles before the flaps can be properly united. If the semilunar fibro-cartilages be permitted to remain con- nected with the femur, they will lessen the degree of retraction of the soft parts; however, when thus allowed to remain, they not infre- quently slough away. Circular Method.—Extend the leg and make a circular incision around it, about four inches below the patella, through the integu- ment and subcutaneous tissues. Dissect it up to the edge of the pa- tella ; flex the leg and divide the ligamentum patella? at its apex; then open the joint in front, and divide the lateral ligaments close to the Fig. 432.— Circular flap method. femur, so that the semilunar cartilage will remain connected with the tibia. Flex the leg and cut the crucial ligaments. Pass a long knife between the bones, extend the leg, and sever the posterior connections as before (Fig. 432). The flaps can be united from before backward Fig. 433.—Anterior-posterior coaptation. Fig. 434.—Transverse coaptation. (Fig. 433), or transversely (Fig. 434), the former being the better method, for obvious reasons. AMPUTATIONS OF THE LOWER EXTREMITY. 281 435.—Line of incisions. Long Anterior, with a Short Posterior Flap.—Flex the leg and make a longitudinal semicircular-shaped flap, beginning a little below the center of the in- ner surface of the inter- nal condyle, extending around in front five inches below the pa- tella to a similar point on the external con- dyle (Fig. 435). Dis- sect the flap upward to the patella, open the joint as before; draw the head of the tibia forward and pass a long knife behind it, mak- ing the short posterior flap from above down- ward, beginning the incision at the upper borders of the anterior flap. When united the cicatrix is well protected and good drainage afforded (Fig. 436). Hood Flap.—This varies but little from the bilateral; having a somewhat oval outline in front, instead of a retiring angle. Results. — The rate of mortality from amputation through the knee-joint varies but little from amputations of the lower limb, as a whole, averaging in the latter about thirty-four per cent; in the former, thirty-two per cent. Amputation through the knee-joint offers, as a rule, a better chance for life than through the upper third of the leg. Amputation through the Condyles.—This measure possesses no advantage over the one made through the articulation. The rate of mortality is somewhat increased, being reported at about forty- eight per cent, although this would be, without doubt, much less- ened by the employment of antiseptic measures ; and the useful- ness of the stump is decidedly in favor of the latter. However, as conditions sometimes arise rendering the disarticulation imprac- Fig. 436.—Appearance of stump. 282 OPERATIVE SURGERY. ticable, amputation through the condyles becomes a valuable expe- dient. Carden's Amputation.—Extend the leg, seize the joint with the left hand, the end of the thumb and index-finger resting as nearly as possible over the center of each condyle. With a stout scalpel make an anterior semilunar flap, commencing at the point indicated by the end of the index-finger, passing around in front about two inches be- Fig. 437.—Carden's method. Fig. 438.—Gritti's and Stokes' method. low the patella to the end of the thumb on the opposite side. If the question of amputation or excision be undecided, reflect the anterior flap first; then, if the condition of the parts require amputation, con- nect the extremities of the anterior flap by a short posterior one car- ried directly down to the bone (Fig. 437). Eeflect both flaps upward to the base of the condyles ; flex the leg to draw down the patella, and divide the remaining tissues surrounding the condyles down to the AMPUTATIONS OF TnE LOWER EXTREMITY. 283 bone ; then saw off the condyles at their base, secure the vessels as before described, and unite the divided parts. Results.—The rate of mortality as reported by Carden was about seventeen per cent. Gritti's Amputation (Fig. 438, a).—Extend the leg and make a rectangular flap, extending from the center of the condyles to the tu- berosity of the tibia. Divide the ligamentum patellae at its insertion and dissect up the flap containing it. Divide the integument on the posterior surface by a circular incision. Eemove the synovial mem- brane from its attachments to the femur in front, and saw the bone just above the articular cartilages. Introduce a long knife and cut the remaining tissues from within outward. Saw off the articular surface of the patella. Allow the anterior flap to fall into position, causing the sawn surface of the patella to come in contact with the divided end of the femur. This operation is osteo-plastic in charac- ter, being allied to Pirogoff's. Stokes' Modification of Gritti's method consists in making an an- terior oval instead of a rectangular flap—the posterior flaps being made one third its length ; and the femur is sawn off an inch above the condyles (Fig. 438, b), instead of through their base. The car- tilaginous surface of the patella is scraped off, and it is then united to the extremity of the femur by strong catgut passed through the soft tissues immediately behind the bone. Results.— The rate of mortality for Gritti's operation and Stokes' modification is reported at about thirty per cent. Amputation of the Thigh.—The muscles surrounding the thigh are of large size and many of them of great length. Those on the pos- terior and many on the anterior surface extend from the pelvis to the leg. On the inner side their length is but little less and their bulk is increased. The greater the length of a muscle from its origin to the point of division, the more marked will be its retraction, other things being equal. It therefore happens, in amputation of the thigh, unless care be exercised to allow for the greater degree of contraction of the long muscles, that the bone protrudes, or presses too strongly against the flap, giving it an undue conicity, or otherwise distorting the stump. The position in which the limb rests during the healing process has an influence on the muscular retraction. For instance, if the limb be extended during the division of the muscles, the posterior ones, on account of their greater length and tension, retract the most, and if to this be added the additional retraction due to placing the stump in a semi-fixed position—on a pillow, or by swinging—during the heal- ing process, the tendency to cause tender, painful, and otherwise troublesome stumps is increased. To avoid this, the limb should be held as nearly as possible at the same angle with the body, when the 284 OPERATIVE SURGERY muscles are being divided, as that in which it will be placed when the dressing is completed and during the process of recovery. In all amputations of the thigh an ante- rior rectangular, or oval periosteal flap should be made, its outer surface remaining associ- ated with the tissues connected with or spring- ing from it (Fig. 439, a). If an amputation be made close to the band of a tourniquet or the elastic bandage of Esmarch, the mus- cles will be held too firmly to admit of the natural retraction until after the bone is sawn and they are liberated ; this is a fault which must be recognized and corrected by cutting the muscles lower than would otherwise be done. Bilateral Flap Method (Fig. 428, c).— This is admirably adapted to both the middle and lower thirds of the thigh. The outlines of the flaps are integument- ary, and are dissected up from the muscles two inches, or about half their length. The muscles are divided by a circular sweep of the knife, and the bone sawn off at the same situ- ation. In the circular division of the mus- cles, accompanied by the circular or equilat- eral flaps, it is advisable that the first sweep of the knife should divide only the superficial layer, which will then retract or can be drawn up- ward and the second layer be severed at a higher point, causing the open stump to pre- sent a conical cavity, the sawn bone corre- sponding to its apex (Fig*. 440). The end of the bone is then seized by strong forceps, the soft parts on its posterior surface and sides pushed up, and with a small, sharp- pointed knife an oval or rectangular-shaped flap of periosteum is marked out and pushed upward from the anterior surface of the bone, together with the soft parts resting upon it (Fig. 439, a). The base of the periosteal flap must correspond to the point of secondary division of the bone, which will be about two inches above the primary section. The bone is sawn again and removed. The portion of the flap having the peri- osteum is allowed to fall into its proper position across the end of the divided femur ; the edges are united, and stump dressed as desired. Fig. 439.—Periosteal flap. Fig. 440.—Conical cavity. AMPUTATIONS OF THE LOWER EXTREMITY. 285 Vermale recommended that these flaps be musculo-integumentary. Although these are favorable for drainage, their weight is liable to lead to exposure of the bone at the upper angle of the wound. Antero -posterior Musculo - integumentary Flaps.—These flaps include all of the tissues down to the bone, and are made by transfixion usually, although the anterior one may be made by cutting from without and the posterior by transfixion at the upper limit of the former. The length of each flap should be about one fourth the circumference of the limb. When both flaps are to be made by transfixion, the tis- sues should be raised somewhat by the left hand of the operator, who then enters the point of the knife at the side nearest himself, pushes it through in close contact with the anterior sur- face of the bone, and raises the handle a little as it passes to cause the pomt to emerge at the opposite side of the limb, exactly opposite the entrance. This flap is then formed by cutting obliquely upward with a sawing motion, and when completed is pulled backward by an as- sistant assigned for that purpose. The kni"e is reinserted at the original point, of entrance, car- ried behind the bone, point elevated so as to emerge at the same situation as before, and the FlG- 44p0rt£n.putated posterior flap is made by cutting obliquely downward. The remaining muscular fibers around the bone are cut by a circular sweep of the knife, retractors applied and the bone divided. In flaps of this structure the skin retracts more than the muscles, causing the lower ends of the latter to be exposed. To avoid this, Agnew recommends that the flaps be formed first from the integu- ment, reflected up an inch and a half, and the muscles be divided by transfixion ; the point of the knife being pushed through at the junction of the reflected integumentary flaps. The Circular Integumentary Flap method can be employed upon the thigh, and with admirable results. The principles governing its construction are similar to those applicable to this method in other situations. The division of the muscles should be at a point not less than two inches below the reflected flap, and their respective layers should be divided independently, as seen in Figs. 440 and 441. The Single Circular Incision Method (Celsus).—Control the cir- culation, and with a long knife divide all the soft parts by a circular sweep down to the bone (Fig. 442), which is then sawn off. The end of the divided bone is now seized by strong forceps, the 286 OPERATIVE SURGERY. surrounding soft parts drawn upward, the bone exposed, when, if de- sirable, an oval periosteal flap can be made, its base corresponding to the site of secondary section of the bone (Fig. 439). Saw the bone a second time close to the periosteal flap, and allow the parts to fall into po- sition. They can be united transversely (Fig. 443) or the re- verse ; the former holds the periosteal flap in position the better. Long Anterior Flap Method (Sedillot).— This can be employed in any portion of the thigh. Mark out on the anterior surface of the limb a flap, the length of which is equal to one third, and its base to two thirds of the circumference. Di- vide the tissues, ob- not making the flap too thick. The Fig. 442.—Celsus' single circular incision. liquely, upward and backward tissues on the posterior por- tion of the limb are divided transversely down to the bone, which is then exposed about two inches higher and sawn off. Results.—The rate of mor- tality, in amputations of the lower third of the thigh for gun - shot injuries, is fifty- five per cent; at the middle third, sixty-five percent; and at the upper third, seventy- eight per cent. About thir- teen per cent more recover with expectant treatment, in gun-shot injuries, than after Fig. 443.—Appearance of stump. AMPUTATIONS OF THE LOWER EXTREMITY. 287 amputation. The rate of mortality after primary amputations is twenty-one per cent greater than after secondary. The results are considerably more favorable when done in private practice, or with an- tiseptic precautions, irrespective of the cause. Amputations at the Hip.—The causes of death from this amputa- tion are, loss of blood, shock, and septicaemia. Various plans to limit the loss of blood have been suggested — compression of the abdominal aorta by the fingers of a hand introduced into the rectum by an assist- ant; combined with digital pressure upon the femoral as it crosses the pubis. In all in- stances, when abdominal pres- sure is to be applied, the intes- tines should be evacuated. Va- rious forms of tourniquets have been designed for the purpose, as Pancoast's (Fig. 444), Es- march's (Fig. 445), and Lister's (Fig. 447). Fig. 446 shows Es- march's elastic tourniquet in position. Fig. 444.—Pancoast's tourniquet. If a tourniquet be not at hand, a pad may be substituted, made by winding a linen bandage about three inches wide and twenty-five feet in length around a stout rod or stick, one inch or so in diameter, and twelve inches long. This is placed immediate- ly below the um- bilicus and held in position by an assistant. It can be con- fined in position, or the pressure still further increased by several turns of a rubber bandage carried over it and around the body (Fig. 448). If the elastic traction around the body be objectionable, a longer stick can be substituted, and the compress secured in position by rubber bands carried over the ends of the stick and under the table (Fig. 449). Fig. 445.—Esmarch's tourniquet. 288 OPERATIVE SURGERY. Davy's lever (Fig. 43) is a useful agent to control bleeding in this situation. It is open to the objection of being easily disturbed by the struggles of the patient, as well as the danger of injuring the intestines, espe- cially when carried to the right side of the body. Trendelenburg's Rod (Fig. 44), which has also been previously men- tioned, is of unquestionable utility. It is a steel rod, fifteen or six- teen inches long, about one fourth of an inch broad, biconvex on Fig. 446.—Esmarch's tourniquet applied. Fig. 447.—Lister's tourniquet. transverse section, and a twelfth of an inch thick at the center, with blunt edges ; but provided with a movable lance-shaped point two Fig. 448.—Compression pad and elastic band. inches in length. The rod is passed through the soft parts in front of the joint; entering an inch and a half below the anterior superior spinous process of the iliupi, passing across the femur behind the AMPUTATIONS OF THE LOWER EXTREMITY. 289 femoral artery, emerging at the posterior scroto-femoral junction. The point is removed and a strong elastic tube or band is wound firm- ly, like the figure 8, around its ends, passing in front of the thigh. Fig. 449.—lirandis' method. A long knife is then inserted in the course of the rod about half an inch below it, and the anterior flap made in the usual manner, and the vessels ligated. The rod is then withdrawn, the hip-joint dis- articulated, and the posterior flap made in a similar manner. Dr. Varick, of Jersey City, N. J., who first employed the rod in this country, did not disarticulate until he had transfixed a second time behind the neck of the femur, including as much of the soft parts on the posterior surface as possible ; compression was then applied as be- fore, and the tissues were divided by a posterior semicircular incision down to the bone. The amount of blood lost was trifling, and the patient made a speedy recovery. The rod can be employed in the various forms of flaps, and therefore has an element of universality. It has not as yet been enough used to be esteemed more than a rational expedient. A seemingly admirable method of controlling hemorrhage in am- putation at the hip-joint has recently been described (Lloyd) : " A strip of black india-rubber bandage, two yards long, is to be doubled and passed between the thighs, its center lying between the tuber ischii of the side to be operated on and the anus. A common calico thigh roller must next be laid lengthwise over the external iliac artery. The ends of the rubber are now to be firmly and steadily drawn in a direction upward and outward, one in front and one be- hind, to a point above the center of the iliac crest of the same side. They must be pulled tight enough to check pulsation in the femoral artery. The front part of the band, passing across the compress, oo- 19 290 OPERATIVE SURGERY. eludes the external iliac artery, and runs parallel to and above Pou- part's ligament. The back half of the band runs across the great sacro-sciatic notch, and, by compressing the vessels passing through it, prevents bleeding from the internal iliac artery. The ends of the elastic band can be held by the hands of an assistant, or bandages may be tied to its extremities, and passed across the opposite shoulder and tied ; care should be taken to prevent the compression rollers from slipping. This device has been employed on several occasions with entire satisfaction-" Amputation at the hip-joint may be done by the single-flap method, anterior or internal; the double flap, either lateral or antero-poste- rior ; the oval and the circular forms. These general methods have been modified almost indescribably, and certainly, in many instances, impracticably. Amputation by a Long Anterior and Short Posterior Flap (Manec). —Place the patient on a table so that half the pelvis, on the side to be operated upon, projects beyond the edge ; draw the scrotum to the opposite side by a towel (Fig. 450). Exsanguinate the limb by the elas- Fig. 450.—Manec's method. tic bandage; after which control the hemorrhage from above by the form of arterial compression selected. Then remove the elastic band- age ; the limb to be amputated is held by one assistant, and another is instructed to control the circulation in the femoral artery as it crosses AMPUTATIONS OF THE LOWER EXTREMITY. 291 the pubes, and to catch the anterior flap and compress it before it shall have been severed from below. The operator then introduces the point of a long knife, midway between the anterior superior spinous process of the ilium and the trochanter major, pushing it down to the bone parallel with Poupart's liga- ment ; draws H back and low- ers the handle ; at the same time the assistant holding the leg flexes the thigh slightly, and the point is passed through the anterior surface of the capsular ligament; the point is then turned downward and made to pass out at the inner side of the thigh, an inch or so from the perineum, and as far posteriorly as it can be car- ried easily (Fig. 451). It is then carried downward, in con- Fig. 451.—Transfixing. Fig. 452.—Making posterior flap. 292 OPERATIVE SURGERY. tact with the bone, with long, sawing strokes, forming an anterior flap six to eight inches in length. This is caught by an assistant, who at the same time compresses the main vessel within it, and raises it upward. The knife is then brought under the thigh to the opposite side (Fig. 452), connecting the sides of the base of the anterior flap by a posterior Fig. 453.—Flaps united. incision extending a little below the gluteal fold, and carried down to the bone ; after which the bone is disarticulated, by dividing the cap- sular ligament and the muscular attachments to the greater and lesser trochanters. Bring the flaps into position, unite with sutures, and insert a long, large drainage-tube into the acetabulum, allowing it to protrude at the center of the flaps (Fig. 453). Circular Method (Dieff en bach's).—Control the hemorrhage as be- Fig. 454.—Elastic ligature. fore, or by means of the elastic ligature (Fig. 454), and with a long knife make a circular incision down to the bone, which is then sawn through. Tie all vessels, veins included. If it be impossible to em- AMPUTATIONS OF THE LOWER EXTREMITY. 293 ploy the bloodless method, the femoral vessels should be secured by forceps, or ligatures at the base of Scarpa's triangle, in two situations, and the vessels be divided between them, the proximal end allowed to remain until the operation is completed (Fig. 455). Eemove the elastic hgature, secure all bleeding points, and insert a knife two inches above the great trochanter, at its outer side ; carry it down to the bone, over the middle of the trochanter, along the outer surface of the femur to the circular in- move the peri- Fig. 455.—Dieffenbach's circular method. osteum in this manner up to the capsule (Fig. 456), which is opened and the head dislocated. The last step of the operation is attended with but slight loss of blood. Fig. 457 shows the appearance of the parts after their coaptation. An additional drainage-tube is inserted at the lower ex- tremity of the wound. If the muscles are large, the flaps can be va- riously modified by employing either the ordinary circular or the long anterior flap, with a posterior circular incision below the gluteal fold. If there be a deficiency of tissue on the anterior surface of the thigh, the long posterior flap can be supplemented by a transverse in- cision below Poupart's ligament, remembering to pass a large drainage- tube in the course of the retreating extremities of the divided psoas and iliacus tendons. Single-Flap Method (Malgaigne).—This admits of rapid execution, and, were it not for the available anassthetic, would be the proper operation to select, in view of the additional shock caused by the more methodical procedures advocated elsewhere. 294 OPERATIVE SURGERY. Having controlled the circulation, place the patient on the table, with the hip overhanging the edge. The surgeon, standing at the outer Fro. 456.—Removing the bone. side of the limb, which is slightly flexed and separated from its fellow, introduces the point of a long knife midway between the anterior su- perior spinous process of the ilium and the top of the trochanter ma- jor, directing it in the course of Poupart's liga- ment down to the bone, from which it is care- fully withdrawn, and the handle depressed sufficiently to permit the easy passage of the point of the knife across the neck of the femur, and through the anteri- or portion of the capsule. If the handle be depressed before the point is raised, the point may be broken. The handle is then raised and pushed onward until the point emerges an inch below and in front of the tuberosity of the ischium (Fig. 458). Fig. 457.—Wound closed. 999� AMPUTATIONS OF THE LOWER EXTREMITY. 295 The flap is then made by carrying the blade downward six or eight inches along the anterior surface of the bone, parallel with its line of entrance, when it is brought directly to the surface (Fig. 430). Before the vessels are divided an assistant seizes the flap, by inserting the hands into the in- cision, above the knife, compresses the vessels, and, when severed, carries it up- ward on the abdomen (Fig. 459) at the same time the surgeon divides the re- maining anterior portion of the capsule with the point of the knife ; another assistant rotates the thigh inward, that he may sever the attachments to the great trochanter, then quickly rotates it outward and abducts it, causing the head of the bone to escape sufficiently to expose the ligamentum teres, which the surgeon divides with the point of the knife, and as the head slips from its cavity he passes the blade behind it (Fig. 459, 460), seizes the head Fig. 458. — Malgaigne's method. A. Point of entrance of knife. B. Point of exit of knife. C. Poupart's ligament. D. Knife passing through capsule. E. Tro- chanter major. Fig. 459.—Compressing femoral vessels. of the bone with the left hand, and quickly severs the posterior tis- sues by an incision directed downward and a little forward. 296 OPERATIVE SURGERY. Fig. 460.—Passing blade behind head of bone. The lateral-flap method offers no advantages over the antero-pos- terior, excepting, perhaps, easier drainage. This point, however im- portant it may have been before, like the drainage - tube of the present time, can not now be said to be of such marked signifi- cance. Anterior Oval Meth- od (Verneuil). — Apply the elastic bandage as far up as consistent with the proposed incision. Control the aorta and make an incision through the integument and fas- cia, commencing an inch below Poupart's liga- ment, in the course of the femoral vessels, two inches in length ; con- tinue it outward, transversely across the base of the great trochanter, to the gluteal fold, and along this to the inner side of the thigh; then obliquely upward two inches below the genito-crural fold, to the lower end of the vertical incision. Isolate the femoral artery and ligate it above and below the bifurcation of the profunda, and likewise ligate the latter a little distance from its origin. If no intervening branches exist, divide the femoral between the ligatures, isolate the femoral vein, ligature it and divide in the same manner. Carry the incision through the muscles, from whichever aspect of the limb is most convenient, seeking for and ligating all bleeding points as soon as apparent. Open the capsule in front, divide its posterior portion as closely as possible to the neck of the femur, together with the remain- ing tendons inserted into the head of the great trochanter. Depress the thigh, causing the wound to gape widely, and divide the muscles on its inner and posterior surface, in the same manner as those preced- ing. Finally, draw down the sciatic nerve, and cut it short enough to be above the border of the flap. The tissues left are not sufficient to close the wound, which is dressed with a thin layer of tarletan in contact with the cut surface, upon which charpie saturated with some antiseptic solution is placed, and the whole covered with cotton batting surrounded by oiled silk, which is held in position by a simple bandage. The wound is kept moist with the antiseptic solution. DEFORMITIES. 297 Results.—The rate of mortality is governed by the cause calling for the operation. In immediate amputation in military practice, ninety-three per cent die. In civil practice, the mortality after the primary amputations reaches eighty per cent. Secondary amputations offer better results ; sixty per cent recover in the civil and military combined. The results are more favorable in non-traumatic cases, being less than forty-one per cent. Taken together, the rate is a little over sixty-four per cent, being a trifle more than for amputation in the continuity of the thigh, which is about sixty-three and a half per cent. CHAPTER XL DEFORMITIES. Deformities may be either congenital or acquired, and in either case they can be referred to the soft or hard parts, either individually or conjointly. The acquired deformities calling for operation in a special sense depend on anchylosis of joints, distorted shafts and extremities of bones, irregular or unequal muscular contraction, and the congenital fusion of parts. To overcome the deformities dependent upon anchy- losis, we resort to forcible movement, if it be fibrous ; and the division of the bone, or joint structure, if it be bony. The forcible breaking of an anchylosed joint, while not an opera- tion in the accepted sense of the term, is nevertheless often associated with consequent complications, which entitle it to a greater degree of prominence than many accepted operative procedures. Brisement Force', as it is sometimes called, should be preceded by subcutaneous section of all the tendons, muscles, and fascia upon which "point pressure" causes reflex action. The incisions having united, place the patient upon a hard table, administer an anaBsthetic, and while the portion of the limb between the joint and the body of the patient is held firmly by assistants, the surgeon seizes the distal portion and forcibly flexes it, employing steady and persistent force. As soon as moderate movement follows flexion, it is then forcibly extended, and by repeated flexion and extension the range of motion of the joint is re-established. If the knee be the one in question, the .patella must be loosened before it is attempted. After the operation strap the toes and band- 298 OPERATIVE SURGERY. age the limb from the toes to the knee firmly, having first applied ad- hesive plaster for the purpose of extension. Pad the popliteal space with cotton, and compress the knee-joint with strips of adhesive plas- ter. Continue the roller over the knee and up the thigh, applying pressure to the femoral artery by means of a small piece of wet sponge, applied over its course and held in position by the ascending bandage. Place the patient in bed, apply extension, with the foot of the bed elevated, also ice-bags to the knee, the limb being immovably con- fined. At the end of five or six days the dressings are opened and again replaced, after slight motion is made. The sponge over the femoral artery is omitted. If the anchylosis be bony, the deformity can be relieved by osteotomy above the condyles, and, if necessary, below the head of the tibia at the same time, or by excision of the joint, or by the removal of a trian- gular piece above the joint, having the same angle as that formed by the junction of the tibia and femur in the popliteal space. The same principle can be applied above the knee as practiced by Barton (Fig. 461). Boring the joint and other expedients The most Fig. 461—Barton's operation. have been resorted to satisfactory of all, however, is os- teotomy above the condyles, which is described under that heading. In all joints, anchylosis is amenable to the same procedures as previously stated. Deformities caused by distor- tion of the long bones can be best corrected by osteotomy, associated with the antiseptic dressing. Curvature of the Spine.— A popular method of treatment at the present time is the application of the plaster - of - Paris dressing. The body of the patient is first surrounded by a closely-fitting knit jacket, between which and the region of the stomach is in- troduced a wedge-shaped "din- ner-pad," with the point down- ward ; composed of several thick- Fig. 462.—Apparatus applied. DEFORMITIES. 299 Fig. 463.—Extension apparatus. nesses of cloth, or cotton wadding surrounded by it. All sensitive parts and projecting points should be relieved from direct pressure by spongio-piline, cotton, or other similar ma- terial. * The same can be placed over the iliac spines and the adjoining portions of the crest. " The mammary glands in the female should be protected, and suitable space be provided by the introduction of properly shaped pads. " Tie the shirt over the shoulders and fasten it between the legs. Then the pa- tient is drawn up by the extending appara- tus (Figs. 462, 463", and 464) gently and slowly until he feels perfectly comfortable, and never beyond that point. A prepared, saturated plaster-of-Paris roller having been gently squeezed, so that all sur- plus water is removed, is now applied around the smallest part of the body, and is carried round and round the trunk downward to the crest of the ilium and a little beyond it; afterward in a spiral direction from below up- ward, until the entire trunk from the pelvis to the axillae has been incased. "The bandage should be placed smoothly round the body, and must not be drawn tight; it should be simply unrolled with one hand while the other follows and brings it into smooth close contact with all irregularities of the trunk. "After one or two thick- nesses of bandage have been placed around the body in the manner described, narrow strips of roughened tin can be placed parallel with each other on either side of the spine, if the case re- quires it, with intervals of two Fig. 464.-Body extended. or three inches, and in number 300 OPERATIVE SURGERY. sufficient to surround the body. Over these another plaster bandage is applied. In a very short time the plaster sets with sufficient firm- ness, so that the patient can be removed from the suspending appa- ratus and laid upon his face or back on a hair mattress, or, what is preferable, especially when there is much projection of the spinous processes or sternum, an air-bed. Before the plaster has completely set, the "dinner-pad" is removed, and the plaster gently pressed in with the hand, in front of each anterior iliac spinous process, for the purpose of molding the case over the bony projections. " While the jacket is drying it is necessary, sometimes, to wet it with a little water and dust it with more plaster. The surgeon often leaves some weak spots that need strengthening in this manner." The preceding is a description as recorded by Dr. Sayre, to whom the pro- fession is indebted for the prominence which has been given this method. The Deformities dependent upon Perverse Muscular Action are, in an operative sense, relieved by subcutaneous division, called myotomy and tenotomy, which has been before considered. Deformities due to Fusion of the parts and supernumerary attach- ments, like webbed fingers and toes, and supernumerary digits, al- though not common, are, nevertheless, entitled to some consideration. Webbed Fingers.—The operative treatment will depend very much upon the extent as well as the thickness of the attachments ; whether the connections be limited to the soft parts alone, or the bones be fused. Digits that are united by their extremities only can easily be separated by the division of the tissues which connect them. If they be united their entire length, even then an incision in the median line of their attachments, down to the line of the normal web, may be sufficient to effect a cure, if the tissues connecting them be not too thick ; if such be the case, great difficulty is often experienced in healing the divided surfaces, owing to the tendency to reunion at their point of junction. To obviate this, various expedients have been recommended? one of which is to introduce a rubber seton at the base of the malformation, on a line with the normal web of the hand, and allow it to remain until the Fig. 465.-Wel>bed fingers. opening becomes permanent (Fig. 465), when the remaining portion is divided and the borders united by sutures. Another plan is to make a trian- gular flap from the posterior portion of the web, the base to remain DEFORMITIES. 301 attached, and to correspond in shape and size to the space between the knuckles. Its apex is of course directed to the free edge of the abnormal at- tachment. The flap having been raised, the remaining portion of the attachment between the fingers is divided, and the triangular flap adjusted to the base of the cleft, and kept in position until union takes place. The remaining borders of the wound are united by su- tures the same as before. It has been suggested to make two such flaps, one on the palmar and one on the dorsal aspect, in the same situation ; to cut off their ex- tremities and unite them at the cleft, when the remaining portion can be divided longitudinally. Another, a very effectual and ingenious method, is best described by M. Nelaton, its de- signer : "A longitudinal incision is made in the center of the phalanx of one finger on the dorsal aspect, for the posterior flap ; on the palmar as- pect of the other for the dorsal flap, the length of the incision will correspond with the depth of the web. From either extremity of the longi- tudinal incision, a small transverse one is to be made toward the phalanx of the connected finger (Fig. 466, B). The lower transverse incision will correspond to the free edges of the web ; the upper one will cross the cleft between the fingers. Each flap is now to be dissected back toward the contiguous fingers. In doing this the two folds of the web will be separated from each other, one entering into the formation of the posterior flap, the other into the formation of the anterior. Each flap will now be found to be attached by one edge only, and is to be wrapped around the de- nuded surface of the finger to which it is attached. The flaps are to be adjusted by strips of adhesive plaster, and by sutures." Annandale says : " The principal objection to this ingenious opera- tion appears to me to be that it necessitates cutting into the palmar and dorsal aspects of the fingers in order to get a flap to cover their sides." If the web or fold of the skin be loose, he deems it pref- erable " to make the longitudinal incision along the sides of each finger instead of along the center of the dorsal and palmar aspects." Triangular flaps may be made at the base of the web, and the remain- der cut directly through (Fig. 466, A). If Nelaton's operation be performed, care must be taken in uniting the flap, or sloughing will follow. When the joints of the digits are fused, it is not wise, as a rule, to attempt their separation, since, though it be accomplished, the remaining digit may have its function greatly impaired ; however, this course is not so imperative now, since the advent of antisepsis. If Fig. 466.—Nelaton's method. 302 OPERATIVE SURGERY. a supernumerary digit possess an independent articulation, it can be removed without any great danger to its associate. Ingrowing Toe-nail.—This is quite a common affliction, to the relief of which various palliative measures have been directed. As a rule, however, they have been found inadequate to effect a cure. This condition is largely induced by improperly fitting boots and shoes, although in some persons there exist additional predisposing causes. Going barefooted would in a ma- jority of cases bring about a speedy cure, but, since this is impracticable, operative measures are often necessary. Operation.—When the affection is fully established, administer an anaesthetic, and with a sharp-pointed scalpel divide the nail its whole length on a line with its ingrowing portion (Fig. 467), which portion can then be quickly and easily removed by a thin-bladed pair of forceps, or a narrow spatula passed beneath it. If the other side be affected, it too should be removed in the same manner. Cauterize the exposed matrix and apply a hot anodyne poultice at once. The patient must keep quiet until the tenderness has in a meas- ure subsided. In no instance ought the entire nail to be removed, unless it be diseased. Bunion.—This affliction is accompanied in a large proportion of cases by malposition of the great toe (Fig. 468), and an increase in the normal size of the bursa, or the development of an adventitious one. The operative means for relief consist either in the excision of the bursa, or its subcuta- neous division into numerous fragments by means of a narrow tenotome. If these means fail, a sufficient amount of the metatarsal bone should be excised to admit of the toe being returned to its normal position, or the operation described on page 222 can be per- formed, after which the toe is confined in place until recovery is established. Flat Foot— Ogston's Operation.—With the foot lying on its outer side, an incision an inch and a quarter in length is made paral- lel with the sole down to and at the inner side of the bones forming the astragalo-scaphoid articulation. The ligamentous structures are detached from the bones for half an inch at either side of the wound, with a knife and periosteal elevator. As Fig. 467.—Ingrowing nail. Fig. 468.—Bunion with hal- lux valgus. DEFORMITIES. 303 soon as the contiguous articular surfaces of the scaphoid and astragalus are well exposed, they are denuded of their cartilage and of a sufficient amount of bone to permit the correction of the deformity and the per- fect coaptation of the cut surfaces. The surfaces are then fastened to- gether by ivory pegs or by wiring. If the motion between the internal cuneiform and scaphoid bones be unusually free, their contiguous surfaces can be treated in a similar manner instead. Results.—If performed with strict antisepsis, the danger to life is slight. The anchylosed arch gives the patient a useful foot. Stokes' operation, it is claimed, corrects the deformity, which if true makes it much the more preferable operation, as it does not involve the joint. Astragaloid Osteotomy (Stokes).—This operation is recommended to relieve the deformity of flat foot, and should only be conducted under strict antiseptic precautions. Operation.—Make an incision an inch and a half in length along the inner side of the foot, the center of which should correspond to the prominence caused by the head of the astragalus ; at the center of this another is made about three fourths of an inch in length at right angles to it, and situated a little behind the medio-tarsal joint. The triangular flaps thus formed are dissected back half or three fourths of an inch. A wedge-shaped piece of bone is then removed from the head and neck of the astragalus with an osteotome ; the foot adducted and supinated, in which position it is retained until recovery takes place. Results have thus far been satisfactory, but as yet there are not sufficient data upon which to estimate a mortality record. Tarsectomy.—In old and obstinate cases of talipes varus and equi- no-varus, this method of treatment has been performed with varying success for a long time. Operation.—Place the foot on its inner side and make an incision parallel to the sole down upon the outer border of the cuboid bone, its entire length, and expose its upper and lower surfaces by means of a knife and periosteotome, carefully protecting the surrounding soft parts from injury. A triangular piece of bone, with the base outward, is then removed from the cuboid of sufficient dimensions to admit of the correction of the deformity. In extreme cases the entire cuboid and even portions of the contiguous bones may be included in the base of the wedge. As soon as the deformity can be reduced, the bony surfaces are wired together, the limb dressed antiseptically, and the foot confined in the corrected position until recovery takes place. Results.—When cautiously done, the dangers to life do not con- traindicate the measure, and the usefulness of the limb is very much enhanced. 304 OPERATIVE SURGERY. CHAPTER XII. PLASTIC SURGERY. This form of operative surgery relates to the various means adopted to overcome or alleviate the deformities of aspect and func- tion resulting from congenital defects, disease, and accidents. Inasmuch as the successful issue of these operations depends far more on the careful attention to the details and small matters con- nected with them than anything else, it is well for the operator to understand at once that there is no precaution too trifling to be treated with indifference. Preparation of the Patient.—The patient ought to be in a vigorous physical condition, his appetite and functions normal, and the sur- roundings of such a character as to combine quietude of mind with close and gentle attention. No association can be allowed with putre- factive processes, or diseases known to engender changes derogatory to union and repair. Prior to the operation, the part should be puri- fied by a solution of carbolic acid or other suitable agent. Size of the Flap.—The shape and size of the flap must be ascer- tained by careful measurement. A pattern of the deformity to be re- paired is to be carefully cut out and used to outline the tissues to be employed in filling the gap, since the contractile power of the normal tissues, when loosened from their underlying attachments, causes enough shrinkage to require undue force to maintain proper coapta- tion of the borders. The reparative flaps must always be made large enough to admit of at least three lines of shrinkage to each inch of their surface. In choosing the material to form the flap, it is necessary that it consist of sound, healthy skin ; and under no consideration can cica- tricial tissue possessed of a pale, glossy surface be employed ; for, when its subcutaneous connections are severed, it is almost certain to slough, especially when the result of a burn. The thickness of the flap should be sufficient to include all the vessels that normally afford it nourishment. The relation which cicatricial tissue bears to a flap is all-important. If it exists at its base, sloughing is quite certain to occur. Cicatricial tissue at the border of a flap is quite certain to die, and its presence must not be estimated in computing the area of the new flap. When the new flap is to be surrounded on three sides by cicatricial formations, its base must be large, vascular, and but little twisted, as the medium of supply at its sides will be very much lessened by its new association. The long axis of the flap should correspond to the course of the vessels from which it derives its nourishment, and its base must be located as nearly as possible to the nutrient vessels. All hemorrhage must be checked before the flaps are united, since it PLASTIC SURGERY. 305 Q not infrequently happens that a thin clot of blood prevents union. The direction of the flap should be such that it can be placed with the least twisting of the pedicle. The silver wire and carbolized silk, or horse-hair, make efficient sutures, which should not be drawn tightly. To avoid the danger of ulceration at the pressure points, small squares of carbolized, bibulous, or unglazed paper, having diameter of half an inch or less (Fig. 469), with small holes through the center, or punctured through the cen- ter by the pin or needle carrier at the time of carrying the ligature, can be used to tie them upon. The edges of flaps may be beveled ; this increases the width of the opposed surfaces, and, when combined with undercutting Fl0# 469._pa. of the other borders, increases the chances of union. A per protective. small slip of the aseptic bibulous paper can be placed be- tween the sutures and the edges of the wound at the point of crossing. The use of carbolized cotton yarn, which is to be frequently changed, in connection with the plastic pins, offers a soft and otherwise ad- mirable retaining agent. If small pins be inserted to indicate the extent of flaps, the incis- ions will be made more accurately than if they be formed by the aid of the eye alone. Methods of Transfer.—The methods of transfer may be classified into six general forms, with their subdivisions : 1. Sliding in a direct line. 2. Sliding in a curved line. 3. Jumping. 4. Inversion, or eversion. 5. The Taliacotian. 6. Grafting. Sliding in a Direct Line.— The first and simplest variety of this method consists in uniting the lips of an ordinary incision, and is sometimes called " simple approximation of divided surfaces." The second variety is called " undercutting," and consists in cut- ting under the edges of the incision at each side, and drawing them together. The third variety consists in sliding in a direct line, by aid of par- allel incisions on both sides of the primary one, which is closed. The out- side incisions are al- Fig. 4Y0.-Parallel incisions. Fig. 471.—Opening closed. lowed to heal by granulation (Figs. 470 and 471). Undercutting in this method lessens the tendency to separation of the parallel lines. In the fourth method the liberating incisions are made transversely, that is, at right angles to the extremities of the oval opening, and undercutting is employed (Figs. 472 and 473) to enable this opening to be closed. The uppermost curve is undercut, and the lowermost is 20 306 OPERATIVE SURGERY. Fig. 472.—Transverse incision. Fig. 473.—Open- ins; closed. liberated by a combination of undercutting and sliding by the aid of the transverse incisions. If this method be applied to those parts which can not resist the traction of the displaced tissue, a second de- formity is liable to follow. Sliding in a Curved Line.—Thn operation can be done with flaps having either curved or angular bor- ders. In the former instance, the space from which the flap is taken is filled by undercutting its borders and drawing them together. In the latter, the space is usually allowed to granulate. Jumping.—Jumping, as the name implies, consists in "jumping a flap connected by a pedicle over intervening undetached tissues." It can be done with or without the pedicle being twisted. If the flap be not moved more than a quarter of a circle, twisting of the pedicle is not necessary. Undercutting is employed in this operation when necessary to adjust the parts properly. The plan of operation without twisting the pedicle is shown in Fig. 474. When the flap is moved more than a quarter of a circle, the pedicle will be twisted, and the degree of twisting will depend on the distance the flap is moved. If the pedicle be too much twisted, the circulation of the flap will be impeded, and sloughing may ensue. Fig. 474.—Jumping method. Inversion or Eversion.—These methods relate simply to the em- ployment of integument in the repair of mucous membrane, or vice versa. Tubular formations may be constructed by either of these methods, as in the formation of new canals, like the urethra, vagina, and the closure of an extroverted bladder. The Taliacotian Operation.—-This operation is familiarly known as the dissection of a flap from another and distant portion of the PLASTIC SURGERY. 307 body, allowing it to granulate, and applying it to the part to be re- paired, as is done in the ordinary operation for the construction of a new nose. Grafting.—This method is but little employed, and the operation is performed by entirely removing a flap from one place to the local- ity to be repaired. Skin-grafting, in the common acceptation of the term, is employed to cause the healing of extensive granulating surfaces, when of a healthy character. It is performed by first making small punctures in the granulating surface with the sharp end of the common pocket- probe, half an inch or so apart ; and, second, by placing over the open mouths of these shallow punctures small pieces of integument, a line or two square, with the fresh surface downward. They are then pushed into the openings of the punctures, by the same probe, in such a manner as to cause a close contact between the raw surfaces of the small "grafts" and those of the punctures in the granulating surface. Small pieces of lint are placed over each "graft," and the whole is confined in position by narrow strips of adhesive plaster. The part should be carefully redressed at the end of three or four days. Rhinoplasty.—This operation consists in the reproduction of a part or the whole of the nasal organ. The present ability of the surgeon to arrest the diseases causing deformities of the nose has lessened the frequency of this operation. Ingenious contrivances of ivory, rubber, etc., have been made to fit the nose, and to thus supply a substitute for the lost parts. These contrivances, when tinted to conform to the complexion of the wearer, often prove quite deceptive to the observer ; but, being unaffected by the various contingencies of the weather and the emotions, they are apt at times to cause the wearer to present a ludicrous appearance. In operating on the nose, save all that is possi- ble of its cartilaginous and bony tissues, for they will each afford im- portant supports for the new structure. The cartilages of the alae should, when possible, constitute the free border of the new structure. The deformities of this organ may be due : 1, to a loss of the su- perficial soft parts, which may vary in extent and degree ; 2, to a loss of the bony or cartilaginous septum, with or without loss of the nasal bones; 3, to a loss of both combined. The soft parts may be restored by either of the five methods before named. The extent of the deform- ity and its situation will determine the choice of a method. When the loss of the integument is small and does not involve the alae and the deeper structures, the deformity may be remedied by the direct ap- proximation of its borders, aided, of course, by a free undercutting with or without parallel incisions. The French method, by transverse incisions combined with undercutting, can be employed (Fig. 475) when the former is deemed inadequate. If the extremity of the nose or the alas be involved, the second method, or " sliding in a curved 308 OPERATIVE SURGERY. line," the flap having either curved or angular borders, is recom- mended. Fig. 476 represents the restoration of the alae by a flap taken Fig. 475.—Closure by transverse incisions. Fig. 476.—Repair by sliding. from the cheek (a). It must be of sufficient size to allow at least one fourth for its contraction, otherwise, when united in position, it will displace the axis of the nose, thereby substituting one deformity for another. Langen- beck repaired a similar deformity by taking a flap from the opposite side of the nose (b). As in the preceding method, the dissec- tion must be care- fully made down to the cartilaginous frame-work. The border of the new ala, although fresh- ly cut, heals in a satisfactory man- ner. Fig. 477 shows the line of incision employed to repair the deformity with a flap possessing an already cicatrized border. Fig. 477.—Repair by sliding. PLASTIC SURGERY. 309 Fig. 478.—Repair by jumping. The vascular supply of this flap is not active, and every precaution should, therefore, be taken to provide against the danger of slough- ing. If either ala be absent, and the resulting gap be a large one, the material for its repair can be taken from the forehead, as shown in Figs. 478 and 479. It will be seen that the pedicles are admira- bly located to receive ample nourishment. The loss of an ala or of the end of the nose may be repaired from the tis- sue of the upper lip (Fig. 480) or the cheek. If the columna be absent, it may be replaced by struc- tures taken from the upper lip. In this operation it is better to include the whole thickness of the lip, tipping the flap directly upward into place, than to make an integ- umentary flap, the adjustment of which will require a smart twisting of the pedicle. In the former instance the cuticle is dissected off and the raw surface carried directly into its position. The mucous surface of the flap soon assumes integumentary characteristics. If the lip be deficient at the point of se- lection, a flap can be taken from beneath either ala and carried into place. Loss of the Bony or Car- tilaginous Septum, with or without Loss of the Nasal Bones.—The loss of the carti- laginous portion of the sep- tum, the other tissues remain- ing intact, causes a flattening of the end of the nose, or a depression at the lower end of the nasal bones. The opera- Fig. 479.—Repair by jumping. tion of sliding the tissues may 310 OPERATIVE SURGERY. Fig. 480. — Repair by jumping. temporarily relieve the deformity ; but traction of the flap and various interferences from without soon reproduce it. Mechanical ingenuity bids fair to afford more relief for this deformity than surgical, especially if the defect be associated with an opening through the hard palate. If the nasal bones be intact, the loss of the bony septum is not manifested by any external deviation of the organ. If both the septum and nasal bones be gone, it then becomes necessary, in order to relieve the deformity, to elevate and maintain in position the tissues composing the soft parts of the nose. To accomplish this requires an internal support of some sort, although much may be gained by dissecting up the soft parts on each side of the nose, and raising them in the line of the bridge by approximating their bases in position by means of pins passed through them, and confining them until union of the flaps takes place. In 1829 Dieffenbach published a method of performing an operation by which he overcame the deformity resulting from the loss of the nasal bones and the septum. An incision was made with a narrow-bladed knife along the outer side of the sunken border of each nostril, the intervening strip being three times broader at its connec- tions with the upper lip than above where it joined the forehead. At the outer side of each of these incisions, another was made down to the bone, which began a few / lines below, and to the outer .' / side of the first, and was carried obliquely down- ward, parallel with the pri- mary one, and external to the side of the nose, around into the nostril, thereby separating the ala. The columna was elongated by short parallel incisions in the upper lip, and the cheeks were dissected up from their bony attach- ments, through the lateral cuts, sufficiently to render them freely movable. The flaps were then raised, their borders were pared oblique- ly, reunited and fastened with pins and sutures, and retained in position by drawing the de Fig. 481.—Dieffenbach's method. PLASTIC SURGERY. 311 tached portions of the cheeks toward the median line of the nose, where they were fixed by two long pins passed through their borders, under the nose. In this instance the pins were passed through two narrow strips of leather, which equalized the force and prevented the producion by the pins of premature ulceration. A quill sur- rounded by oiled lint was then introducd into each nostril. The accompanying figure illustrates the proceeding, with its result (Fig. 481). Superimposed superficialfiaps were successfully employed by Ver- neuil. In this case the alae and tip of the nose were uninjured, but Fig. 482.—Verneuil's method. were flattened by loss of the support of the septum. He made a longi- tudinal incision along the median line of the nose at the center of the depression, and a transverse one extending from each end of the first to just beyond the contour of the nose (Fig. 482), and dissected the flaps freely from their attachments. An oblong flap of suitable size was then raised from the forehead, its pedicle being located directly between the eyes ; this flap was turned downward, bringing its raw surface uppermost. The lateral flaps were then drawn inward and placed upon it and united in the median line. The Indian Method (483).—This was at one time the prevailing method of operation when the septum and a large proportion of the soft parts of the nose were absent, and was employed even when the lower extremities of the nasal bones had sustained a loss. The tend- ency to atrophy and sliding down of the flap after union had taken place, accompanied by closure of the nostrils and danger to the life of the patient from the operation, caused the substitution for it of more 312 OPERATIVE SURGERY. satisfactory measures. A flap was made from the integument of the forehead of the same shape, but of one fourth larger size than the gap to be filled ; its base was half an inch broad, and located between the eyebrows. The flap was therefore substantially the shape of the ace of spades, and included all the tissues down to the periosteum (Fig. 483, a), the stem above being intended to form the columna. The edges of the gap were freshened, and the flap, with the raw surface un- dermost, was twisted on its ped- icle and attached to the mar- gins of the gap. The flap was then made prominent, b, by the aid of greased plugs introduced into the nostrils, and also by drawing the cheeks toward the median line, where they were fastened by means of pins passed The tendency of the flap to slide various ways—such as connecting 483.—Indian method. through them beneath the nose. downward has been combated in the pedicle with a longitudinal incision at the side of the nose, the attachment of its whole length to a newly formed raw surface at its base, and grafting the sharpened pedicle into the integument at its base. Italian Method.—This old method has many virtues, and, were it not for the great difficulty of keeping the parts in position, would be much more em- ployed. The flap is taken from over the biceps, with its apex toward the shoulder. It is first dissected up, and its extremities allowed to remain at- tached, until suppuration is established, when the proximal end is separated and the dressing continued until the flap is well shrunken and the under surface cicatrized. It is then applied to the gap after the borders of both have been freshened (Fig. 484). When Fig. 484.—Italian method. PLASTIC SURGERY. 313 union is completed, the pedicle is cut, and the flap is fashioned so as to relieve the deformity in the best possible manner. Osteoplastic Rhinoplasty.—The periosteum has been removed fre- quently from a part of the frontal bone, in connection with the flap, and consigned to the gap, with the hope that the formation of new bone might occur, so as to give solidity as well as prominence to the new nose. The removal of the periosteum from the frontal bone is not by any means devoid of danger. Osteo-myelitis has arisen there- from, followed by pyaemia and death. The periosteum may be used to form a portion of the flap first applied, in the double-flap method, illustrated in Fig. 485. It is true that the relation of its surfaces will be reversed, but this can not change its bone-producing value ; more- over, if bone be formed, it can be easily shaped by manipulation to suit the proposed outline of the or- gan. Oilier's Meth- od. — An opera- tion was per- formed some time since by Oilier, for a deformity caused by the loss of the alae, co- lumna, cartilages, lobe, and a por- tion of the sep- tum, due to lu- pus. The nose was not more than an inch long, due to ar- Fig. 485.—Ollier's method. rest of develop- ment of the ossa nasi, to which was attached a strip of cartilage. The integument of the lip and cheeks had been involved, and could not therefore be depended upon for flaps. Oilier commenced two diverging incisions in the median line of the forehead, two inches above the eyebrows, and carried them down- ward to a fourth of an inch from the outer side of the nasal orifice (Fig. 485). The upper portion of the triangular flap included the corresponding portion of periosteum down to the upper end of the nasal bones. The dissection was continued along the right nasal bone, omitting the periosteum, down to its lower end, from which the car- tilage was separated ; but it remained attached to the flap. The left nasal bone was separated from its bony connections with a chisel, 314 OPERATIVE SURGERY. leaving it attached to the flap by its anterior surface ; the cartilagi- nous septum was then divided from before backward and downward with scissors, and left attached by its base to the cutaneous cartilage, that a central support might be provided for the new structure. The whole flap was then drawn downward, until the upper border of the loosened nasal bone (left) came opposite to the lower border of the right one, when they were fastened together with a metallic suture. The sides of the flap were then united to the cheek and the frontal incision closed above its apex. In this case, the space left by the removal of the left nasal bone was filled by bone developed from the periosteum that had been slid down from the forehead. This variety of deformity has also been relieved by attaching a finger to the sides of the nasal chasm. The nail was first removed and the palmar surface of the finger was denuded, by the formation of lateral flaps, down to the distal third of the first phalanx. The finger was then fastened into position upon the freshened borders of the deform- ity, by means of sutures passed through the lateral flaps, and, when union was sufficient to sustain the nutrition of the part, the finger was amputated at the juncture of the middle and distal thirds of the third surgical phalanx, and the distal end turned downward to form the end of the nose and its columna. The detail essential to the proper description of this operation, which was lately done with success by Prof. T. T. Sabine, is too ex- tensive to be considered here. A full account of this very interesting case can be found in the April number of the " Illustrated Quarterly of Medicine and Surgery," 1882. Subcutaneous Method.—This method consists in the subcutaneous division of the depressed tissues, so that they are separated from their bony connections, as was done by Prof. Pancoast in 1842, and can be best described in his own language : " A long, narrow-bladed tenotomy-knife was introduced on either side by a puncture through the skin over the edge of the nasal pro- cess of the upper maxillary bone. The knife was pushed up under the skin to the top of the nasal cavity, and then brought down, shaving the inner side of the bony wall, so as to detach the ad- herent and inverted nose upon either side. The point of the nose could now be brought out. The nose still remained adherent to the top of the nasal chasm. The knife was a third time introduced under the skin, in a direction corresponding nearly to the long diameter of the orbit of the eyes, and the adhedons separated from the nasal spine and the internal angular processes of the os frontis. The soft parts and the cheeks were loosened, by sweeping the knife outward along the surface of the bone, so far as to divide the infra- orbital nerve and artery on each side, down toward the median line, PLASTIC SURGERY. 315 and held together with sutures passed through the cavity of the nose." As before mentioned, mechanical appliances can be employed to support the soft parts of the nose, provided an opening exist through the roof of the mouth. Fig. 486 shows a lever sometimes employed to raise and sup- port the parts in proper posi- tion. In this instance, however, the lever is attached to an apparatus intended to relieve an additional deformity. " The processes E E pass into the nose, and support the sunken portion. The nasal elevator must be so arranged as to fall back of the line B B, Fig. 486.—Kingsley's nasal lever. to be introduced, and then must extend into its position. This is accomplished by attaching the elevator to the denture by a joint, -as seen in the engraving, and also by extending an arm of the elevator within the shell, and terminating it with a hook." The dotted lines show the lower end of the lever and the elastic attachment which retains it in position. The irritation consequent upon the pressure of the lever is not severe, and can be lessened by covering the ends with lint, cerate, etc. The degree of elastic tension can be regulated at the will of the patient, and even be entirely removed during the night. Hare-lip.—This deformity constitutes a large proportion of the congenital defects calling for operations upon the face. Operations for its relief can be performed at any age, but the best time is as soon after birth as the infant becomes well eduoated to take its food and enabled to bear the loss of blood. If the infant be plump and robust, it can be performed earlier than if weak and puny. The exceptions are rare when it is not admissible at three months of age. It is important to have complete control of the patient during the operation. For this purpose, an anaesthetic should always be given, chloroform being usually selected. The arms of the patient are placed at the sides, and are held in position by a napkin surrounding the body and pinned sufficiently tight to prevent their withdrawal. One assistant takes the child in his lap, while another stands be- hind the former and holds the infant's body. The head is firmly held between the hands of the first assistant, so that he is able not only to control the movements of the head, but likewise the circu- lation in the facial and coronary arteries, and to bend the head for- 316 OPERATIVE SURGERY. ward, that blood may escape from the mouth. He can also administer the anaesthetic with a small sponge held between the index-fingers. The success of the operation will depend in a very large degree upon the entire absence of tension when the parts are placed in position. To prevent tension, it is often necessary to separate the lip and cheeks to a considerable extent from their bony connections. In some in- stances, owing to the difficulties of the case, the loss of blood will be considerable, unless every precaution to prevent it be taken. The coronary vessels usually supply the bleeding points, but they can be easily controlled by grasping the lip at both sides of the incision, be- tween the thumbs and fingers. By this procedure, the same force that puts the part upon the stretch also checks the flow of blood. The fingers of the as- sistant often hinder the operator, especially if the cleft be a large one, but their action can readi- ly be supplemented by passing through the lip, at each side of the proposed cut, a strong silk ligature, which, when looped, makes it possible to keep the parts on the stretch without in- convenience. The ligature can be so placed that when the parts are put upon the stretch the cor- onary vessels will be compressed. Either Milne's artery compres- sion forceps or Langenbeck's ser- refines (Figs. 55 and 58) will con- trol the hemorrhage admirably if one of them be fixed at the angle of the mouth on each side. If the blades of the ordinary dressing forceps be surrounded by adhe- sive plaster and closed upon the lip by rubber bands passed around the handles, a useful substitute will be had for the instruments just mentioned. The additional Fig. 487.—Butcher's bone pliers. instruments needed are a strong pair of scissors, two scalpels- one sharp pointed—and Butcher's bone pliers (Fig. 487), if the case be complicated with a projecting intermaxillary bone. The projecting PLASTIC SURGERY. 317 portion may be pressed into position often by direct manual force. A liberal supply of hare-lip pins, Buck's needle-carrier (Fig. 48), silver sutures, and needles and needle-holder are required. The variety of suture to be employed and the degree of tension allowable have been already considered under the heading devoted to that purpose. The borders may be pared with a sharp-pointed scalpel, strong scissors, or the triangular cataract-knife ; the latter is a very useful instrument for this purpose. It is not permissible to sacrifice the parings taken from the free borders of the cleft, except in cases with but little de- formity ; they should remain attached and be utilized in filling in the gap, this being the only satisfactory manner of avoiding the occur- rence of the objectionable notch often seen after operations for hare- lip. The points of the pins should perforate the flaps at least a third or fourth of an inch from the borders of the wound, and even far- ther, if there be any degree of tension. One or two pins will be suf- ficient in-the majority of cases. Neither pins nor sutures are passed through the flaps, but are passed near to their under surface. The sutures may be inserted nearer to the edge of the wound than the pins, and in sufficient number to properly connect its lips. The latter are removed within two or three days ; the former may remain longer. If ulceration begin around the pins, they should be removed after others have been inserted at new points to receive the strain. Simple Hare-lip.—This variety of deformity can be treated by paring and uniting directly the borders of the cleft, or by uniting them after incisions extending more deeply, which likewise sacrifice the borders of the cleft (Fig. 488), and also by the single and double flap method. Fig. 488.—Incisions for direct union. The simplest method consists in refreshing the borders of the cleft, loosening the labial connections to the bones, and bringing the edges directly into contact. Care should be taken to secure an accurate co- aptation of their vermilion borders. Unless the operation is carefully performed, this method is often followed by a notch at the border of the lip where the flaps are joined. Single Flap (Fig. 489).—Draw down both borders of the cleft and freely sever their connections with the bone ; pare the border of the 318 OPERATIVE SURGERY. longer portion, c, and make the flap on the shorter, b ; approximate and unite them, as before described. Double Flaps.—Pass a silk ligature through each angle of the fissure (Fig. 490, c); divide the sublabial connections, make one side Fig. 489.—Single-flap method. Figs. 490, 491.—Double-flap method. tense, transfix it near the border of the lip, and cut upward to the apex of the cleft; repeat the operation on the opposite side of the fissure ; draw both flaps downward, bringing their cut surfaces in contact with each other (Fig. 490, d) ; close the cleft with a pin or suture passed near to the vermilion border, and insert another above if necessary ; unite the everted flaps by a fine silken thread or horse- hair, e ; cut off their extremities obliquely, leaving enough tissue to form a permanent projection at the margin of the lip, in order to ob- viate the formation of a notch. If the cleft be shallow (Fig. 491, a), the flaps should remain connected above and be turned downward and united, as before (Nelaton) (Fig. 491, b). Double Flaps, Giraldes' Method.—This method is principally em- ployed only when the deformity extends into the nasal cavity, and the flaps are constructed so as to provide a floor to its entrance (Fig. 492). Figs. 492, 493.—Giraldes' method. When the flap c is carried upward to repair the floor of the nostril, the angle of the cut b a is then brought in contact with the angle of the border d, and their cut surfaces are made of a similar length. The border b then comes in contact with d, and the point of the flap a rests upon the undermost cut, in which position they are united (Fig. PLASTIC SURGERY. 319 493). This operation is an admirable one, and should be employed on all occasions where an extensive deformity exists. Double Hare-lip, simple.—Pare the central portion (Fig. 494, c) on both sides ; make lateral flaps with their attachments be- low (Fig. 494, a b) ; liberate the labial attachments, and approx- imate the raw surfaces by the aid of pins and sutures. Complicated Hare-lip.—Hare- lip is often complicated by a fissure through the alveolar process, which sometimes extends to the hard palate, and even beyond, to the soft parts. For a time before the-operation, it is well for the parents or nurse to make gradual pressure upon the more prominent bony portion, combined with out- ward traction on the depressed side, endeavoring thereby to cause the alveolar arch to assume as nearly as possible a normal outline. A reasonable degree of patience in making these painless manipulations will in time effect a more satisfactory result than the application of sudden force by means of forceps. The practice of forcing the alve- olar extremities into position, paring and wiring them, is a pernicious one, since to do it still further shortens the outline of the arch of mastication of the superior maxilla, and does not result in a bony union of the extremities. The gentle but constant traction exerted by the united lip will in time as certainly reduce the bones as the more vigorous measures. It is better to allow the deformity of the hard parts to remain un- molested until the teeth appear, when the outline of the biting surface of the upper jaw may be compared with that of the lower jaw, and made to meet it by rectifying the upper, and introducing, if neces- sary, additional teeth upon a plate to fill the gap in the biting surface. Giraldes' method offers the best opportunity of closing the fis- sures in the lip in these cases. The fissure may be double, and involve both the hard and soft parts, back to and through the soft palate. The intermaxillary bone in this connection may project freely, and even be adherent to the soft parts cover- ing the end of the nose (Fig. 495). If such be the case, after the division of the vomer, or the removal of a triangular piece from the Fio.495.-ComPlicatedhare- septuni) the projecting portion is forcibly pressed into position, its borders refreshed, and the soft parts united, as in the simpler forms ; except, perhaps, Fig. 494.—Double hare lip. 320 OPERATIVE SURGERY. it may not be prudent to unite both sides simultaneously, for fear of causing too great traction. When the protruding portion is connected to the nose, it should be Fig. 496.—Hainsley's compressor. Fig. 497.—Operation by V-shaped incision. separated from this with care, or the columna will be impaired. The parings are utilized in correcting the upper lip, when practicable. The cheek-compres- sor, designed by Hainsley, may be employed to hold the parts in position when the conditions require it (Fig. 496). Cheiloplasty is an operation directed to the restoration of de- formities of the lips dependent on dis- ease or congenital defects. Deformity of Low- er Lip, V-Incision. ~"N^ —This incision is Fig. 498.—Celsus' method. employed for the re- moval of epithelio- mata, or other morbid growths, that do not require the removal of PLASTIC SURGERY. 321 Fig. 499.—Celsus' method. more than one third of the lip. The whole thickness of the lip is di- vided ; the length of the arms of the V being increased proportionate- ly to the width of its base. The usual liberating incisions may be required, and the cut sur- faces are united by the same means, and cared for in the same manner, as in operations for hare-lip (Fig. 49*7). Method of Cel- sus. — When the morbid growth in- volves the whole or half of the lip, the broad-based V in- cision is supple- mented by trans- verse ones extending outward, from each angle of the mouth, a suf- ficient distance to admit the easy joining of the V borders after the tissues have been freely liberated from their bony attachments (Figs. 498 and 499). If difficulty be ex- perienced in sliding the flaps, it may be overcome by making short vertical incisions through the cheek at the outer extremities of the horizontal ones (Fig. 498, e, e). The most in- genious feature of this method consists in divid- ing the buccal mucous membrane at least a fourth of an inch above the incision made through the cheek and parallel with it, so that when the outward cuts are completed, and the parts joined in the median line to form the lip, its raw upper borders can be covered by turning the processes of mu- cous membrane over them, thereby forming an excellent vermilion border. The angles of the mouth are also to be formed by stitching the membrane and buccal cuts to each other. Horizontal Incision (Fig. 500).—When the morbid process does 21 Fig. 500.—Horizontal incision. 322 OPERATIVE SURGERY. Fig. 501.- -Syme's method. not involve the free border of the lip, it can be removed by an oval incision, and the gap closed in the usual manner. If the space be too large to admit of closure, it can be left to heal by granulation, or bo remedied by the sliding process, either with or without parallel or transverse incis- ions. Syme's Method (Fig. 501). — In this method the operation is per- formed by contin- uing the sides of the V downward and outward in a curvilinear direc- tion for about two inches, dissecting up the flaps in the usual man- ner, raising them up to form the lip, uniting them in the median line, and allowing the remaining portion to heal by granulation. The mucous membrane should then be stitched to the integument, to pro- vide a suitable border. Buchanan's method differed from Syme's in making the extremities of the flaps straight, as shown by dotted lines (Fig. 501). In other respects, no radical difference exists between these methods. Buck's Method.—He first re- moved the morbid growth by the V-shaped incision, and united the parts in the usual manner. After union had taken place, the short lower lip was overhung by the up- per, giving to the patient a sucker- mouthed appearance (Fig. 502). The steps taken to relieve this de- formity can best be described in Dr. Buck's own language : "In order to insure precision in mak- ing the requisite incisions, their course should first be designated by pins, temporarily inserted erect in the skin at certain points, as shown Fig. 502.—Operation for contracted lower lip. PLASTIC SURGERY. 323 by Fig. 503. Letters a a represent two pins inserted at one finger's breadth below the under-lip border, one on either side of the chin, a lit- tle to the outside of the angle of the mouth, and both equidistant from the median line ; b b are also two pins inserted, one on either side, into the upper lip at the margin of the vermilion border, both equi- distant from the median line, and at such a distance apart as to in- clude between them sufficient length of lip border with which to form a new upper lip. The steps of the operation are then the following : with the forefinger of the left hand placed on the inside of the mouth; the cheek is held moderately on the stretch, while with a sharp-pointed knife it is transfixed at the point a, as marked by the lower pin in the side of the chin. An incision is then carried through the entire thick- ness of the cheek upward and a little outward a distance of one inch and a half to a point c, near the middle of the cheek. The upper lip should next be trans- fixed at the point b, marked by a pin on the vermilion bor- der, and the incision carried through the lip and cheek outward and a little upward to join the first incision at its terminus c in the middle of the cheek. A triangular patch, b, c, a, will thus be formed, which will include the entire thickness of the cheek, with its apex free and disconnected, while its base remains attached toward the mouth. The next step is to transfer the patch from the cheek to the side of the chin. For this purpose an incision should be made on the side of the chin from the starting-point of the first incision a, vertically downward to the edge of the jaw and to the depth of the periosteum (Fig. 503). The edges of this incision retracting wide apart, afford a V-shaped space for the lodgment of the triangular patch, which is now to be brought around edgewise and adjusted by sutures in the new location. By this transfer the portion of the upper-lip border that formed a part of the base of the patch, is brought into a transverse line, continuous with the upper lip, and forms an extension of it. The space upon the cheek from which the triangular patch was taken is closed by bringing its edges together and securing them by sutures. By this adjustment a new and naturally shaped angle is Fig. E03.—Buck's incision. 324 OPERATIVE SURGERY. formed for the mouth at the point b, where the lip was transfixed in commencing the second incision of the cheek. The incisions must be made with the utmost precision, and special care taken that the mu- Fig. 504.—Malsaifme's method. Fig. 505.—Sedillot's method. cous membrane is divided exactly to the same extent as the skin. The same procedure may be applied to the other side of the mouth and executed at the same operation." Malgaigne's Method (Fig. 504).—The growth is removed by means of one horizontal and two vertical incisions. The vertical incisions begin at the angles of the mouth, the horizontal one is located between them and below the disease. Two additional horizontal incisions are subsequently made on each side, to permit the closure of the gap by the sliding method. The flaps are freely separated, brought forward, united in the median line, and the mucous membrane of their upper borders stitched to the integument. The mucous membrane can in this instance be taken with the cheek- flap to form the vermilion border, as in Celsus' method. Sedillot's Method (Fig. 505).— The diseased portion is removed as in the preceding method, after which Fig. 506.—Buck's method. the vertical incisions are extended PLASTIC SURGERY. 325 to the lower border of the jaw, then backward far enough to make flaps of sufficient width to fill the gap ; thence directly upward to a point opposite the angle of the mouth. These flaps are dissected up, and united in the median line by the usual means. Deformities of the Upper Lip.—If the deformity here be slight, it can be remedied by the simple means employed upon the lower lip. Intero-lateral Flap (Buck). —This operation was done to restore one half of the upper lip and the adjacent portion of the cheek (Fig. 506). Di- vide the under lip where it joins the cheek by a vertical incision, a, b, at right angles to its border, and one inch in length. Make a second ill- Fig. 507.—Semicircular-flap method. cision, b, c, one inch and a half in length, beginning at the lower end of the first, a, b, and run- ning forward parallel with the border of the lip. An oblique incision, c, d, about half an inch in length, is then made upward and forward from the end of the horizontal one, leaving the flap with a good at- tachment at this point. Pare the edges of the deformity and the end of the half-lip above ; separate the half-lip from its bony attachments by free section of the underlying tissues directed upward toward the orbit; the under-lip flap is then tipped endwise, and its upper extrem- ity connected by sutures with the end of the upper half-lip. The re- maining space between the flap and the cheek is closed by sutures. Fig. 512 shows the result of this operation. Entire Loss of the Upper Lip.—This deformity may be repaired by semicircular or vertical flaps. Semicircular-Flap Method (Buck).—Commence an incision at the median line, on a level with the floor of the nasal cavity on each side ; carry it outward and downward in a semicircular manner below the lower lip, to a point corresponding to its middle third, a, b and a, c (Fig. 507). These incisions are to be carried through the entire thickness of the cheeks and lips at a uniform distance of an inch and a quarter from the border of the opening. Dissect up the remaining portions of the cheeks freely from their attachments beneath, that they may be easily brought forward. The upper extremities of the semicircular flaps are 326 OPERATIVE SURGERY. trimmed off at a proper angle, e, d, after which, they are united in the median line by the usual means. The interval between the cheeks and the newly constructed mouth is closed by sutures. Figs. 508, 509.—Sedillot's vertical-flap method. Vertical-Flap Method (Sedillot).—The bases of the flaps in this method may be made either upward or downward, the former being the better plan. They should com- prise the entire thickness of the cheeks; their length and width corre- sponding to the di- mensions of the proposed new lip, plus the one-fourth allowance for its shrinkage. They are carried into po- sition, and united Figs. 510, 511.—Dieffenbach's method. in the median line. The gaps in the cheek may be closed by sutures, or allowed to heal by granulation. Dieffenbach's Method.—Freshen the lower border of the remaining �5757236 PLASTIC SURGERY. 327 portion of the original lip, then raise two S-shaped flaps, one at each side of the nose, turn them across the space in front of the alveolus, unite them to each other, and also to the freshened border beneath the nose (Figs. 510 and 511). Stomatoplasty.—This operation is employed to increase the size and regulate an abnormally shaped mouth, when resulting either from disease or from previous operations. The deformity can be corrected by an operation already described (Fig. 502), when the lowTer lip is the contracted portion. The angles of the new mouth may be formed by means of transverse incisions, made at the proper situation. Whenever this is done the mucous membrane must be stitched over the raw surfaces, to pre- vent them from becoming united to each other. The operation described by Buck for restoring the angles of the mouth is simple and effective (Fig. 512). An incision is made with great exactness along the line of the vermilion border, circumscribing the circular half of the mouth, and extending to an equal dis- Fig. 512.—Stomatoplasty. tance in the upper and lower lips, a to b. This incision should only divide the skin, and not involve the mucous membrane. A sharp-pointed double-edged knife is inserted Fig. 513.—Whitehead's mouth-gag. Fig. 514—Mason's mouth-gag. 328 OPERATIVE SURGERY. at the middle of this curved incision, and directed toward the cheeks, flatwise, between the skin and mucous membrane, so as to separate The skin alone is next divided outward toward the cheeks, on a line with the commissure of the mouth, d to c. The underlying mucous membrane is then di- Fig. 519.—Tenaculum. vided in the same line, but not so far outward. The angles at the outer ends of the two incisions are accurately united by a single-thread suture. The freshly cut edges of skin and mucous membrane, above and below, that are to form the new lip-borders, are to be shaped by PLASTIC SURGERY. 329 paring first the skin, and then the mucous membrane, in such a manner that the latter shall overlap the former after they have been secured together by fine-thread sutures at short intervals. Operations upon the Palate.—The op- erations employed to relieve the deformities of the hard and soft palate are denomi- nated staphyloplasty, staphylorrhaphy, and uranoplasty. The in- struments required are the gag, for the purpose of holding the mouth well opened (Figs. 513 and 514) ; cheek-retractors (Fig. 515) ; seizing forceps (Figs. 516 and 517) ; variously shaped knives for refreshing the borders of the de- formity (Fig. 518) ; tenaculum employed in holding the flaps, etc. (Fig. 519); curved scissors (Fig. 520) ; periosteotomes (Figs. 521 and 522) Fig. 520.—Curved scissors. Fig. 521.—Sayre's periosteotome. Fig. 522.—Good- willie's perios- teotome. spiral needle Fig. 524.—Sims' suture-adjuster. Fig. 525.—Sims' wire-twisting forceps. Fig. 526.—Goodwillie's oral saw. 330 OPERATIVE SURGERY. for sutures (Fig. 523) ; suture-adjuster (Fig. 524); forceps for twist- ing wire sutures (Fig. 525) ; oral saw (Fig. 526); hoe for dividing the muco-periosteal membrane (Fig. 527) ; sponges, sponge-holders, etc. Staphylorrhaphy consists in closing an abnormal opening in the soft palate by bringing its freshened borders in con- tact with each other. The openings vary from a simple cleft of the uvula to a complete fissure of all the soft parts (Figs. 528, 529, and 530). Some time prior to C**0 Fig. 527.—Whitehead's hoe. Figs. 528-530.—Degrees of the deformity. the operation, the patient should be instructed by manipulation to control properly the fauces, so that the surgeon may handle the parts without causing involuntary movements of them. If the fissure be a small one, it can be closed by the aid of a solution of cocaine with- out further preparation. If the cleft extend through the whole of the soft palate, even en- croaching somewhat upon the hard portion, it will be neces- sary, especially if the gap be a wide one, and the muscles con- trolling it be active, to destroy their influence before attempt- ing to unite the cleft. The ten- sor- and levator-palati muscles, together with palato-glossi and palato-pharyngei, are the ones that exercise contraction on the part, and if they be properly severed, the velum will remain motionless and flaccid. The ac- companying illustration shows their relations to the surround- ing parts (Fig. 532). Fig. 531.—Freshening the borders. The palato-pharyngei mUS- PLASTIC SURGERY. J31 cles should be cut, with a pair of blunt-pointed scissors, by dividing the posterior pillars of the fauces, of which they form the principal part. The palato-glossi muscles, comprising the anterior pillars may be cut in the same manner. The remaining muscles are divided after first passing a silken thread through the velum at a point correspond- ing to the origin of the uvula, on each side of the cleft; the extremi- ties of the thread are looped and a tenaculum is used to make the ve- lum tense, while the following muscles are divided : Tensor Palati.—Recognize the hamular process'around which the tendon tensor palati runs, a little behind and internal to the posterior moar tooth. Make tense that segment of the velum by the suture just introduced, and enter the point of a narrow-bladed knife a little Qf b a 9 Fig. 532.—Muscles of the soft palate. below and at the inner side of the process, with the edge upward ; carry it upward, backward, and inward, until the point is seen through 332 OPERATIVE SURGERY. the gap ; this divides almost the entire width of the velum, with the main, if not the entire portion of the tendon of the tensor palati. Levator Palati.—Many of the lowermost fibers of this muscle will be cut by the preceding incision. If a greater section be required, depress the handle of the knife and carry it outward, so as to make an oblique incision on the posterior surface of the velum as it is with- drawn. It is well to allow two or three days to elapse before attempt- ing the union of the cleft, so as to permit hemorrhage and inflammatory action to subside, and to determine more clearly whether further sec- tion will be required. This muscle, if it be made tense by drawing the velum toward the incisor teeth by means of the silken thread, may be cut with blunt scissors under direct observation, especially if the cleft be a deep one. Operation of Staphylorrhaphy.—There are three steps to the opera- tion of staphylorrhaphy : 1. Freshening the edges of the cleft. 2. Pass- ing the sutures. 3. Coaptating the divided borders, and tying the su- tures. First apply a solution of cocaine to the palate, and then place the patient in a chair which will permit the head to be thrown well back so as to expose the parts to a strong light. The lower point of the cleft is then seized with the forceps, made tense, and the border freshened from below upward (Fig. 531), or the reverse if desired. Treat the opposite side in a similar manner. The patient is allowed to rest after the completion of the first step, until the hemorrhage ceases and self- control is regained. The sutures should be one yard in length, and doubled before passing, and thoroughly antiseptic. Either silk, horse-hair, silk-worm gut, or metallic sutures can be employed. Three or four are usually sufficient. The first should be introduced at the middle, the second at the lower extremity of the gap, while the remaining ones close the spaces between. They can be passed from before backward on one side, and from behind forward on the other, by means of the needle-holder and the ordinary short-curved needle (Fig. 533), or in the following manner by means of Whitehead's spiral needle (Fig. 523). Seize the left side of the cleft with a pair of forceps, and carry the needle through it at the point selected from before backward ; draw one end of the suture through between the borders of the cleft; withdraw the needle, arm it with another suture, and pass it on the opposite side in the same manner ; catch the thread and withdraw the 3.-Gross' nee(ile, leaving the looped suture in the border of the needle-forceps, cleft (Fig. 534); then pass the end of the ligature, first PLASTIC SURGERY. 333 inserted, through the loop, which is then drawn out, carrying the single thread through the opposite side. The remaining sutures are passed in a similar manner. Each one is then tied some- what loosely, to allow for the swelling, with a reef-knot, or, what is better, the slip-knot held in place by a second knot over it. Per- forated shot may be passed over the sutures, and held in position by compressing them, or by the ordinary knot. If silver wire be used, it must be very fine and flexible, and applied Fig. 534.—Looped suture. with an adjuster. The sutures are left suf- . ficiently long in either case to admit of their easy removal, which is done at the end of a week. The diet should be plain, and all con- versation interdicted. The sponging during the operation must not be done with any form of antiseptic fluid that possesses a poisonous nature, since the patient may swallow a certain portion of it, with an unfavorable if not an unfortunate result. Results.—The prospect of union of the parts is very favorable, scarcely more than five per cent of the operations being failures. The time necessary to acquire a distinct voice is variable, and often this is not attainable. Uranoplasty.—This operation is performed to close a fissure in the hard palate. It should not be attempted on a patient under two years of age, and not then unless the patient is in all respects in per- fect health. It can be completed at one sitting, or may require sev- eral, depending on the obstacles to be overcome. If the deformity in the hard palate be complicated with a complete cleft of the soft palate, each one should be treated separately. If, however, the cleft of the soft palate be partial, it can then be operated on at the same sitting. The soft portion should be united first, in the manner before described, to prevent it from being obscured by the blood associated with the operation on the hard palate. This operation consists of four stages: 1. The paring of the edges of the fissure. 2. The making of a longitudinal curvilinear incision along the alveolar process close to the teeth (Fig. 535). 3. The rais- ing of the muco-periosteal flaps from the roof of the mouth. 4. Their union along the median line. The patient is anaesthetized, placed in a chair facing a good light, the gag introduced, and the first step is performed easily with an ordinary knife and forceps. The flaps are made by beginning the incision at the posterior border of the last molar tooth, or, more practically, in front of the hamular process, and carrying it down through the periosteum and forward along the inner margin of the alveolar process to the line of junction between the lateral and middle incisors. If the curvilinear incision be made 334 OPERATIVE SURGERY. at the base of the alveolar process, or be carried forward to the central incisors, the posterior and anterior palatine vessels will be divided. These flaps are now to be carefully detached by a periosteotome from without inward and from before backward until the edges of the fis- sure are reached ; they are then carried toward the median line, and, if no degree of traction be noticed, uuited throughout to each other by silver sutures. The displaced peri- osteum fills in the gap and often de- velops sufficient bone to produce an admirable degree of firmness. The sutures are allowed to remain in po- sition ten days or two weeks, the patient is fed on liquid food, any cough is relieved by anodynes, and the parts are kept clean. Langenbeck closed the fissure by two flaps, which were formed by an antero-posterior division of the hard palate on either side of it ; fresh- ened their contiguous borders and pushed them against each other at the median line, where the mucous membrane was united by sutures, the anterior and posterior extremities of the osseous flaps being still connected with the soft parts. Ferguson divided the hard palate with a chisel. Mears uses Ad- ams' saw after drilling an opening for its entrance, and claims less injury is done to the bone than by any other means. The hemorrhage is quite severe during the removal of the periosteal flaps, but it is readily controlled by pressure and cold. When the osseous flaps are made, the bleeding is usually still greater. If the fissure be not in the center, the flap is generally taken from the side of the hard palate which has the greatest width. Lannelongue closed the opening by taking a properly shaped flap of the mucous membrane from the septum, its base being lowermost, and stitching its upper border to the opposite side of the chasm. Mechanical means are employed to fill the opening in the hard and soft parts, and to provide even an artificial uvula. This apparatus is made of vulcanized rubber, and is held in position by being attached to a plate fitted to the roof of the mouth. An expert dental surgeon ought to be consulted, since he is, as yet, the only one fully compe- tent to treat the cases by this method. The ability to speak and to Fig. 535.—Uranoplasty. OPERATIONS ON THE MOUTH, PHARYNX, AND ESOPHAGUS. 335 otherwise control the action of the throat and pharynx with this con- trivance is very satisfactory ; in the majority of instances equaling, if not exceeding, the best results from an operation. Staphyloplasty consists in filling in the gap of the soft palate, and as much as possible of the hard, by a flap taken from the posterior wall of the pharynx. The degree of success attending this operation is suf- ficient to warrant its adoption when the conditions demanding it are present. Operation.—Anaesthetize the patient, perform a preliminary tra- cheotomy, and introduce the tampon-canula into the trachea. The flap from the posterior wall of the pharynx is made with the base down- ward, and the apex is carried as far upward as possible to permit its introduction into the cleft without the least tension. The width and shape of the flap must be determined by the size and outline of the deformity, plus its normal shrinkage. It should consist of the mucous lining of the pharynx, along with the subjacent muscles. The fibro- mucous coverings of the hard palate are dissected up until its tissues and those of the velum are freely movable. The borders of the cleft are freshened, and the flap brought in place and united by several sutures. The tampon-canula can be removed as soon as hemorrhage has ceased, or, at the farthest, on the day following the operation. The parts should be cleansed frequently and carefully with a mild an- tiseptic fluid, to wash away the abundant secretions. The sutures should be removed on the sixth or seventh day following the opera- tion. Elongated Uvula.—An elongated uvula is easily shortened by caus- ing the patient to withdraw the tongue by aid of a dry towel ; seizing the end of the uvula with forceps and removing the required amount with scissors. The little pain that may be caused by the operation can be relieved by the application to the part of a solution of cocaine. CHAPTER XIII. OPERATIONS ON THE MOUTH, PHARNYX, AND OESOPHAGUS. Salivary Fistula.—With this morbid condition the saliva is dis- charged on the external surface of the cheek instead of into the mouth. The object of an operation is to establish an internal com- munication so that the external opening can heal. The cure may first be attempted by passing the ends of several long silken threads through the external opening directly into the 336 OPERATIVE SURGERY. Fig. 536.—Seton in position. mouth, or through the internal opening of the duct, and bringing them out at the angle of the mouth and tying their extremities (Fig. 536). The internal communication is easily established in eight or ten days ; then the seton can be removed and the borders of the external opening freshened and closed. The patient should be ad- vised to chew upon the opposite side during the healing of the external open- ing, to limit as much as possible the flow of saliva on the diseased side. Another method consists in passing a good-sized thread of silk into the mouth, through the fistula, from without inward, and leaving it there ; removing the needle and attaching it to the end of the thread remaining outside, and carrying it through the tissues into the mouth in the same direction as the former, but not exactly in the same track. The needle is then removed, and the extremities of the thread are firmly tied within the mouth. A fine rubber ligature can be substituted for the silk. The loop cuts its way through the tissues grasped, forming an internal opening, which per- mits the healing of the external one. The method recommended by Dr. Horner, which is employed in obstinate cases, consists in the introduction of a wooden spatula into the mouth, opposite the site of the fistula, upon which, by means of a saddler's or other suitable punch, the diseased tissues, duct and all, are removed (Fig. 537). The ex- ternal opening is closed, a cold, dry dressing is applied, and quiet ordered. The end of the duct can be dissected up and passed through a small incision made through the mucous membrane into the mouth, after which the external opening is closed (Van Buren). A small probe should be introduced into the duct from without to prevent it from being cut during the dissection ; when turned inward, the borders of the Fig. 537.—Horner's method. OPERATIONS OX THE MOUTH, PHARYNX, AND (ESOPHAGUS. 337 open extremity can be confined to the edge of the incision by a stitch of catgut or horse-hair. Excision of the Tonsils.—This operation can be done with an or- dinary tenaculum and bistoury, or with curved scissors. The various forms of tonsillotomes, while they simplify the operation by giving the operator a perfect control over the cutting edge, are not necessary to its execution. To remove the Tonsil with the Knife or Scissors.—If the patient be young or unable to retain self-control, give an anaesthetic or apply a strong solution of cocaine. Cause a bright light to shine into the open mouth, depress the tongue, seize the tonsil with the tenaculum or for- ceps, draw it inward from between the pillars of the fauces, and with scissors curved on the flat or the probe-pointed bistoury, or an ordi- nary bistoury with the point guarded by adhesive plaster, sever the gland from below upward. It is not necessary at first to remove the entire tonsil, since a curative influence is often established by its incom- plete removal. Among the forms of tonsillotomes in common use are Tiemann's (Fig. 538), Hamilton's (Fig. 539), Mackenzie's (Fig. 540), Fig. 539.—Hamilton's tonsillotome. and others, the majority of which combine the ability to seize, hold up, and sever the growth. The patient is placed as before stated, and 22 338 OPERATIVE SURGERY. with the index-finger the ring of the instrument is adjusted around the tonsil properly, and the tonsil elevated with a tenaculum, and Fig. 540.—Mackenzie's tonsillotome. severed by pressing the knife against it. Any undue hemorrhage can be controlled by ice, pressure, and astringents ; actual cautery is rarely needed. In four instances the internal carotid artery has been wounded by recklessness in cutting the tonsils. OPEKATIONS ON THE TONGUE AND (ESOPHAGUS. It is often necessary to remove the tongue in part or entirely on ac- count of hypertrophy, and malignant and other growths of its structure. The arteries supplying it are the dorsalis linguae, ranine, and branches from the ascending pharyngeal. The ranine is the principal branch, and runs along the under surface of the tongue, from its base to the apex. The buccal, sublingual, and submaxillary glands are closely associated with this organ in a surgical sense. The facial and sublin- gual arteries will not be endangered, unless the floor of the mouth is operated upon in conjunction with the tongue. It should be remem- bered that the circulation in the opposite sides of the organ does not communicate freely, and consequently ligaturing of the lingual artery of one side will permit of free incision on that side with but trifling hemorrhage. Tongue-tie.—This condition depends on an undue extension for- ward of thefraenum linguae, either with or without an abnormal short- ening of it. If the condition be severe enough to call for treat- ment, the end of the tongue is pressed upward by passing the first two fingers beneath it, palm downward, bringing the tense fraenum between them on the palmar surface, when it can be divided with a blunt-pointed scissors at a little distance from, but parallel with its under surface, care being taken not to sever the ranine artery. Ranula.—The closure of the ducts of the sublingual and other glands in this situation causes a cystic distention of the ducts, and OPERATIONS ON THE MOUTH, PHARYNX, AND OESOPHAGUS. 339 even of the glands themselves. If it be not possible ±0 find and probe the duct-openings, it will be necessary to evacuate the contents at the floor of the mouth below the tongue, or, if the tumor be of large size, this must be done in the median line externally, close to the hyoid bone. In either instance it may be necessary to pack the cavity with lint and liquor ferri sulphatis, or cauterize the sack with nitrate of silver, and even to dissect it partially or entirely away. Excision of the Tongue.—The tongue may be removed with the knife, scissors, galvanic cautery, ecraseur, or ligature. The last method should be excluded, as the time required and the pain caused by it is greatly in excess of that by the other methods. If the diseased portion be small, it may be taken away by the form of incision best calculated to accomplish the object, since it is not a good plan to se- cure symmetry at the expense of future safety. If the hypertrophy involves the apex, or if a tumor be located at this situation, it can be excised by removing a V-shaped piece in the following manner : Operation.—Anaesthetize the patient, place him in a chair in a strong light with the mouth well opened by a special gag, or any suitable in- strument, forced, with a string attached, between the posterior molars. If the patient be in the recumbent posture, the head is turned to one side, to collect the blood in the hollow of the cheek. Pass a stout ligature through each side of the tongue, just outside of the intended site of the apex of the V-incision ; loop them and give each to an assist- ant with instructions to pull the tongue forward ; seize the tip with a pair of forceps, or between the thumb and finger, and with a sharp- pointed, narrow-bladed knife transfix the organ posteriorly from below upward at the point of the V, cutting outward and forward through its borders ; check the points of severe hemorrhage with forceps, and make the incision on the opposite side in a reverse direction backward Fig. 541.—Removal of a V-shaped piece. Fig. 542.—Flaps united. to join the first incision (Fig. 541). Ligature the bleeding points and unite the flaps by sutures in the usual manner (Fig. 542). A method 340 OPERATIVE SURGERY. has been recommended by Langenbuck to control the hemorrhage when but half or two thirds of the anterior portion of the tongue is to be removed by cutting. A long, well-curved needle, armed with a strong ligature, is entered at the left of the median line of the tongue, behind the portion to be removed, and passed through to the right side and under surface of the organ, so as to carry the ligature beneath the branches of the lingual artery. The ligature is then carried through the right border of the tongue and firmly tied. A similar procedure is repeated on the opposite side of the tongue. These liga- tures can then be used to draw the tongue forward. Dr. Howe, of this city, has devised a "safety-pin clamp," with which he proposes to control the hemorrhage by passing the pin above the arteries and screwing the clamp into position against the intervening tissues. Heath highly commends the drawing of the stump of the tongue for- ward by the finger passed into the pharynx. This traction not only renders the bleeding point more accessible, but the hemorrhage is also directly checked by means of the pressure necessary to draw the tongue forward. Hypertrophy of the Tongue (Fig. 543), involving its entire struct- ure, can be treated by the re- moval of a V-shaped piece in the manner just described. This will shorten its trans- verse diameter and diminish its length. The flaps are then united, and, after union has taken place, the thickness of the tongue can be diminished in the following manner: A strong ligature is passed lat- erally through the organ near to the base, and by this it is drawn forward and held while a wedge-shaped piece is re- moved by transfixing laterally as far back as possible and Fig. 543.—Hypertrophy of the tongue. midway between its upper and lower surfaces. The un- der flap is first made by cutting downward and forward through the under surface of the organ, then the upper flap is formed by applying the knife to the tissue above the last incision. The bleeding points should be ligatured, and the flaps united with sutures. Half of the organ can be removed by first ligating the lingual artery corresponding to that half, after which two long stout ligatures are passed through it near the tip, one on each side of the median OPERATIONS ON THE MOUTH, PHARYxNX, AND (ESOPHAGUS. 341 line, by these the tongue is drawn forward and upward ; the frsenum and the mucous membrane beneath the tongue are cut with scissors back to the base of the organ ; the tongue is then divided in halves from before backward, with a knife or scissors, its deeper tissues are separated by tearing with the finger or handle of the knife, and the portion to be removed is finally separated with scissors. The remain- ing half can be removed in a similar manner. If the lingual arteries have not been tied, the ecraseur can be employed, or if it be divided by scissors the bleeding points should be secured as soon as possible. Removal of the entire Tongue.—This can be done either through the mouth or beneath the inferior maxilla, or by division of the lower jaw at the symphysis, or on either side of it. It can be removed through the mouth by the knife, scissors, the gal van o- cautery, or the ecraseur. When the knife or scissors are to be employed, it is a wise precaution to ligature both lingual arteries to prevent the profuse hemorrhage which must otherwise occur. A stout thread is then passed through the tongue at the juncture of the middle and anterior thirds, and by this the organ is drawn forward and upward, and detached from its connections with the jaw and pillars of the fauces. The muscles of the tongue are then divided by scissors back to near the larynx, as closely to its under surface as the disease will permit. The glosso- epiglottidean folds are now brought under control by passing a long ligature through each. These ligatures are allowed to remain in situ, in order that the floor of the mouth may be drawn forward by them in the event of secondary hemorrhage. The excision is then com- pleted, and all bleeding points are checked. The surface is permitted to heal by granulation. Mr. Whitehead, of Manchester, has frequently operated in this manner with great success, without previously ligating the lingual arteries, but by tying the bleeding points as they presented themselves. The ecraseur offers an ad- mirable means of removing the whole organ, with less danger from hemorrhage than by the use of the knife or scissors ; the results, too, are quite satisfactory. This instrument may be applied through the mouth, or by M 544.-Ecraseur in position. way of a free puncture made with a stout, sharp-pointed knife introduced from without between the hyoid bone and the jaw, a little nearer the latter, 342 OPERATIVE SURGERY. and caused to enter the floor of the mouth, near the fraenum (Fig. 544). The wire or chain is passed through this opening, around the base of the tongue, in which position, after the tongue is well drawn forward, it is confined by means of three or four stout hare-lip pins passed at short intervals through its base from side to side; after which the organ is slowly and carefully severed. If the tongue be drawn forward in the usual manner and freely detached from its con- nections with the jaw and floor of the mouth, the same instrument can be quite as readily applied without the submental puncture. The use of the ecraseur for complete ablation can be recommended with confidence; and it should, if accessible, be selected in preference to galvano-cautery, which is much more likely to be followed by second- ary hemorrhage. The removal below or through the jaw does not offer the chances of success enjoyed by the former methods. The operation devised by Regnoli affords easy access to all portions of the tongue, except its base, and also furnishes good drainage, but*creates a large and some- what dangerous wound. Operation.—A crescentic-shaped incision is carried along the base of the lower jaw (Fig. 545), extending from in front of its angles. A vertical incision is then made from the center of this to the median line of the hyoid bone. The flaps are reflected, and the attachments of the lingual and hyoid muscles divided from the surface of the lower jaw. The tongue is then drawn through the opening and sev- ered by the knife or ecraseur, the bleeding points being secured as fast as they appear. The flaps are united, and the remaining raw surfaces allowed Fig. 545.-Regnoli'^ndiion. to heal ty granulation. _ ^ _ Knox made a vertical incision through the lower lip down to the hyoid bone, extracted a tooth and sawed through the symphysis mentis. The mucous membrane and the muscular attachments of the tongue were then divided, the lin- gual arteries cut and tied, and the tongue removed close to the hyoid bone. Mr. Heart employed the ecraseur instead of the knife. Se- dillot made an <-shaped section of the bone to prevent the frag- ments from sliding after approximation. Billroth divided the jaw between the canine and last molar teeth, corresponding to the dis- eased side of the tongue, and wired the fragments after the removal of the diseased portion. If the floor of the mouth be involved in addition to the tongue, Bill- OPERATIONS ON THE MOUTH, PHARYNX, AND OESOPHAGUS. 343 roth made an incision about one inch below the border of the lower lip from one facial artery to the other ; at the ends of this incision he made two vertical ones extending to a point about four fifths of an inch below the border of the inferior maxilla ; at the juncture of these vertical incis- ions with the jaw, he divided the bone and turned it downward along with the soft parts, thereby affording ample room to reach the diseased parts within. If the portion to be removed be extensive and the danger from hemorrhage great, a preliminary tracheotomy is advisable. This measure not alone prevents the blood from obstructing respiration, but lessens the dyspnoea frequently caused by a wide separation of the jaws. Kocher recommends the following plan if the floor of the mouth, the pharynx, and contiguous glands be involved along with the tongue. After a preliminary laryngo-tracheotomy and thorough cleansing of the parts, a triangular flap is made, with the base upward, its lower boundaries corresponding to the course of the digastric muscle, and its apex being at the point of connection of this muscle with the hyoid bone (Fig. 546, c, e, d, b). The posterior incision may also be made from this point' directly to the anterior border of the sterno - mastoid muscle, thence upward along its border to the angle of the jaw, so as to afford a greater space than is afforded by the former line of incision. These flaps cover the re- gion of the jaw and neck occupied by the facial ar- tery and the submaxillary gland posteriorly, and the lingual artery and sublin- gual gland anteriorly. The flap is dissected up, the ar- teries are tied, and the glands, if involved, are re- ¥lG 546._Kochcr's operation. moved. This exposes the side of the tongue and floor of the mouth for easy inspection and ma- nipulation. The larynx and pharynx are then protected from the en- trance of blood by a large sponge to which a string should be attached, and the myo-hyoid muscle is divided close to the jaw, exposing the tongue freely. The organ is now drawn through the opening, split, and the half of it corresponding to the flap is removed, including, if neces- sary, the floor of the mouth, pillars of the fauces, and pharynx down to the hyoid bone. The remaining portion can be removed in a similar manner, through a triangular opening on the side corresponding to it, or 344 OPERATIVE SURGERY. through the primary opening, if the extent of the disease will permit. As before remarked, the operation, which involves the bone and soft parts around it, results less favorably than when the tongue is re- moved through the mouth by the methods described for that purpose. The after-treatment consists in keeping the mouth cleansed, while to the raw surfaces iodoform and iodoform gauze, or other suitable anti- septic dressings, are applied. The tracheotomy-tube should not be re- moved until all dangers from inflammation and the discharges are ended. Results.—The rate of mortality from removal of the tongue by all of the methods described is considerable, fixty-six out of two hundred and forty-four cases having died. (Esophagotomy.—It sometimes becomes necessary to open the oesoph- agus on account of obstruction due to foreign bodies lodged in its cer- vical portion. In this connection it is well to recall the relations of the oesophagus. It begins opposite to the cricoid cartilage, and is located, in this region, somewhat to the left of the median line. The situation of the foreign body is usually marked by a greater or lesser prominence on the left side, below the cricoid cartilage ; or, if this be not mani- fest, the exact site of the canal can be determined by the introduc- tion into it, through the pharynx, of a good-sized bulbous or other form of probang. The following are the important surgical relations of the oesophagus in the cervical region : In front, with the trachea, above, and with the thoracic duct and the thyroid gland below; be- hind, with the vertebral column and longus-colli muscle ; at the sides, especially the left, with the common carotid and inferior thyroid ar- teries, and thyroid lobes. The recurrent laryngeal nerves lie between it and the trachea. Operation.—Always employ an anaesthetic ; place the patient on the back, with the chest and shoulders elevated and the head turned to the opposite side ; feel for the foreign body, and, when it is found, make the incision directly at that point. If the foreign body be not discernible, make an incision about four inches in length on the left side, between the sterno-mastoid muscle and the trachea, beginning at the upper border of the thyroid carti- lage. The platysma and fascia are divided on a director ; the borders of the wound are separated, the omo-hyoid is drawn outward, and the sterno- and thyro-hyoid muscles inward ; this exposes the sheath of the carotid, which is drawn outward and retained ; the lobe of the thyroid gland is raised and drawn inward ; the larynx carefully outlined and drawn forward and held while the location of the foreign body is sought for ; if not present or distinguishable, the bulbous probang is then introduced to mark the outline of the tube, the wall of which is raised with a tenaculum and opened sufficiently to admit the finger, care being taken to avoid the recurrent laryngeal nerve. The site of the obstruction is located by passing the finger into the tube, and the cause OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 345 is removed by suitable forceps, aided by manipulations from without, and by lengthening the incision if necessary. The opening in the oesophagus may be closed with fine catgut, the external incisions united in the usual manner and dressed antiseptically, and liquid food introduced through a tube for a few days. Or the entire wound may be left open, a feeding-tube introduced through it into the stomach, and allowed to remain three or four days at a time ; then it is re- moved, to be cleaned. As soon as the cut surfaces become granulated, the tube may be removed from the opening, and a smaller one em- ployed, which is passed into the stomach through the nostril. The patient is fed through this until the oesophageal opening has com- pletely closed. Fallacies.—The foreign body may be mistaken for an enlarged gland on external examination. The oesophagus may be confounded with the longus-colli muscle at first; however, a moment's examina- tion will serve to dispel the doubt. If the probang be introduced through the pharynx, its exact location will be established. The re- spiratory movements of the oesophagus, distending and collapsing alternately, are important aids in determining its identity. Results.—Eighty-two cases are reported, of which nineteen died ; but from causes independent of the operation in many instances. The rate can be placed at about twenty-two per cent, which will surely be lessened in the future if the operation be done as early as it should be. Stricture of the (Esophagus.—This condition depends upon a cir- cumscribed inflammatory action or other morbid process, involving one or more coats of the tube, and causing a narrowing of its caliber, which manifests itself proportionately to the degree of constriction. It may be limited to one side, or involve the whole circumference of the tube. The most frequent site is opposite the cricoid cartilage, where the pharynx and oesophagus become continuous with each other. The stricture can be treated by dilatation, for which purpose various forms of dilators have been constructed (Fig. 547). These and all other Fig. 517.—(Esophageal dilators. forms should be introduced as often as necessary by extending the neck and passing the instrument carefully downward in contact with the posterior portion of the pharynx, guided by the index-finger of the disengaged hand. No force should be employed, for fear of causing a false passage. The surgeon should always eliminate the possibility 346 OPERATIVE SURGERY. H of aneurismal constriction of the tube before an attempt is made to overcome the obstruction. The sponge extremity of the probang can be used where unusual caution is desirable in explor- r\ {jiX ing this passage. "'\ \ if H Retrograde Divulsion.—In 1883 Loreta, of Bo- logna, opened the stomach, passed a divulsor through the opening into the lower third of the oesophagus, and ruptured a stricture at this point sufficiently to allow the passage of food. He has since repeated the operation on two occasions, and in each case it was followed by satisfactory results. Internal (Esophagotomy.—This operation is per- formed by an appropriately constructed instrument (Fig. 548), sometimes so arranged as to be passed upon a guide, as in internal urethrotomy, and has been successfully practiced on several occasions. How- ever, the contiguity of important anatomical struct- ures, and the inability to comprehend the exact re- lations of the stricture to the outer wall of the tube, make the operation an exceedingly hazardous one. If it be attempted, the constriction should be incised only sufficiently to admit a bougie, by the means of which the treatment should be continued. Strictures of the cervical portion of the oesopha- gus may be divided from without. The stricture is first located by a bougie introduced into the tube, and is then cut down upon through an incision simi- lar to that for cesophagotomy. Results.—Internal cesophagotomy has been per- formed, in all, about nineteen times, of which one third died in sixteen days from results associated with the operation. Of the remainder, three are said to have recovered, while the others survived for a period from one month to several years. About one third of the cases required one or more repeti- tions of the operation. (Esophagectomy.—(Esophagectomy consists in ex- cising a portion of the cervical oesophagus through an incision made in the same manner as for cesophagotomy, for the removal of a cancerous growth. The upper end of the lower portion of the tube is then raised forward and united to the wound ; thereby forming an opening through which food may be introduced by means of a tube. Results.—Only five or six cases have as yet been reported. In two of these, life was prolonged for months ; the remainder died soon .yy Fig. 548.—Sands' instrument for internal cesoph- agotomy. OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 347 after the operation. There is reason to believe that life can be more prolonged by feeding through a tube in the usual manner, than by this procedure. (Esophagostomy—This procedure is employed to establish a fistu- Fig. 549.—Bris- Fig. 550.—Sponge and Fig. 551.—Cusco's throat- tie probang. bucket probang. forceps. lous opening, with the tube, below the point of an incurable, impassa- ble constriction. It provides for the introduction of food into the stomach, and serves as a temporary palliative measure. Results.—It has been performed thirty-two times, in which about sixty per cent of the patients perished. Of this number, twelve died from the operation directly or from its sequels. The removal of foreign bodies from the oesophagus is accomplished 348 OPERATIVE SURGERY. Fig. 553.—Burge's throat-forceps. by probangs (Figs. 549 and 550) and various forms of long forceps (Figs. 551, 552, and 553). CHAPTER XIV. OPERATIONS ON HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. The injuries of these organs which require surgical treatment may result either from external violence, or become part of the pro- cedure necessary for the removal of obstructions in the intestinal tube, or of malignant growths from the duodenum, stomach, or intestines. In these operations it is important: 1, to avoid all unnecessary hem- orrhage ; 2, to prevent the escape of irritating matter into the abdom- inal cavity ; 3, to unite the divided surfaces so that they shall remain properly opposed, and be followed by perfect union; 4, to avoid all unnecessary shock and septic or irritating influences. 1 he first indi- cation is met by carefully avoiding any incisions through the line of the established course of vessels, and by the use of needles which do not possess cutting edges (as when their points somewhat resemble those of the ordinary sewing-needle), but enter the tissues by causing their separation. To meet the second indication requires a great degree of caution irrespective of the knowledge of any established measures. The lips of the wound should always be kept uniformly and well raised by means of forceps; or, by strong ligatures passed through their bor- ders at suitable situations. If the nature of the case will permit, the contents of the viscus should be removed before the operation is com- menced, and at all times the serous surfaces must be protected from con- tact with irritating matters, by means of broad, thin, antiseptic sponges or other suitable agents moistened in a warm, mild, antiseptic fluid. To fulfill the third indication, sutures of various forms and meth- ods of application are employed ; the aim of all being to bring the serous surfaces in contact, and maintain them so until firm union is HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 349 Fig. 554.—Lembert's suture. established. To do this, it is necessary to roll the borders of the wound inward, since the mucous surfaces will not unite to each other (Fig. 554). The size of the wound has to do with its treatment. If it be of large size, it may be advisable to connect it with the opening in the abdominal walls, and allow the resulting fistulous opening to close spontaneously. When it is possible, however small the wound of the intestine may be, it should be closed, or it may permit the escape of irritating matters into the abdominal cavity. The fourth indication is very important, especially if the operation be prolonged and tedious, or if the intestines be removed from the cavity of the abdomen. The room in which opera- tions on the abdominal contents are performed should be thoroughly cleansed and fumigated when possible, and in every way made aseptic. If its temperature can be raised to about 90° F., and the atmosphere moistened with antiseptic vapors, the surroundings will be much im- proved, especially if the abdominal contents are long exposed. If the intestines be removed from the cavity, they must be surrounded by cloths saturated with antiseptic fluids, and kept warm and moist by re- peated applications of the same until they are replaced. The " toilet" of the abdominal cavity must be cautiously and perfectly made before it is closed, and suitable provisions for drainage established, if per- nicious secondary local processes be apprehended. As a rule, the su- tures should not include the mucous surface, but should extend down to it. They should not be more than two lines apart, nor include more than one line of the intestinal substance, and should be cut short. Continuous Suture. — The name defines its method of ar- rangement. It is exceedingly useful in join- ing the borders of long cuts of either a serous or cutaneous surface. In the latter the stitch- es are further apart than when applied to se- rous surfaces, and the cut surfaces of the wound are brought directly in contact with each other (Figs. 555 and 80). Fig. 555.—Continuous suture. Fig. 556.—Lembert's suture. 350 OPERATIVE SURGERY. Lembert's Suture (Figs. 554 and 556).—This form of suture is an admirable one, easy of comprehension and of application. It can be Fig. 657.—Gely's suture, external appearance. used indiscriminately in all wounds of serous membranes, either in the continuous or interrupted forms. Gely's Suture (Fig. 557).—In this variety a long suture is selected and armed with a needle at each end. The needles are inserted near the angles of the wound, about two lines from the edges, and carried along the interior of the bowel for a sixth of an inch, then brought out precisely on the same level, so as to again appear on the peritoneal surface. The sutures are then crossed, the right needle being passed through the puncture made by the left, and conversely. If a knot be made at each crossing, slip- ping of the sutures will be prevented. The number of the crossings will vary with the size of the cut. By this method the edges of the wound are thoroughly inverted (Fig. 558), and all danger of extravasation is prevented. Jobert's Method.—When the intestine is completely divided transversely, its lower end is turned or tucked in for a short distance, the upper end pushed within it, and their serous surfaces are united by fine sutures (Fig. 559). It will be necessary to separate the mesentery from each extremity of the intestine for a short distance in order to per- mit the coaptation just described (Fig. 560). If the mesentery Fig. 558.—Gely's suture, internal appearance. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 351 Figs. 559, 560.—Jobcrt's method. be separated unnecessarily, sloughing of the intestine is likely to occur. Czerny-Lembert Suture.—Two rows of sutures are employed in this method, neither of which, however, is passed through the mu- cous membrane (Fig.. 561). The first series brings the edges of the Fig. 561.—Czerny-Lembert suture. Fig. 562.—Gussenbauer's suture, a. a. Mucous coat. b. Muscular coat. Mucous coat. b. Muscular coat. c. c. Serous coat. Serous coat. mucous membrane together ; the second, or external series, unites the serous surfaces of the bowel. Owing to the eversion of the intestinal structures, the first row can be introduced without difficulty. Gussenbauer's Suture.—By means of this form of suture the mu- cous and serous structures of the intestine may be brought together by one suture (Fig. 562). However, this stitch is complicated and somewhat tedious, and affords no additional security to repay for the delay and difficulty attending its use. 352 OPERATIVE SURGERY. '7/i. ,£ OPEKATIONS ON THE STOMACH. It sometimes becomes necessary to open into the cavity of the stom- ach in order to remove foreign bodies, or to establish a permanent communication with it through the abdominal walls, for the purpose of supplying alimentation. It is therefore very important to understand its relations to the abdominal walls, and likewise to other contiguous parts. It lies principally in the epigastric and left hypochondriac regions. Its anterior surface is directed upward and forward, and is in relation to the diaphragm and the under surface of the left lobe of the liver, and, unless empty or adherent posteriorly, comes in contact with the abdominal walls in the epigastric region. It is altered in its position and rela- tions by the act of respiration, de- scending with in- spiration and as- cending with ex- piration ; when empty, it retires posteriorly and is covered by the left lobe of the liver. The convexity of the stomach sel- dom rises above a line extending be- tween the carti- lages of the ninth ribs. The trans- verse colon lies at its lower border when the stomach is moderately dis- tended. The identity of the stomach is es- tablished by the knowledge of its relation to the under surface of the liver and dia- phragm, by its pale color and great A^'yaX\f: ^-'-^ -"--C—-7 -Ji Fig. 563.—a, b. Left lobe of the liver. the stomach, c. Transverse colon. . Cardiac end of Ascending colon. d. Descending colon. g,g,g. Sigmoid flexure. size, and by the arrangement of the gastro-epiploic vessels. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 353 Gastrostomy.—This term is applied to the operation of opening the stomach through the abdominal wall and establishing a permanent fistula to it. Antiseptic precautions should be taken, and anaesthesia produced by chloroform, as ether is more likely to cause vomiting. Operation.—Place the patient on the back, and make an oblique incision on the left side, about two and one half inches in length, from right to left, parallel with and one inch below the lower border of the cartilage of the eighth rib, and terminating opposite to the ninth car- tilage (Fig. 563, 1). The tissues composing the walls corresponding to this incision are divided successively on a director, down to the perito- neum. All bleeding points must now be closed and the peritoneum opened, and its divided borders caught and drawn outward with long ligatures, or forceps, which are permitted to lie on the external surface, to prevent its retraction. The lower border of the left lobe of the liver can now be seen. The thumb and forefinger of the left hand are then introduced, and, guided by the under surface of the liver, readily grasp the stomach. If possible, a portion of it should be brought through the opening, or, guided by the thumb and finger, forceps may be in- troduced and its anterior surface grasped and drawn through the open- ing. It is very important at this time to be certain that the portion drawn through be not the colon or some other organ. The dense white appearance of the stomach, the arrangement of its superficial vessels, and its size should serve to distinguish it from any other vis- cus. Often, as soon as the peritoneum is divided, the entrance of air into the abdominal cavity causes the stomach to retire upward and backward, thereby mterposTrrg an annoying obstacle to grasping it. To obviate this difficulty it has been recommended to pump air into the stomach just before the beginning of the operation through a tube carried down to the obstruction, or to cause the entrance of carbonic-acid gas, produced by chemical action at the time, or to introduce the fumes of ether by means of a tube. These expedients are, however, hardly of sufficient practical importance to merit the trouble incident to their utilization. As soon as the surgeon is satisfied that the stomach is within his grasp, it is drawn into the opening and fixed, by passing through it in opposite directions two or three long stiff needles (Fig. 564), allowing Fig. 564.-Needles in position. their extremities to rest upon the external surface of the abdomen; or, a strong ligature is passed through the center of the protruding por- tion, is looped and given to an assistant. The parietal layer of peri- 23 354 OPERATIVE SURGERY. toneum previously grasped and drawn outward should now be care- fully stitched with antiseptic silk or catgut sutures to the visceral layer on the stomach, being careful not to carry the sutures entirely through the wall of the stomach. Still further security is given to the opposed surfaces by putting a row of stitches of strong antiseptic silk through the whole thickness of the abdominal walls, and also through the te/ous and muscular walls of the stomach. Two other stitches may be introduced, so as to transfix the end of the wound only, care being taken not to include the peritoneum. Finally, a ligature is passed through the serous and muscular walls of the center of the exposed portion of the stomach (if this was not done in the first in- stance), and left hanging to be used as a future guide to opening the organ in case the condition of the patient will admit of four or five days delay, sufficient to permit adhesive union to take place between the serous surfaces. If not, then the operation should be completed at once. This is done by making a vertical incision about half an inch in length through its coats into the cavity, care being taken to prevent the escape of its contents. If troublesome hemorrhage be apprehended from this incision, the opening can be made by a thermo-cautery. The wound in the abdominal wall is reduced in size to correspond to that of the stomach by stitches carried through its entire thickness. The lips of the opening into the stomach are then united to those of the abdominal opening, by antiseptic silk carried through the entire thick- ness of both, being careful to oppose the mucous lining of the stom- ach to the integument of the abdomen. Fallacies.—The colon may be mistaken for the stomach. However the difference in color, extent, and muscular arrangement, together with the difference in mobility, and the fixed relation of the stomach to the under surface of the liver, should make the distinction easy. Confusion may arise in distinguishing the cartilage of the eighth rib from the contiguous ones. The seventh articulates with the sternum ; the first one below it will therefore be the eighth. Other external incisions differently located and variously shaped may be employed; such as, a curvilinear one with the convexity toward the median line, extending from the seventh costal cartilage downward and outward for nearly four inches, one through the left linea semilunaris, or one along the outer side of the rectus, etc. That which has been described in detail seems the most favorable from an anatomical basis. The results, however, are of necessity very unfavorable, since the conditions calling for the measure are often of themselves speedily fatal; moreover, the delay in resorting to it frequently renders the pa- tient unable to withstand the shock of the procedure. Two hundred and seven gastrostomies are reported, from which sixty-one deaths have resulted directly. In about one hundred and seventy of the whole HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 355 number fifty died from the direct effects and from the sequels of the measure, making a death-rate of about thirty per cent. This is about fourteen and a half per cent greater than when the operation was per- formed for the removal of foreign bodies alone. When due to malig- nant disease it only acts as a palliative measure, while more than sixty per cent have recovered when performed for non-malignant cicatricial obstructions. This operation, and also gastrotomy, is sometimes em- ployed for making an opening into the stomach to remove a foreign body which has entered it through the oesophagus. The line of in- cision, and all the steps and precautions, are similar to those for gas- trostomy proper. After the foreign body is removed, the opening in the stomach is closed by catgut sutures, after the manner of intestinal sewing, and returned to the abdominal cavity, and the opening in the abdominal walls closed. The patient must be nourished by the rec- tum, and all gastric disturbances quieted by anodynes. Gastroenterostomy.—This is essentially a palliative operation, and was performed first by Woelfler in 1881, since which time it has been done upward of twenty times for advanced pyloric cancer and non- malignant pyloric stenosis. When performed for the former reason, about sixty-four per cent of the cases have died, while for the latter but twenty-five per cent have died. All the antiseptic precautions that surround abdominal surgery (gastrostomy, enterectomy, etc.) should be observed. Operation.—An abdominal incision is made in the median line from just below the tip of the ensiform cartilage downward nearly to the umbilicus, and the abdominal cavity is entered in the usual manner. The viscera to be united (stomach and jejunum) are caused to present at the ex- ternal opening, where they are carefully iso- lated from the abdom- inal cavity and pro- tected by warm, moist antiseptic sponges. The loop of intestine to be attached to the stomach is emptied by gentle pressure, and the intestinal contents cut off from it by the intestinal pincers, by Fig. 565.—Gastroenterostomy. the fingers of an assist- ant, or by strips of loosely tied iodoformized gauze. The stomach 356 OPERATIVE SURGERY. should have been emptied and thoroughly washed out with a salicy- late-of-soda solution before the operation. An incision about an inch and a half in length is made through the anterior inferior wall of the cardiac half of the stomach, down to the mucous membrane (Fig. 565). An incision of a similar size is then made on the intestinal loop down to its mucous membrane, b. The lower borders of the cut surfaces are placed in contact and united with a continuous suture of silk or catgut, carried from without inward between the mucous and muscular coats of the respective viscera, thereby causing the borders of similar structures to be brought in contact with each other. The mucous coats are then opened by scissors, taking care to prevent the least extravasation into the abdominal cavity. The remaining por- tions of the borders are now united in a similar manner to the first, and the whole circumference of the wound is fortified by a second row of either the continuous or interrupted suture, carried through the serous coats only. Duodenostomy, or the formation of a permanent artificial opening into the duodenum through the abdominal wall, has been suggested as an alternative to pylorectomy. It has been performed three times, with a fatal result in each case. It is not, at the present time, thought to be a justifiable operation. Jejunostomy has been recommended as a substitute for pylorec- tomy. It is, no doubt, much more easily performed than duodenos- tomy ; but the advantages in favor of gastro-enterostomy are too numerous and important to admit of its being superseded by either of the other operations. Resection of the Pylorus.—This operation has been quite frequently employed since 1879 to relieve obstruction occurring at the pylorus, due to malignant disease, and stenosis from other causes. While its inception and performance are in keeping with the rapid strides made in abdominal surgery in the past few years, the nature of the opera- tion and the causes for which it is done must of necessity insure a large number of deaths. The pylorus is in the epigastric region, be- tween the median line and a line falling from the tip of the cartilage of the eighth rib on the right side to the middle of Poupart's liga- ment, and is in contact with the under surface of the right lobe of the liver. The duodenum, which is the next most important factor, is located in the right hypochondriac region, being, of course, a direct continua- tion of the pyloric extremity of the stomach. The normal relations, however, will avail but little in connection with the abnormal size, and the displacement attendant upon an already over-distended stom- ach. All primary incisions must therefore be located so as to meet the indications of the case in question. The difference in the outlines of the stomach is noted, both in its distended and empty condition, HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 357 to better enable the surgeon to properly locate the abdominal incis- ion. In some cases the greater curvature may reach the symphysis pubis. The patient is prepared by washing out the stomach daily with sali- cylated water or any suitable antiseptic for four or five days prior to the operation, the stomach-pump, or siphon, being employed for the pur- pose. The intestinal canal is evacuated the day before the operation. An anaesthetic is given, chloroform being preferable as less likely to produce vomiting, and the patient is placed on the back in a good light. The stomach should be thoroughly washed out before begin- ning the operation. Operation.—An incision is made about four inches in length in the median line, or parallel to the right costal margin (Fig. 563, 2), as nearly as possible over the displaced pylorus. The tissues are divided carefully down to the peritoneum, and all bleeding stopped before this membrane is divided ; an exploration with the finger is also made, to determine, if possible, the exact location of the indurated portion, after which the final opening is made to correspond to it. If it be impossible to satisfactorily outline the organ, it may be distended with fluid—which must be withdrawn when the location of the diseased portion is determined—or with carbonic-acid gas ; even the fumes of ether can be introduced as in rectal anaesthesia. The peritoneum is cut, and the pylorus and such other portions as are necessary are then drawn through the wound and isolated and sur- rounded by napkins or large flat sponges wrung out in a warm anti- septic solution. A large, flat, soft sponge, moistened with an anti- septic solution, is then passed beneath the part to be removed, to prevent the entrance of blood and other fluids into the abdominal cavity. Strong ligatures may now be passed through the walls of the viscus at three or four points outside of the proposed incision, so as to raise the walls of that extremity as soon as it is divided, that its con- tents may not escape. The omenta are separated the necessary distance along the curva- tures of the stomach by tying them in small portions and dividing them between the ligatures. The pyloric extremity of the stomach is then incised with strong, long-bladed scissors from above downward, and from left to right, for about two thirds of its depth, through both walls, at a point at least two thirds of an inch from the diseased growth in its structure. The stomachal borders of this incision are then joined by the Czerny-Lembert suture, the threads being located about one-eighth inch apart. The pyloric extremity of the stomach is now cut entirely across, and the resulting opening in the stomach should correspond in its extent to the width of the duodenum, which should now be cut completely across in the same manner as the stomach. The divided extremity of the duodenum is carefully sewed to the opening 358 OPERATIVE SURGERY. in the stomach by the Czerny-Lembert suture, or such other form of suture as may suit the surgeon. The diseased growth should be removed with great care, and with due regard to the preservation of the vascular supply of the viscera. Sloughing of the gastric or duodenal margin of the wound or the walls of the colon caused by disturbance of nutrition is one of the greatest dangers. The pyloric, gastro-duodenal, and gastro-epiploica dextra arteries and their branches should be preserved for this reason, when this can be done, and the removal of the diseased tissues be still ac- complished. If any oozing occur from the cut surfaces, it may be controlled by the protected blades of the T-shaped pincers (Fig. 566), etc. The extent of the incisions, as well as their shape, will be governed by the diseased tissue to be removed. If adhesions exist be- tween the growth and the contigu- ous parts, they can be separated if ox- Fig. 566.—Cross-bar forceps. -, ■ , •» pedient ; if not, no further attempt to complete the operation need be made, and the abdomen should be closed. The respective extremities of the Fig. 567.—Abbe's intestinal pincers. divided viscera can be well controlled by the fingers of an assistant with or without the use of the intestinal pincers (Fig. 567). The outline of the pyloric cut may be greater than the caliber of the re- maining duodenum (Fig. 568). The caliber of the larger portion must be reduced to a suitable size to be joined to its fellow, c, a to d, HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 359 Fig. 568.—Outlines of incisions. e ; or c, b may be sewed until it shall conform in width to d, e, to which it is sewed, thus transferring the pyloric opening to the greater curvature of the stomach ; the Czerny-Lembert suture answers admirably for the purpose ; or the borders of the openings may be joined by means of a double row of the Lembertform of suture. The first row should be car- ried down to the mucous membrane, and be inter- rupted ; the second row should be deposited outside of the first one, and include the serous membranes only. This row may be continuous. After all bleeding is checked, and the peritoneal cavity is thoroughly cleaned, the parts are returned and the abdominal wound is closed in the usual manner. The patient is then quieted by anodynes and nourished by the rectum during the first three or four days, until fluid food can be given by the mouth. The contraindications to the operation are : Old or weak patients; evidences of malignant secondary deposits ; existence of extensive ad- hesions ; chronic incurable dilatation of the stomach, etc. Results.—Of the twenty-three cases reported by Rydigier in 1883, five had recovered. Still, one of these died four months after the operation from a return of the disease. At the present time pylorec- tomy has been performed at least eighty-two times, with twenty-one recoveries from the operation. Of thirty-six cases for carcinoma, seven had recovered and two were doubtful. The prognosis is much better in the colloid than other forms of carcinoma. In only about five per cent of the cases were adhesions and enlarged glands absent. Ad- hesions to the pancreas and enlarged glands of the great omentum were most frequent. Twenty-nine cases are reported where it was not deemed advisable to continue the operation, owing to exten- sive adhesions, shock, etc. The time occupied in the operation is modified by the complications, being from an hour and a quarter to five hours. The rate of mortality from the operation is about sev- enty-five per cent as the cases occur. If uncomplicated, it is fifty per cent, heart failure, from shock, being the fatal element. The per- centage of ultimately successful cases is but little above eight and a quarter. Loreto's Operation is divulsicn of the pylorus by the fingers, or other similarly effective agents. In this the abdominal incision is made to correspond to the location of the disease as in the preceding operation ; 360 OPERATIVE SURGERY. or, if the condition will permit, it is commenced an inch and a half be- low the ensiform cartilage and carried obliquely downward and out- ward for four or five inches to within an inch and a half of the ninth costal cartilage (Fig. 563, 2). The opening is sometimes made through the linea alba. The abdominal incision is made with the same precau- tions as in the preceding operation. The pyloric extremity of the stomach is drawn out and an opening made into it between and at equal distances from its two curvatures, about two and a half inches in length, beginning an inch and a half from the situation of the pyloric valve. The hemorrhage is then controlled ; the index-finger is introduced through the pyloric valve and carefully rotated, with pressure and counter-pressure. The second finger is introduced beside the former in the same cautious manner, and so on until the constricted portion is well distended. The wound in the stomach is then closed by the Gely or Lembert suture, the parts are returned, and the ab- dominal wound is closed as before. The results of this operation are much more favorable than those for excision of the pylorus, and it is entirely proper that dilatation should be considered in connection with it; the incision through the abdominal walls being made with a view to excision, if it be malignant, and divulsion if the stenosis be due to non-malignant causes. Divul- sion has been performed eight or ten times, with a rate of mortality varying from fifty to seventy-five per cent. OPERATIONS ON THE GALL-BLADDER. It occasionally happens that obstructions of the cystic duct and distention of the gall-bladder from gall-stones or other causes give rise to an abdominal tumor of considerable size, which is dangerous on account of the liability to rupture, and is distressing from the pain and tenderness. Cholecystotomy.—This operation consists in cutting down through the abdominal wall upon a tumor, caused by a distended gall-bladder, and evacuating its contents. The incision is made, as a rule, over the center of the tumor, parallel to the free border of the ribs. At first it should be about three inches in length, large enough for ex- ploration, after which, if need be, it can be enlarged. The various layers composing the abdominal wall are divided on a director down to the peritoneum, which should not be opened until all hemorrhage is arrested. Two methods of procedure are now recommended : 1. As- certain if the serous covering of the tumor be adherent to the parietal layer of the peritoneum ; if such be the case, open into the tumor and evacuate its contents. If it be not adherent, and the conditions of the patient will permit, fill the wound with strips of antiseptic gauze or marine lint. After five or six days sufficiently firm adhesions will have been caused to permit the opening of the gall-bladder, which should HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 361 be done in the same manner and be treated in all respects as the simi- lar step in the second method of procedure. 2. After hemorrhage is arrested, divide the peritoneum cautiously, catching its free borders by forceps, which are then allowed to rest on the surface of the abdo- men. If the wall of the tumor be not adherent, introduce two fingers through the opening into the abdominal cavity, and even the entire hand if necessary, and examine the condition of the contiguous ab- dominal organs, size of the tumor, nature of its contents, etc., care being taken not to rupture it by the manipulation. If gall-stones be found in the cystic or the common ducts, they should be dislodged if practicable. If the tumor be distended with fluid, it should now be aspirated, and then held firmly in contact with the external opening, while an incision about an inch in length is made into it. Its fluid con- tents must be carefully excluded from contact with the peritoneal lin- ing, and also from the raw surfaces of the incision. This can be quite satisfactorily accomplished by means of a narrow, trough-like arrange- ment made of tin, gutta-percha, or other suitable material to conduct the fluid beyond the wound. If the cut surfaces around the point to be opened be smeared with carbolic acid and oil, and covered with small pieces of antiseptic gauze, and the borders of the incision in the tumor be quickly grasped with forceps and held upward, any danger of un- wholesome contact of the fluid will be obviated. The distended gall- bladder and its associated ducts are carefully examined, and all gall- stones are removed with forceps. The edges of the opening in the gall-bladder are now stitched to the abdominal incision, a drainage-tube is introduced, and the whole is covered by an antiseptic dressing. The resulting fistula will soon close if the common duct be not obstructed, and the parts will resume their normal functions. If the wall of the tumor be not adherent to the abdominal wall, it is recommended by some—after the evacuation of its contents—that the opening be care- fully stitched and the sac returned ; also that the sac be ligated at its neck and removed. It can not be said, however, that these procedures are as rational in all respects as the one more fully de- scribed. Results.—Forty cases have been reported, of which ten were fatal. The second method anticipates the dangers of rupture and the struct- ural changes induced by over-distention, which are offset by those of opening into the abdominal cavity ; the latter, however, when done under antiseptic precautions, is rarely followed by an unfortunate result. These facts emphasize the wisdom of an early operative in- terference. Cholecystectomy, or extirpation of the gall-bladder, is employed instead of cholecystotomy when, by reason of the presence of a trouble- some biliary abdominal fistula, malignant disease, or tumors of the gall- bladder, the latter is rendered useless. If the opening through the 362 OPERATIVE SURGERY. abdominal walls be the same as in cholecystotomy, and the case is found to be better adapted to cholecystectomy, the incision will then require to be extended upward sufficiently to command the neck of the sac. If, however, the latter operation be contemplated in the beginning, the abdominal incision can be made in the right hypo- chondrium, parallel to the lower border of the liver, and joined by a second incision running along the outer border of the right rectus muscle (Fig. 563, 3). The abdominal cavity is then to be opened, the transverse colon and small intestines pushed down by a large sponge, and the liver elevated, so as to bring the hepatic duodenal ligament into prominence. The gall-bladder is easily separated from the liver, the cystic duct exposed and ligatured in two places with carbolized silk, and severed between them, the tumor removed, and the abdomi- nal wound closed. This operation, like the ones preceding it, should be done with full antiseptic precautions. Results.—Cholecystectomy has been done six times, with a death- rate of fifty per cent. The base of the gall-bladder has sometimes been connected to an opening made in the duodenum to admit the discharge of bile into the intestine, when this had been prevented from taking place by a perma- nent stoppage of the common duct. Nothing definite can be said, as yet, of its adoption as a practical measure in such cases. Laparotomy, or Abdominal Section.—This operation is employed to overcome intestinal obstructions due to various causes, such as in- vagination, adhesions, etc., to ligature arteries, and for the operative treatment of penetrating wounds of the abdomen. Laparotomy should be divided into two varieties : 1, the explorative operation ; 2, the op- eration in entirety—i. e., the addition of enterotomy or enterectomy, etc., for the relief of the trouble calling for the abdominal section. Explorative Laparotomy consists in opening the abdominal cavity, usually in the median line, sufficiently to permit the inspection and examination of its contents for the morbid condition, and to determine whether the culs-de-sac of the cavity contain blood or other extravasa- tions. If nothing be found, or further operative procedure is not required, the abdominal opening is then closed. Results.—The large number of abdominal sections performed, both in this country and abroad, with favorable results, serves to establish the belief that an explorative laparatomy, under favorable precau- tions, does not expose the patient to any unusual dangers. If it be performed for intestinal obstruction, the opening can be made over the seat of obstruction ; but it is better to make it in the median line below the umbilicus (Fig. 503, 4). It should be a free incision, and of sufficient size to permit the easy introduction of the hand, and should be made under strict antiseptic precautions. If any HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 3(53 difficulty be experienced in locating the seat of the trouble, or over- coming it, the opening should be still further enlarged. Care must be taken not to tear or injure the intestine. It is better, if the obstruc- tion does not yield readily, to raise the obstructed portion out of the opening, and surround it, along with such of the intestines as may es- cape, with the Lister gauze, wet in a warm antiseptic solution, or with large flat sponges treated in the same manner. As soon as the obstruc- tion is relieved and the intestines are restored to their normal position, the abdominal cavity is cleaned by warm antiseptic sponges, and the external wound closed. Results.—The rate of mortality in all cases of this character is about sixty-five per cent. The prognosis would be much better were it not that the diagnosis is uncertain, or the operation objected to, until the condition of the patient almost precludes a successful issue. Enterotomy consists in opening the intestine above or at the point of an obstruction, and, when the opening is low down, it may be at- tached by its borders to the abdominal walls, thereby establishing a fecal fistula. This operation can also be done when the gut is gangrenous or otherwise unfit to be returned. At the present time, in both of these conditions, it is thought to be proper by some authorities to relieve the obstruction by means of abdominal section, followed by enterec- tomy or enteroraphy, and return the intestine into the abdominal cavity. The final percentage of recoveries, however, is much greater if a fecal fistula is established at first, which can afterward be closed by the usual method or by enterectomy. This particular form of enterotomy is commonly performed in the right iliac fossa, since the intestines above the obstruction lie principally in this situation. The intestines above the obstruction are filled ; those below are empty ; consequently the selection of the proper one to open becomes easy on inspection. In "Right Inguinal Enterotomy" (Nelaton), as this operation is sometimes called, an incision is made an inch above Poupart's liga- ment and parallel with it, beginning at the anterior superior spine of the ilium and ending opposite the internal abdominal ring (Fig. 563, 5). The layers of the abdominal walls are divided consecutively on a director, down to the peritoneum, which is opened, after all hemor- rhage has ceased, for one inch and a half. The first intestinal loop presenting is drawn through, provided it be not an empty one ; a long thread is passed through the muscular walls and looped, and the in- testine again returned and kept from the opening by a small-sized carbolized sponge, to which a string is attached ; this is forced through the opening and allowed to remain, while the peritoneum is drawn outward and stitched to the integument. The sponge is then re- moved, and the intestine pulled out by the looped ligature which has 364 OPERATIVE SURGERY. remained upon the abdominal wall. The coats of the intestine are carefully united to the walls of the opening by a deep row of inter- rupted carbolized silk or catgut sutures passed in the transverse axis of the gut, through its serous and muscular coats, being entered two or three lines from the border of the integumentary wound, and, after including the gut, returned through the same border of the wound from below upward, and tied. After the serous surfaces are accurate- ly apposed by a row of stitches, the intestine is raised to a level with the surface of the abdomen, and the space between it and the border of the abdominal wound is packed with absorbent cotton or lint saturated with carbolic acid and oil for the purpose of protecting their surfaces from contact with any of the intestinal contents. The gut is opened longitudinally for one inch, its edges being caught with pincers as fast as cut. After the intestinal contents near the opening are evacuated, a small sponge with a string attacned should be pressed into the opening in the gut to prevent any further escape while its borders are being carefully sewed to the integumentary margin by the continuous or interrupted suture. The immediate results of this operation are better than those of laparotomy in entirety, but the patient is subjected thereafter to the annoyance of a fecal fistula. If the obstruction be due to a foreign body in the gut, and its position be located, the intestine can be incised, obstruction removed, wound of the intestine closed by the Lembert or other suture, the gut returned, and the abdominal incision closed. Enterectomy consists in removing a segment of intestine and unit- ing the divided extremities, which, when combined with abdominal section, constitutes a laparotomy in entirety. Enterectomy is per- formed for penetrating shot and stab wounds of the intestine, and for the removal of malignant growths and gangrenous portions of the same. The antiseptic precautions relating to the operator, to the patient, and to the surgical surroundings should be of the most com- plete kind, and, in addition thereto, the patient and the abdominal viscera should be kept warm and the latter moist. Warmth and moisture can be secured by operating in a thoroughly purified room, charged with antiseptic vapor, and having a temperature of 98° to 100° Fahr. The warmth of the abdominal viscera can be quite well maintained if they be surrounded by large, flat sponges or anti- septic gauze moistened in warm solutions of mercuric bichloride (1-10,000), carbolic acid (1-100), or Theirsch's fluid. If blood or intestinal contents escape into the abdominal cavity, the site of the injury causing it must be sought for and closed. All bleeding points should be tied with fine catgut, no matter how insignificant the bleeding may seem at the time ; for after the parts are returned into the abdominal cavity, and their normal relations and tempera- HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 365 ture have been restored, a trivial oozing may become a serious hem- orrhage. All wounds of the intestine, at other than its mesenteric attachment, may be closed by the continuous suture of Lembert, or by the Gely suture. Catgut or antiseptic silk may be used for this purpose. A double row of sutures may be deposited, provided, however, the closure does not reduce the caliber of the intestine more than one third. If the wounds be too large or too closely as- sociated to admit of closure, or if they be at the mesenteric border of the gut, enterectomy or removal of the injured portion should be done. The contents of the portion to be removed should be pressed out into the uninjured portion of intestine, and its return pre- vented by the intestinal pincers (Fig. 567), by the fingers of an assist- ant, or by strips of iodoformized gauze tied loosely around the gut. The incisions for the removal of the injured portions should be made as closely as possible to the incoming mesenteric arteries, so that the extremities of intestine will be well nourished. The mesentery may be treated by one of the following methods : 1. A triangular portion of it may be removed, its base corresponding to the length of the por- tion of intestine excised, after which the gap is closed by bringing the divided borders of the mesentery together and uniting them. 2. It may be tied in small segments, about a quarter of an inch from the intestine, with catgut, divided and allowed to remain free, or may be sewed to the mesenteric border of the gut after it has been repaired. 3. The serous coat for a quarter of an inch each side of the mesen- teric attachment may be divided and stripped from the subjacent tissue, intestine excised, ends approximated, and the loop formed by the serous slip closed by sutures. During the sewing the ends of the intestine may be held by the fingers of an assistant or by introducing a small, distended rubber bag. Pieces of stale bread may be made of a size to support the ends during the sewing. The rubber bag should be removed before the intestine is entirely closed, and care must be taken or it will be sewed in position. The bread or large macaroni tubes will escape from the natural opening. It is difficult to manage these extremities and at the same time properly coapt the borders and deposit the sutures so that effective and permanent union will be secured, since the point above the obstruction will be distended by air and fecal accumulation, while the portion below will be collapsed and appear smaller than normal. The mobility of the extremities, the danger of the escape of fecal matter, together with hemorrhage, and the'length of time necessary to triumph over the obstacles already enumerated, bring about a degree of exposure which adds more to the gravity of the operation than the division and removal of the diseased tissue. Anything, therefore, which will expedite matters in this respect must constitute a real advance in surgery. The instru- ment devised by Mr. Treves, of London (Fig. 569), is certainly in- 366 OPERATIVE SURGERY. genious, but does not seem to be sufficiently simple to become of practical utility. It can not be better described than in Mr. Treves' own language : " The apparatus consists in the first place of two clamps, b b, to secure the gut, e e, above and below the point of resec- tion. Each clamp is made of two separate and light metal bars, pro- vided with an India-rubber pad on the surfaces that are in contact with the gut. The clamp is two inches and a half in length, and, one part being placed beneath the gut and the other upon it, the two are then approximated by screws placed at each end. By these means the gut can be evenly and ac- curately compressed with as much or as little force as may be thought fit. I first apply a clamp to the gut one inch and a half below the proposed resection- line, and, having emptied the part to be excised by squeezing its con- tents upward, I apply the second clamp at a similar distance beyond the second resection-line, which will, in most cases, insure an empty con- dition of the part to be removed. A triangular piece of mesentery should then be excised, the base of the triangle exactly corresponding to the amount of gut to be re- moved ; secure the divided vessels and excise the diseased gut. The clamps are now united with each other by means of the long, narrow reel-rods, A a, which are secured to each clamp by a small screw. By means of these bars the two clamps can be evenly approximated, and the divided ends of the gut brought into accurate contact. If the screws be now tightened, the bowel extrem- ities are held in a rigid frame, and can be turned or moved in any direction without disturbing the contact of the divided ends. The Fig. 569.- -Treves' apparatus for en- terectomy. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 357 ends to be united will be easily commanded if a very thin India-rubber bag, G, about three inches in length, of sausage-shape, that can be distended by air to a large size, be inserted about the middle of its long axis. Having blown out this bag till it was about the size of the divided bowel, I inserted one end into the lower piece of the intestine and the other end into the upper piece. The supply-tube, d, will thus occupy the suture-line. After the bag is suitably distended the sutures are applied all round the gut, and almost up to the interrup- tion in the suture-line occupied by the tube that fills the bag. The last sutures are then applied, but not tied, the bag exhausted of air and withdrawn from the bowel through the interruption in the suture- line." Two rows of sutures should be used—the first an interrupted Lembert of iron-dyed silk, extending to the mucous membrane; second, the continuous Lembert, including the serous surfaces only. The Czerny-Lembert is entirely suitable for this purpose. Great care is requisite to properly close the mesenteric border of the intestine. A small artery is found here that often bleeds persistently. The en- tire intestinal tract should be carefully examined for other injuries, even though it be necessary to remove the intestines from the cavity to do it. Severe intestinal contusions should be treated like pene- trating wounds of the intestine. The "toilet" of the abdominal cavity must be patiently and thoroughly performed by soft, moist, antiseptic sponges. It is not enough to wipe off the intestines only, but all the culs-de-sac must be examined, and all blood and other ex- travasations, together with antiseptic fluids found therein, should be sponged out and drainage provided if deleterious discharges appear likely to be produced. The abdominal wound is dressed antiseptically. Results.—The general result shows a death-rate of about fifty per cent. This is very satisfacto- ry, when it is considered that over ninety per cent of penetrat- ing shot-wounds of the abdomen die when treated expectantly. When this operation is done for causes that do not involve ex- travasation into the abdominal cavity, the death-rate is much diminished. It is not advisable to excise the intestine for malig- nant disease if the mesenteric glands be much involved, since an artificial anus can then be made with better prospects of prolonging life. Fig. 570.—Guide to colon. 368 OPERATIVE SURGERY, Left Lumbar Colotomy (Amussat).—In this operation the descend- ing colon is opened between the crest of the ilium and the last rib. Linear Guide to the Operation (Fig. 570).—Draw a line which shall connect the anterior and posterior superior spinous processes of the ilium; draw a second line perpendicular to this, one inch posterior to its center. This line marks the course of the colon. Draw a third line four inches in length obliquely downward and outward, midway between the lower border of the last rib and the crest of the ilium, its center corresponding to the perpendicular one, parallel with the lower border of the last rib. The third line marks the course of the incision, half of which is behind the perpendicular line. Muscular Guides.—The outer border of the erector spina?, also the outer border and anterior surface of the quadratus lumborum. Contiguous Anatomy.—The colon at this situation is covered by peritoneum at its anterior surface and sides ; its posterior internal surface is not covered by this membrane. If the gut be collapsed, it retreats toward the median line, behind the quadratus lumborum, and is followed by its peritoneal covering. The collapsed condition of the gut, therefore, exposes the peritoneum to greater danger of being in- jured. When distended, it presses its peritoneum outward, and can be readily seen projecting beyond the outer border of the quadratus lumborum. The surfaces not covered by peritoneum are surrounded by areolar tissue, which separates the intestine from the left crus of the diaphragm, the left kidney, and anterior surface of the quadratus lumborum ; and externally it is in contact with the small intestines. The left kidney is situated posteriorly to it, and its lower extremity can be easily felt at the upper border of the wound. The vessels lying in the course of the incision are the abdominal branches of the lumbar vessels. The ilio-hypogastric and ilio-inguinal nerves likewise cross in front of the quadratus lumborum at this situation. The colon is recognized by its greenish color and its longitudinal bands, which are three in number—one anteriorly, which is covered by peritoneum, a second corresponding to its attachment, the third or lateral at its inner side. It is not quiet during respiration, although it does not move upward and downward as the small intestines are sure to do. It can not be raised, while the small intestines can. Finally, if it be filled with air after the fascia lumborum is divided, and the fat be pushed aside, it will become distended quickly and assume a proportionately greater size than the small intestines. Fallacies.—The colon may be mistaken for a loop of small intes- tine, also for the kidney, especially in the young subject. From the former it is readily distinguished by the differences already given; from the latter, by the density of the structure of the kidney, its rounded extremities, reniform shape, lobulated appearance, and the upward and downward movements of the kidney with the respiratory HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 369 acts. If the preceding be not satisfactory, the introduction of a hypo- dermic needle will demonstrate not only the density of the kidney, but the absence of fecal matter and offensive gases. If the conditions will permit, the bowel should be thoroughly washed out before the operation is begun ; after which the patient is etherized and placed on the right side, with a hard pillow under the loin, so that the left side may be made more prominent. Operation.—An incision is made in the course of the line already marked out, and carried through the integument, fascia, and thick layer of fat usually found at this situation, down to and through the latissimus dorsi muscle and the posterior fibers of the external oblique, the internal oblique, and transversalis, which are divided upon a di- rector, bringing into view (Fig. 571) the outer portion of the quad- Fie. 571.—Surgical relations of descending colon, a. spine of fourth lumbar vertebra. b. Cartilage between third and fourth vertebrae, c. Umbilicus, d. Quadratus lumbo- rum m. e. Psoas magnus ra. /. External oblique m. g. Rectus muscle, h. Descend- ing colon, covered anteriorly and externally by peritoneum, i. Transverse colon. /. Aorta, k. Inf. vena cava. /. Ureter, m. Adipose tissue covered by the transversalis fascia, n. Internal oblique muscle, o. Transversalis m. p. Reflection of peritoneum. ratus lumborum inclosed within its compartment of the lumbar apo- neurosis, which extends outward to become continuous with the trans- versalis muscle. The aponeurosis is carefully divided upon a director, and the fascia transversalis that lies beneath it is divided in a similar manner, thus bringing into view the fatty areolar tissue that separates the gut from the quadratus lumborum and the left crus of the dia- 24 370 OPERATIVE SURGERY. phragm. The fat is pushed aside by the finger and handle of the scalpel, and the bowel distended with air, when its situation will become positive. By the means already given, confirm its identity before proceeding further. As soon as the gut is distended it will appear at the opening, and perhaps even rise above its level; roll it outward with the finger from beneath the quadratus, cutting the outer border of the muscle, if necessary, so as to reveal its inner aspect, which is known by the longitudinal band ; seize it with a tenaculum or forceps, and hold it upward while a stout, curved needle, armed with a well-carbolized silk ligature, is passed deeply through the skin and deeper tissues at one side of the perpendicular incision, about four lines from the border, into and transversely through the intestine, to emerge on the other side of the opening at a similar distance from Fig. 572.—Surgical relations of ascending colon. 1. Spinous process of fourth lumbar vertebra. 2. Cartilage between third and fourth vertebra?. 3. Erector spina? m. 4. Inferior vena cava. 5. Psoas magnus m. 6. Fascia lumborum. 7. Subcutaneous fat and latissimus dorsi m. 8. Quadratus lumborum m. 9. Adipose tissue covered by the transversalis fascia. 10. Cavity and wall of the ascending colon, it. Internal oblique m. 12. External oblique m. VS. Limits of peritoneal reflection. 14. Transversalis m- 15. Ureter. 16. Great omentum. 17. Rectus muscle. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 371 the border of the wound ; this suture is drawn through, and each end given to an assistant. The needle is then passed in a similar manner at the opposite extremity of the incision, and its ends are also given to an assistant (Fig. 573). All the space between the walls of the gut and borders of the wound is then packed with lint saturated with carbolic acid and oil. The gut is opened by a longitudinal or oblique incision, about an inch and a half long (Fig. 574). The liability to a Fig. 573.—Sutures passed through colon. Fig. 574.—Hooking up sutures. subsequent protrusion of the mucous membrane and of injury to the peritoneum at the time is less with a longitudinal than with a trans- verse incision. After the contents of the bowel are evacuated, a sponge, with a string attached, should be pressed into the open- ing to retain any remaining dis- charge until the edges of the gut have been stitched to the borders of the wound. The finger or hook should now be inserted into the bowel, and the loops of the ligature just passed be caught, drawn out (Fig. 574), and divided at the middle, when each one will become two distinct sutures which, after the oiled lint has been re- moved and the wound cleansed, {f can be tied (Fig. 575). The re- Fig. 575.—Sutures tied. 372 OPERATIVE SURGERY. maining portion of the gut-wound is then stitched, sprinkled with iodoform (Fig. 576), and a carbolized pad is bound over the open- ing. This pad, together with the sponge, must soon be removed to allow the escape of fecal mat- ter. If malignant disease of the rectum be the cause for the operation, it is recommended to bring the intestine through the opening as far as possi- ble, divide it, turn in the borders of the upper ex- tremity of the lower portion, sew them together, and drop it into the abdominal cavity. This plan will prevent any fecal matter from passing down the rectum and irritating the malignant growth. The upper opening is then carefully sewed to the borders of the abdominal wound. Great caution is necessary in taking these steps, or the peritoneal covering of the colon will be torn through. If this accident should happen, close the peritoneal opening with catgut sutures. Inflammatory products, and even fecal matter, may collect below if great care be not observed. Results.—The rate of mortality from this operation is variously estimated, being from twenty to thirty-eight per cent. Recently Dr. Bott reported two hundred and forty-four cases, with a death-rate of a little more than thirty-one and one half per cent. Right Lumbar Colotomy.—In this operation the incision is made at the right side. Its formation, however, is in all respects governed by the same rules as the preceding. The caput coli is the portion to be opened, and, owing to its size, can be more readily distinguished than the colon on the left side of the body (Fig. 572). The results are much less favorable, owing partly to the loss of the function of the colon, and also to the more objectionable location of the disease compelling the operation in this situation. Left Inguinal Colotomy (Littr6).—This operation consists in open- ing into the sigmoid flexure of the colon by an incision into the left iliac fossa through the abdominal walls, including the peritoneum. Linear Guide to the Operation.—Draw a line two inches in length over the left iliac fossa, commencing about an inch internally to the anterior superior spine of the ilium, and extending downward parallel with Poupart's ligament (Fig. 563, 6). Operation.—The patient is placed upon his back, and an incision made to correspond to the line given above. All hemorrhage is stopped before the peritoneum is opened. As soon as the peritoneum is cut, insert a small antiseptic sponge connected with a string, which will prevent the escape of the intestines; stitch the peritoneum to the integumentary border ; withdraw the sponge, and draw out the intes- tine which is located directly under the opening, and which can be recognized by the peculiarly shaped fatty fringe attached to it. This HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 373 is then stitched to the external wound in the same manner as in the lumbar region. In all respects the treatment is the same as for colot- omy in other situations. Results.—Left inguinal colotomy is not as safe an operation as that in the left lumbar region, since the peritoneum is directly involved. The rate of mortality is from ten to twenty per cent greater. Abscess in the Right Iliac Fossa.—This abscess may be super- ficially or deeply seated. If it be of the former character, it can be opened readily. Operation.—If the development of a deep-seated abcess be sus- pected, aspiration should be frequently performed to detect the earliest existence of pus. If pus be found, make an incision four or six inches in length, commencing an inch internal to and above the anterior superior spinous process of the ilium, and extending downward parallel with Poupart's ligament; divide cautiously the various layers of the abdominal wall on a director, and, when the abscess wall is reached, insert an aspirating-needle again as a precautionary measure; open the cavity freely in the course taken by the needle ; wash it thorough- ly, insert a drainage-tube, and allow it to heal from the bottom. If pus be not present, the incision may be made, if expedient, and the wound allowed to remain open, when, if pus form, its discharge can be readily effected. Results.—This operation is to be earnestly commended to the at- tention of all practitioners of medicine and surgery. The association of typhlitis with abscess located in this situation, and the great danger to the patient from a rupture into the abdominal cavity, emphasize the necessity of an early diagnosis and a thorough treatment. The prognosis is flattering when active measures are early and promptly taken. Artificial Anus, or Fecal Fistula.—When the distal extremity of the bowel is pervious and the fistula has served its purpose, it should be closed. If the sep- tum between the openings be shallow and yielding, it can be forced back by means of a sponge pressed against it and confined in po- sition ; wooden plugs and lint are employed in a similar manner ; failing in this, the sep- tum should be grasped by a clamp or entero- tome (Fig. 577), passed into the opening on either side of it, and the blades firmly screwed together. In a few days the constricted por- tion sloughs, and the instrument is released. The external opening usually closes spontane- ously ; if not, a plastic operation may become necessary. If these methods fail, the affection 577.—Enterotome ap- plied. 374 OPERATIVE SURGERY. may be cured by enterectomy, as was practiced by Kinloch, of South Carolina, in 1863. OPEKATIOXS ON THE KIDNEYS. The surgery of the kidney has made rapid strides within the last few years. The accepted operations on this organ are nephrotomy, nephrectomy, nephro-lithotomy, and nephroraphy or fixation of a movable kidney. Nephrotomy.—Nephrotomy consists in opening into the kidney through an incision in the lumbar region. The operation should be preceded by the introduction of an aspirating needle, both to locate and define the nature of the tumor. Operation.—The patient is placed in the same position as in lum- bar colotomy. The incision is made in the same direction; and in other respects its location is similar, although it is often made nearer to the last rib than in colotomy. A vertical incision, just outside the quadratus lumborum, extending from a point immediately below the last rib four or five inches downward, is preferred by some. The same precautions preparatory to and attending the operation are re- quired that characterize colotomy, and the tissues resting upon the tumor are divided in the same manner. When the sac is reached it should be aspirated to confirm the diagnosis. An opening is then made into it, the contents evacuated, and the cavity washed out with a solution of the bichloride of mercury, 1 part to 2,000 of water. Carbolic solutions should be avoided, since carbolic-acid poisoning seems more likely to occur from its use in this situation than else- where. Remove all calculi that may be present, and unite the edges of the kidney to the wound, and allow it to heal by granulation ; or a drain- age-tube is inserted and the external opening is closed by deep sutures, and dressed antiseptically. If the kidney structure be destroyed, or be the seat of malignant disease, it is then wise to remove the entire organ. Results.—Nephrotomy has been practiced, for various causes, nearly one hundred and twenty-five times, with an average mortality of about twenty per cent. The death-rate after operations for calculous pye- litis was about forty-three per cent, but for other causes in no case did it reach eighteen per cent. Nephrectomy.—Nephrectomy consists in removing the kidney in part, or entirely, from the body. The removal is indicated in cases of a wounded or painful floating kidney, cystic kidney, hydronephro- sis, pyelitis, with or without calculi, neoplasm, and urinary fistula from a communication with the ureter. Before the operation is per- formed, it should be ascertained, if possible, whether the other kidney is present, and in a healthy condition. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 375 The primary incision may be made in the loin or through the ab- dominal walls; which is the better one is a matter as yet unsettled. The character of the case will have much to do in determining this point. If the tumor be movable, malignant, of large size and ad- herent, or if it be suspected that the disease be bilateral, the abdomi- nal incision is preferred, since it admits of the examination of the other kidney. The rate of mortality, however, favors the lumbar incision. Lumbar Nephrectomy is to be done with every possible antiseptic precaution. The primary incision is made usually in the same situa- tion and direction as in nephrotomy, although the vertical one, in large tumors, is highly commended. If the space will permit, the tumor is isolated, and its pedicle tied en masse, or, what is better, the vessels are secured separately. The ureter must always be tied, and the lower extremity brought through the external opening. It often happens that the size of the tumor and its adhesions to surrounding tissues re- quire the opening to be enlarged. This can be done by extending it toward the spine as well as in the opposite direction. If the opening, when taken in conjunction with the additional space to be gained by pushing upward the last rib, be inadequate, the rib can be resected subperiosteally for three or four inches, and this will be found to afford quite sufficient room. After the removal of the tumor, the wound should be thoroughly disinfected with a solution of carbolic acid or other suitable substance ; ureter secured externally, and the opening closed'by deep sutures, and dressed antiseptically. Abdominal Nephrectomy.—In abdominal nephrectomy the opening into the abdominal cavity can be made in three situations : 1, the most frequent situation is through the linea alba ; 2, at the outer side of the rectus (linea semilunaris) ; 3, in the inguinal region. The first two require that the peritoneum be divided ; the last admits of a sub- peritoneal removal, but can scarcely be employed except in well-marked cases of movable kidney. In either case the abdominal opening is made in the usual cautious manner, about six or eight inches in length, and larger if the size of the tumor demand it. The hand is introduced, tumor located and outlined, and the condition of the other kidney noted. The diseased organ is then enucleated and raised through the opening, its vessels and the ureter are tied separately with strong carbo- lized ligatures, and are cut short, and returned. The opening remain- ing in the peritoneum after the removal of the kidney can be closed after all hemorrhage has ceased by uniting its divided borders with fine catgut. The abdominal cavity is then cleansed of all foreign matter, and its walls united and dressed antiseptically. If the ureter is to be returned into the cavity of the abdomen, its extremity should be thoroughly asepticized with the carbolic acid, or the bichloride of 376 OPERATIVE SURGERY. mercury solution. It is considered better, however, to attach it to the abdominal opening. It is recommended to tie the vessels of the pedicle before commencing the enucleation, thus lessening the danger of hemorrhage. The advantages of an opening outside of the rectus are said to be, less hemorrhage from the abdominal walls than when the opening is made through the linea alba; also, it brings the sur- geon more directly on the tumor, its pedicle, and the ureter. If the space from which the tumor has been removed be a large one and show a strong tendency to bloody oozing from the surface, the perfo- rated glass drainage-tube should be introduced, carried directly to the bottom, and allowed to protrude through the abdominal incision. The fluid which accumulates in the tube can be removed by carbolized sponges under the antiseptic spray. Drainage may also be provided by passing a small drainage-tube through the abdominal wall in the lumbar region, communicating with the former site of the diseased organ ; then the posterior peritoneal incision should be closed. It is impossible to lay down more than the general means of pro- cedure in this operation, since the conditions surrounding individual cases often call for the employment of other than stereotyped rules. Results.—Of two hundred and thirty-three nephrectomies collated by Prof. S. W. Gross, about forty-five per cent died. The mortality from the lumbar incision was forty per cent, .that from the abdominal incision about fourteen per cent greater. Shock was the cause of death in forty per cent of the entire number operated upon. Nephro-lithotomy, or renal lithotomy, is the exploration of the pel- vis of the kidney with a long needle, to ascertain the presence of cal- culi within it. If calculi be present, they are removed with forceps, through an incision made into the kidney. Operation.—The external opening is made similar to that for lum- bar nephrotomy ; the kidney is exposed, calculus detected, and an in- cision is made through the cortex into the pelvis in the long axis of the kidney of sufficient size to remove it with suitable forceps. The hemorrhage resulting from the division of the kidney structure is quite severe at first, but is quickly controlled by pressure. The wound in the kidney usually heals readily; nevertheless, urine will sometimes escape through it for ten or twelve days. With a view to cause union of its structure, the lips of the kidney-wound have been united by fine catgut sutures with favorable results. The external wound is suitably drained, closed, dressed antiseptically, and the pa- tient given demulcent drinks. Results.—All of the reported cases (six) of this operation have ter- minated favorably. Nephrorraphy (Fixation of a Floating Kidney).—-To accomplish this purpose in cases where all ordinary means have failed, an incis- ion is made from a little below the lower rib to the crest of the ilium, HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 377 along the outer border of the erector spinae, and down to the quad- ratus lumborum. The same tissues are encountered in this as in the vertical incision of nephrotomy. There is a greater danger of hemor- rhage, however, than from the oblique incision, as the vertical incis- ion is made at nearly right angles to the lumbar vessels. As soon as the fascia lumborum is divided, the kidney should be pushed into the wound, the fascia transversalis slit up, the fatty capsule surround- ing the kidney opened longitudinally, and its borders stitched to the deep structures of the wound with eight or ten catgut or carbolized silk sutures. The wound is then stuffed with carbolized gauze and allowed to heal from the bottom; the patient remaining in the dorsal position until the healing is well completed ; after which, any of the various forms of pads or other retentive apparatus may be applied to retain it until the adhesions are thoroughly established. Results.— Nephrorraphy has been performed eighteen times, with one death. In about forty-four per cent of the cases but little or no relief was gained. Forty-one per cent die from nephrectomy for this condition. The subsequent giving way of the fixation point under the influ- ence of movement, suggests the practicability of continuously wearing some form of retentive apparatus. Splenectomy, which consists in the removal of the spleen, has been performed between thirty-five and forty times. It has not proved suc- cessful, however, in any instance when practiced for leucocythemia. When employed for displacement or simple hypertrophy, the results are flattering, being in excess of fifty per cent. Operation.—An incision about eight inches in length is made at the outside of the rectus or in the median line, its center corresponding to the umbilicus ; the peritoneal cavity is opened in the usual manner, the omentum and intestines displaced, and the tumor carefully raised through the opening; after which the vessels at the hilum, and those of the gastro-splenic omentum, are clamped and tied. This omentum should be divided into several sections by transfixion, and each sec- tion should be tied by two ligatures and divided between them. All hemorrhage is stopped, and the abdominal wound closed either with or without a drainage-tube, depending on the amount of prospective oozing. The spleen must be handled very carefully during the removal, or it may be ruptured. Paracentesis Abdominis.—This procedure is an operation employed to remove fluids from the abdominal cavity. The instruments neces- sary are the scalpel and the trocar, Fig. 578 being an admirable ex- ample of the latter. Fig. 579 represents the ordinary form, which will meet all common indications. The aspirator (Fig. 580) is cheap, durable, and efficient. The 378 OPERATIVE SURGERY. handy aspirator of Fitch (581) is not expensive, and can be used in conjunction with the canula figured above. In either case the caliber Fig. 578.—Wood. Harris trocar. Fig. 579.—Trocar and canula. Fig. 580.—Potain's aspirator. of the canula should be small enough to admit of the gradual dis- charge of the fluid, for if it be discharged too rapidly the dan- ger of syncope will be immi- nent. If the canula be sharp- pointed, it can be introduced without the aid of the scalpel, after the presence of the fluid has been determined by the aid of the hypodermic syringe. An anaesthetic is not neces- sary. A local injection of a so- lution of cocaine will suffice to relieve all pain caused by the in- Fig. 581.—Fitch's aspirator. troduction of the needle. The HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 379 bladder and rectum should be emptied, and the abdomen carefully per- cussed to determine the limits of dullness. The belly is then sur- rounded by a broad, many-tailed bandage, having a small opening in the center corresponding to the point of proposed puncture. If unable to sit up, the patient is placed upon his side near to the edge of the bed, but if his strength will permit, he can be placed in an ordinary chair, with the body bent forward, and the head and arms resting upon the back of another chair in front. Operation. — The instrument is seized firmly with the in- dex-finger resting on its upper surface (Fig. 582) to limit the ex- tent of its introduc- tion, and is plunged quickly through the wall of the abdomen in the median line, midway between the umbilicus and pubes, and the trocar is with- . drawn. As the fluid FlG. 582.—Introducing trocar. escapes, the bandage is tightened to facilitate the flow, as well as to support the patient. The flow is permitted to continue until the fluid is removed, unless the patient is threatened with syncope, when the trocar is withdrawn at once. The puncture should be closed by a strip of adhesive plas- ter, or, better, by a hare-lip pin, confined in the usual manner; the tails of the compressing bandages are then tied firmly to maintain the pressure. Care is taken that no air be permitted to enter the cavity of the abdomen. Fallacies.—A distended uterus or bladder, or a displaced or en- larged liver, may be punctured. If the canula be sharp-pointed, the intestines may be injured during the withdrawal of the liquid. A blood-vessel of the abdomi- nal walls may be injured by its introduction. If the uterus be dis- tended from any cause, the puncture can be made through the right or left semilunaris or above the limit of the distention. OPEBATIONS APPLICABLE TO THE VAEIOUS CONDITIONS OF ABDOMI- NAL HEKNIA. The operations on the various forms of hernias that are amenable to operative procedures are : for the reducible hernia, an operation for a radical cure ; for the strangulated, taxis, and division of the 380 OPERATIVE SURGERY. Fig. 583.—Sac of a hernia. Fig. 584.—Sac and contents. constriction ; for the simple irreducible and obstructive forms, the liberation of their contents, and their return to the proper situa- tion. A hernia may be defined to be the protrusion of a portion of the contents of the abdomen through any opening in its walls. Each protrusion is composed of a sac and its contents, surrounded by more or less of the tissues composing the abdominal walls. With but few exceptions all hernias possess a sac, and this sac, in every case, is com- posed of the parietal peritoneum (Fig. 583). Only those viscera, such as the caput coil, colon, bladder, pan- creas, etc., which are not normally surrounded by this membrane, can form a hernia without a sac. The contents of a hernial sac, in the ordinary sense of the term, then consist of the small intestine and omentum, either singly or conjointly (Fig. 584). If the larger viscera escape, it will be exceptional, and probably de- pend upon an abdominal wound. Such a condition is then called a protrusion of this or that organ rather than a hernia of the same. The normal appearance of the omentum and small intestines should be given a careful study, that the operator may be able to determine the various degrees of change in their appearance when subjected to the different influences associated with hernial protrusions. The granular appearance of the omental fat, together with its pale color and extra fibrous structure, will distinguish it from the subserous tissue fat. The omentum and gut, while in the sac, usually bear the same comparative relation to each other as in the abdominal cavity, the former being in front. The sac has a neck and a body; the shape and size of the latter depend upon the amount and density of the surrounding tissues and the nature and compactness of its con- tents. The neck is its constricted portion, and corresponds to the opening through which it escaped ; its size is governed by the density of the tissues by which it is surrounded, the age of the protrusion, degree of traction, and compressibility of its contents. A knowledge of the normal characteristics of the peritoneum is as essential to the surgeon as is a knowledge of the peculiarities of the contents of the sac. Its rough outer and smooth inner surfaces, the arrangement of its vessels, and its transparency should be understood. It must not be forgotten, however, that the physical appearance of the sac and its HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 381 contents become changed when long subjected to the vicissitudes at- tending hernial protrusions. The tissues composing the walls of the protrusion, or the " cover- ings of hernia," vary according to its situation, rapidity of develop- ment, and size. While they may readily be distinguished in their proper places as component parts of the abdominal wall, yet, when stretched around the body of a hernia and more or less changed from the effects of pressure and extraneous influences, their identity often becomes difficult of recognition. In a recent hernia the cellular tissues and fat will vary but little from their normal conditions ; in an old one, these tissues will be much thinner than usual. In a recent protrusion the muscular fibers of the cremaster will be exceedingly sparse and illy developed, while in the older ones the influence of the coincident traction will lead to their becoming well developed and of great diagnostic importance, not only as to the depth of the incision, but the variety of the protrusion. The transparent sac often becomes more or less opaque, and so con- nected with the cellular tissue upon it as to be scarcely distinguish- able from it. It can be safely said that the changes in the appearance and the anatomical relations of the component parts of a hernia, and the influ- ences and processes to which it is subjected, may be so manifold that it will present as varied and perplexing problems, requiring a speedy so- lution, as any morbid condition of the hodj. Prior to attempting any form of operation upon a hernia, it is necessary that the surgeon be acquainted with the important blood- vessels and their relation to the body, and more especially the neck of the sac. He must know the bony landmarks, the ligamentous asso- ciations, and the direction of the exit, else he will be unable to distin- guish the variety of hernia or to manipulate its return. OPERATIONS FOR RADICAL CURE. Heaton's Operation.—This consists in injecting into the inguinal canal with a syringe, constructed for the purpose, ten or fifteen drops of a mixture, composed of one half an ounce of Thayer's fluid extract of quercus alba, prepared in vacuo, and fourteen grains of the solid extract of quercus alba. Triturate with gentle heat until the solu- tion is as perfect as possible. A grain of morphia to the ounce can be added to alleviate the pain caused by the injected fluid. The patient is placed on the back, contents of the sac returned, and if necessary retained by the finger of an assistant. Locate the external abdominal ring with the right forefinger passed upward and outward, invaginating the scrotum ; press the left forefinger perpen- dicularly upon the integument over the ring, using sufficient force to press the integument together with the finger directly into the ring, 382 OPERATIVE SURGERY. thus leaving nothing between it and the external pillar but the in- tegument and subjacent fascia. The syringe, already charged, is taken in the right hand, and quickly introduced through the integu- ment and fascia into the inguinal canal, closely hugging the external pillar. The forefinger is then removed, and the needle carried care- fully along the posterior surface of the aponeurosis of the external oblique, for an inch or so, when the fluid is deposited, drop by drop, in various portions of the canal, by moving the point around during its withdrawal. A small portion should be deposited at the extreme end of the canal ; the intercolumnar fascia and the pillars of the ex- ternal ring should be well medicated. The needle is then withdrawn, the opening sealed, compress and bandage applied, and the patient kept in the dorsal position. If undue inflammation occurs, it is to be treated in the usual manner. As a rule, the pain and tenderness will disappear in two or three days, after which the patient is to be kept quiet for ten days before attempting to walk, and then the part should have proper support, which should be continued in use for six or eight weeks, and even longer in the interest of discretion. The results claimed for this method by its originator have not been substantiated by the trials to which it has been subjected by many careful and unprejudiced surgeons. It is, however, devoid of clanger, provided the fluid be not thrown into the peritoneal cavity, and is rarely followed by suppuration. In a recent oblique hernia with a small neck it is a harmless expedient, which often affords relief. It must not be forgotten, however, that unless constant caution is ob- served, the protrusion may recur. The percentage of cures and failures are about the same—thirty per cent. In the remainder the result is indifferent. Wiitzer's Method.—The protruded parts are returned, and a fold of integument is pushed as far as possible into the canal with the index-finger of the Fig. 585.—Wiitzer's apparatus. tal extremity of the instrument is passed up to the internal ring, the needle projected, passing through HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 383 the neck of the sac and tissues of the abdominal wall; the concave cover is then screwed down and a cork fixed on the end of the needle. The instrument is allowed to remain in position eight or ten days. ■ After the removal, the patient is kept in bed as much longer, and is then permitted to get up, keeping the parts supported by a truss for five or six months. Agnew's Modification.—Evacuate the patient's bowels thoroughly the day before the operation. Place him in a horizontal position, shave and cleanse the parts, make an incision through the integument, com- mencing at the external abdominal ring and terminating two inches below it: separate the integument from its fascial connections at either side of the incis- ion, then invaginate the fascia and dartos, pushing it to the outer extremity of the canal by the index-finger, along which the instru- ment is now passed. The instrument (Fig. 586) is introduced with its grooved blade resting internally to carry the invaginated integument to the outer extremity of the ca- nal. The blades are then widely separated, and the long needle, armed with a silver wire, is inserted into one of the grooves of the inner blade, and, guided by it, is passed through the superimposed tissues, the end of the wire grasped, needle withdrawn and directed by the other groove through the tissues in the same manner, causing the points of puncture to be about half an inch apart. The wire is then cut of sufficient length to be twisted around a piece of cork, or bent, thus securely fastening the apex of the invagination within the canal. The sides of the inguinal canal are now drawn together by three transverse sutures half an inch apart, introduced by a needle armed with stout silk thread, which is passed between the blades of the instru- ment. This should then be withdrawn, the wound closed and dressed antiseptically, the patient confined to the bed, and the bowels Fig. 586.—Agnew's apparatus. kept closed by opium to avoid straining. The transverse sutures are allowed to remain in position for eight or ten days, the silver one somewhat longer, the object being to cause a firm agglutination of the invaginated plug to the surrounding tissues. The results of this operation are flattering. If the cases be cor- rectly reported, over eighty per cent are cured. 384 OPERATIVE SURGERY. Wood's Method.—This consists in drawing together and retaining the tendinous structures of the inguinal canal and pillars of the ring by the means of a ligature, until the parts become united by effused lymph. The instruments required are a tenotome, semicircular needle at- tached to a strong handle, and a silver-plated copper wire (Fig. 587). The method of procedure is suc- cinctly portrayed by Mr. Druit: "The patient be- ing tied on his back, with the shoulders well raised, with the Fig. 588.—Tis- knees bent, the Fig. 587.-Wood'8 apparatus. sues^ invagi- pubes deanly shaved, the rup- ture completely reduced, and chloroform administered, an oblique in- cision about an inch long is made in the skin of the scrotum over the fundus of the hernial sac. The knife is then carried flatwise under the margins of the incision so as to separate the skin from the deep coverings of the sac, to the extent of about an inch, or rather more, all around. The forefinger is then pressed into the wound, and the detached fascia and fundus of the sac invaginated into the canal as Fig. 589.—Transfixing conjoined tendon. represented in Fig. 588. The finger then feels the border of the in- ternal oblique muscle, lifting it forward to the surface. By this means the inner edge of the conjoined tendon is felt at the inner side of the finger. The needle is then carried carefully up to the point of >.—Transfixing Poupart's ligament. Fig. 591.—Passing through or behind the sac. puncture before made. The outer end of the wire is hooked on to the needle, and the wire is then drawn back into the scrotal puncture as before, and detached. Next the sac at the scrotal incision is pushed up between the thumb and forefinger, and the cord slipped back from it, as is done in taking up varicose veins. The needle is then passed across behind or through the sac, between it and the cord, entering and emerging at the opposite ends of the scrotal incision, as shown in Fig. 591. The end of the inner wire is again hooked on and drawn back behind the sac. The needle may be made to pass through one or both of the pil- lars at the same time close to their insertion. Both ends of the wire 25 386 OPERATIVE SURGERY. are then drawn down until the loop is near the surface of the groin above, and they are twisted together down into the incision and cut off at a convenient length. Traction is then made on the loop so as to invaginate the sac and scrotal fascia well up into the inguinal canal. The loop of wire is firmly twisted close down iuto the upper puncture and bent downward to be joined to the two ends below in a bow or arch, beneath which is placed a fine pad of lint (Figs. 592 and 593), and the whole confined in position by a spica bandage. ^ =^> -=^) Figs. 592, 593.—Invagination completed. Fig. 594.—Wood's rect- angular pins. Modification with Pins.—For small hernia? and hernia? in children Dr. Wood employs a pair of rectangular pins (Fig. 594). With the finger in the inguinal canal, as in the preceding operation, one pin is made to pass through the conjoined tendon and the internal pillar from above down- ward, and the other to pass through Pou- part's ligament from below upward (Fig. 595). They should both be caused to enter and emerge at the same point of cutaneous Fig. 595.—Passing the pins. puncture. The pins HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 387 are bent at a right angle at the blunt extremity, the angle being looped. After the transfixion they are locked to each other and twisted around to more closely entwine the included structures. The ends of the pins are then cut off and the blunt extremities are pressed against the abdominal wall, con- fined in position, and allowed to remain eight or ten days (Fig. 596). The results obtained by this method, as recorded by Dr. Wood, are most excellent, seventy per cent being satisfactory; be- tween one and two per cent died. These results have not, as yet, been du- plicated by other operators. Czerny's Method.—Expose the sac by a free incision in its long axis and separate it from the surrounding tissues, isolate its neck and tie it with a strong catgut liga- ture. Amputate the sac below the liga- tured point, push the stump into the ab- dominal cavity, refresh the borders of the opening, and unite them by a continuous catgut ligature. Results.—Of the cases reported all but Fig. 596.—Pins in position. one resulted in a satisfactory manner. It is suggested by Prof. S. D. Gross that the method can be modified by simply tying the sac as before and returning it to the abdominal cavi- ty, which will expose the patient to no unnecessary danger. It is recommended that the sac be twisted after tying its neck, to excite adhesive inflammation. The lower end of the sac may be drawn to the outer end of the inguinal canal by a ligature extending from it through the abdominal walls, and the sac is then fastened in place by tying the ligature around an antiseptic com- press. The author has employed a method of treating the sac of ordinary- sized hernia?, which he has not, as yet, seen described. After the neck of the sac is tied, a looped ligature armed with a large needle is carried through the lower extremity and tied. Two parallel incisions are then made half an inch apart, the lower one being made half an inch above the border of the internal pillar. They should correspond in length to the width of the sac. The external pillar is treated as nearly as possible in the same manner ; the first incision being located a little below its upper border. The sac is first carried upward behind the internal pillar, drawn through the upper slit, and returned through the lower slit of the same pillar ; then it is carried behind the external pillar, out through its upper slit, and returned again by being pushed 3S8 OPERATIVE SURGERY. inward through the lower slit of the pillar. The sac is drawn tight- ly, the borders of the external ring are approximated and sewed with catgut or silver wire, the stitches being carried through the walls of the sac lying beneath. This " weaving " process not only thor- oughly closes the external abdominal ring, but also introduces ad- ditional layers of peritoneum in front of the weakened point of the abdominal wall. Results.—Sufficient time has not yet elapsed since the first opera- tion performed by this plan to admit of a positive expression of opin- ion regarding the result. Dowell's Method.—Prepare the patient as in the preceding methods. He is then placed in a recumbent posture with the shoulders elevated and the limbs flexed. Operation.—Be sure the hernia is reduced. Invaginate the scrotal tissues with the index-finger. Take the semicircular needle, especially designed for the purpose, and arm it with a strong silken ligature. The needle is entered one inch and a half above the external ring and passed beneath and close to the tip of the finger and brought out through the skin on the opposite side, near to Poupart's ligament. This stitch passes through the integument, the aponeurosis of the ex- ternal oblique, and the hernial sac near the posterior wall of the canal. The needle is withdrawn till its point is disengaged from the tendon, and is then carried over the point of the finger in close contact with it, and pushed through the first puncture, situated near to Poupart's ligament. By this procedure the loop is made to surround the in- guinal canal, and both its extremities lie together in the primary puncture. To one end of the silken ligature just passed attach a sil- ver wire which is then drawn into the position of the former. Two or more silver wires are introduced in a similar manner at different situations along the canal. Each of these is then twisted over a cylinder of antiseptic gauze placed upon the abdomen and the whole is dressed antiseptically. The patient should be kept quiet in bed for eight or ten days, upon a restricted diet, after which the stitches can be removed ; and the patient allowed to walk, three or four days later. Results.—Dr. Dowell some time since reported ninety-six cases treated in this manner, with eighty cures and sixteen failures. In many cases of the so-called radical cures obtained by any method, the fondest anticipations of the patient and surgeon are too often dis- pelled by the return of the protrusion. To avoid this, if possible, an easy-fitting truss should be worn for a long time afterward. The direct methods can be employed in the treatment of all forms where the neck of the sac can be reached and the borders of the opening ap- proximated. Radical Cure of Femoral Hernia (Wood).—The same instruments are required for operation upon femoral hernia as upon inguinal. The HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 389 patient is placed on the back with shoulders well elevated, and an inci- sion an inch in length is made in the long axis of the protrusion through the integument. The subjacent fascia is separated from the integument and is pushed into the femoral opening with the index- finger, which is placed at the inner side of the femoral vein to protect it. The needle is passed upward through the sac, and is directed so as to include with it the pubic portion of the fascia lata over the pec- tineus muscle (Fig. 597, b). The point of the needle appearing at the wound is then pushed upward and through Poupart's ligament toward the nail of the invaginating finger. The skin of the groin is drawn outward and pierced by the needle. A wire is passed through the eye of the needle and is carried downward by its withdrawal. The wire is removed and left in the wound, and the needle again carried through the pubic portion of the fascia lata about an inch outside of its preceding course, and upward through the falciform process of the fascia lata and Poupart's ligament through the integumentary punct- ure previously made (Fig. 597, a). The other end of the wire is then inserted into the needle and pulled down as before. The lower ends are then twisted together in the incision, the twisted end cut off five or six inches long, and the upper external loop twisted firmly down upon the integument (Fig. 598) and looped as before (Fig. 599). 390 OPERATIVE SURGERY. on the back, the shoulders are raised, the thigh flexed on the abdo- men, and the contents of tumor reduced. The spoon-shaped director, b, with its concave surface uppermost, is pushed into the highest portion of the opening, upon either the right or left side, carrying the integument beneath the free border of the tendinous outline of the open- ing. The needle, d, is carried along the concave surface and thrust through the invaginated integu- ment, fibrous border, and also the superimposed integument, after this has been drawn upward. The end of the wire a, is then introduced into the needle and drawn through the puncture. The lower portion of the opening is pierced in the same manner, the skin being drawn downward to cause the needle to emerge at or near the puncture previ- ously made. The second wire is then drawn through in a similar manner. The operation is repeated on the opposite side, the end of the needle being introduced, first, at the puncture first made and carried along beneath the integument situated between the fibrous boundaries of the open- Fig. 599. — Wire looped in posi- tion. Fig 600.—Instruments for umbilical hernia. ing, thence out through the tendinous border of the rupture as before described. The extremities of the wire are then twisted until the opening is closed, when they are cut of a sufficient length to be hooked over a compress of lint and retained by adhesive plaster and a bandage. STRANGULATED HERNIA. Strangulation is a condition induced in the sac by a constriction located at the neck or within the sac itself, which obstructs the circu- lation entirely or in part, thereby exposing the contents of the con- stricted portion to the danger of gangrene. The operations for its relief are taxis and herniotomy, the latter sometimes being called kelotomy, and in common parlance "an operation upon strangulated hernia." HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 391 Taxis.—This consists in returning the constricted viscus to the ab- dominal cavity through the channel of its escape by manipulation aided by force of gravity and the relaxation of the constricting agen- cies. As a rule it will be found that strangulation occurs to a protru- sion of long standing, where the patient has become self-educated in the practice of returning it. It therefore follows, when the case is brought to the attention of the surgeon, that the patient has made persistent but ineffectual efforts to reduce it; under these circum- stances the outlook for the surgeon's success is not brilliant. He should first diagnosticate the variety of hernia, that his efforts may be intelligently directed ; also its condition, that his efforts may do no further injury to the parts or cause harmful procrastination. If mod- erate effort be not sufficient to return it, a hypodermic injection of morphia may be given near the seat of the constriction, and the pa- tient kept in a warm bath, with the pelvis elevated, until the com- bined influences are felt on the general system. It can thus often be returned without difficulty, either by the patient or surgeon, the for- mer being less liable to employ harmful force because of the pain pro- duced. If these measures fail, and if the strangulation be of recent date and the symptoms not urgent, the patient is then thoroughly dried, surrounded by warm wraps, placed in a bed with its foot weil elevated, and hot applications applied to the parts. These measures are of themselves often sufficient to cause its return. If they fail, then taxis is repeated with or without an anaesthetic. If an anaes- thetic is used, it should be with the understanding that a failure at reduction will be followed by an immediate operation. Taxis is practiced by elevating the hips, relaxing the tissues, and endeavoring to return the part first which escaped last, in the direc- tion of the channel through which it came. Empty the bowels and bladder, flex the thigh upon the body, abduct and rotate it inward to relax the muscular and fibrous tissues about the groin, grasp the tumor with the right hand, and draw it downward carefully to disengage its neck and at the same time to give to it the proper direction for reduc- tion. Gentle, uniform, and continuous pressure is then made upon it by the right hand, while the thumb and fingers of the left steady the upper extremity. If successful, in a few moments the surgeon will be conscious of a slight gurgling noise, followed by a diminution in its size and tension. This is caused by the escape of gas or fecal matter, and will soon be followed by the return of the entire protrusion. Properly directed taxis should not be continued longer than fifteen or twenty minutes, when the herniotomy should be proceeded with. If it be improperly directed, the sooner stopped the better. If taxis be applied to a femoral protrusion, if it be a complete one, it must not be forgotten that it is necessary to first press downward, and then backward and upward. It not infrequently happens that a 392 OPERATIVE SURGERY. large femoral hernia is mistaken for an inguinal one, and efforts are directed to returning it through the inguinal canal. Kelotomy.—The instruments required for this operation are the ordinary scalpel, thumb-forceps, and artery-forceps, scissors, hernial knife (Figs. 601 and 602) and hernial director (Fig. 603), hypodermic Fig. 603.—Levis' director. Figs. 601, 602.—Hernial knives. syringe, ordinary grooved director, needles, and the materials for com- plete antiseptic treatment. The steps of the operation may be logic- ally divided into six : 1, division of the tissues; 2, recognition of the sac ; 3, opening of the sac ; 4, examina- tion of the contents; 5, division of the stricture and return of the protrusion ; 6, closure of the wound. Division of the Tissues.—After the patient is etherized, and the parts are shaved and cleansed by scrubbing, and suitably placed in a good light, an incision two or three inches in length is made through the integument, by transfixion or otherwise, in the long axis of the tumor. The remaining structures, forming the wall of the sac, are picked up one after another with the thumb-forceps at the lower angle of the wound and nicked, the grooved director is pushed beneath each one, and it is then divided with the knife or scissors. The possibility of recognizing the different layers will depend very largely on the length of time the hernia has existed, as well as upon the amount of exter- nal irritation to which it has been subjected. It is exceptional, how- ever, when many of the layers can not be easily recognized, especially those of a muscular character and the dense fascia. As the sac is ap- proached, the question which will most annoy the surgeon is, which is the sac ? am I without or within it ? The sac is recognized by the various layers and their anatomical characteristics ; the fascia trans- versalis, which surrounds it and is separated from it by the fatty sub- serous tissue, is quite liable to be mistaken for the peritoneum. The HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 393 fascia is dense, opaque, non-translucent, and always present. If a similar tissue has not been divided before, this, then, can not be the sac. A minute opening should be made through it at the lower por- tion of the wound, a grooved director passed beneath it, and its divis- ion carefully made. The next layer is the subserous fat, which is often quite well marked. If the surgeon with hesitation divides the fascia transversalis under the impression that it is the sac, he will become somewhat reassured by mistaking the subserous fat for the omentum in the protrusion. This feeling of security will be quickly dispelled, however, when he attempts to find the intestine, or to return the sup- posititious omentum. Recognition of the Sac—It is globular in form, of a bluish color, and often transparent. A sense of fluctuation is often discernible at its lower portion. It can be pinched up be- tween the thumb and finger, and its smooth serous surfaces can be rubbed together, if they be not adherent to its contents. This is diag- nostic. The intestine may be pinched up in the same manner before the sac is opened, when it will quickly and easily escape the grasp on account of the smooth opposed serous surfaces. If a needle be intro- duced, a drop of fluid will escape; this is characteristic of a hernial sac. Finally, if the membrane be ex- amined, it will be found to surround and limit the protrusion, being mova- ble only as a whole, denser than the intestine, and devoid of its external serous surface. The sac is now to be picked up with the thumb-forceps at the fluctuating point, or the point where the drop of fluid escaped, and a small slit made in it with the knife- point held at right angles to the for- ceps (Fig. 604). If fluid be present it will then escape. A grooved director is inserted (Fig. 605) and an opening made of sufficient size to admit the index-finger, which is introduced to determine with cer- tainty the tissue just cut, as well as the location of the constriction (Fig. 606). If the finger be in the sac, it will come in contact with smooth surfaces, and, after division of the constriction, can be passed through the neck of the sac into the abdomen. If the fin- Figs. 604, 605.—Opening the sac. Fig. 603.—Introducing the finger. 394 OPERATIVE SURGERY. ger be without the sac, it can not be passed upward without being arrested. The existence of cysts in the line of incision may con- fuse the surgeon. If, however, the finger be introduced into them, their non-serous lining and limited extent will expose the fallacy. The sac is now opened sufficiently to expose its contents to a careful scrutiny, that the propriety of returning them may be carefully con- sidered. Examination of the Contents.—Under all circumstances there will be more or less injection of the vessels. If the constriction be recent or slight, the changes in the imprisoned tissues will not be great; but when severe or long continued, the intestine will be of a more or less purple or blackish color, with isolated ecchymoses. The bowel may present this appearance, and yet may possess sufficient vitality to re- cover. The color is not of as much importance in determining the presence of gangrene as the inability to restore the circulation after division of the stricture by the aid of warm fomentations. If the bowel be pricked or slightly scarified and no blood flows ; if sensi- bility be absent and the part becomes cool; if its luster be destroyed and its structure be softened and crackling, it should not be re- turned. If to all these be added the odor of gangrene, it should be opened to afford exit to its contents and be treated with warm fluid carbolized dressings. It is considered good practice at the present day to excise a circular portion of the intestine correspond- ing to the gangrenous part and unite the extremities as described under the head of enterectomy. If the omentum be gangrenous or bulky, ligature it near the mouth of the sac and cut it off; if not, it can be returned. If the contents be adherent to each other or to the sac, the adhesions may be ruptured if of recent date. It is often necessary, however, to sever them with the knife or scissors, and in doing so, the vessels should be ligatured with fine catgut as soon as seen. When the adhesions are very firm and limited, the corre- sponding portion of the sac may be dissected off and returned with the bowel. Division of the Stricture.—The constricting agency may be with- out or within the sac, the former being the more frequent site. If without, it may be divided before or after the sac is opened, the latter being the almost universal custom. If the hernia be a small one, and strangulation have lasted but a few hours without stercoraceous vomit- ing or other severe symptoms, and be composed of intestine alone, the constriction may be divided external to the sac. This can be readily done by passing beneath the constricted tissues of the neck of the sac the hernial director of Levis (Fig. 603), which is cautiously carried upward until the constricting band falls into the notches at either side of the groove ; a probe-pointed bistoury or the ordinary hernial knife is then carried along the groove, and the structure divided (Fig. HOLLOW VISCERA IN CONTACT WITII SEROUS SURFACES. 395 607); not freely, but just sufficiently nicked to permit the return of the intestine When the gravity of the case'requires the con" stnction to be divided within the sac, so that its contents may be examined, the finger is carried up to the point of the obstruction, followed quickly by the director, which is em- ployed as in the preceding instance. The edge of the knife should be di- rected away from important vessels and the extent of the cut be only suf- ficient to relieve the constriction. If the gut be gangrenous, great caution must be observed in cutting the band, or the adhesions may give way and allow the bowel to re-enter the abdom- inal cavity. If gangrene of the gut be assured, it is better not to divide the constriction, since to do so not only exposes the pit ent 9ltv rgH f 1the/eturn of th* gangrenous gut into the abdomi- nal cavity, but also to the entrance of discharges from the wound. As soon as the bowel is returned, stop all hemorrhage, unite the He"1! "^ "T^ thr°Ugh the SaC> introd-e a ^ailge- nd\Tl Z comPress, dress antiseptically, raise the foot of the bed, and quiet the patient with an opiate. Fig. 607.—Dividing the constric- tion. Figs. 608, 609.—Oblique inguinal hernia. Strangulated Inguinal Hernia.—A hernia in this situation may be direct or indirect, either of which may be complete or incomplete. In the indirect or oblique form (Figs. 608 and 609), if it be a complete nernia, it enters at the internal abdominal ring, passes downward and 396 OPERATIVE SURGERY. forward to, and through, the external ring. The constricting agent external to the sac may be located at either the internal or external ab- dominal rings, and rarely in the inguinal canal. The manner of cutting down upon the sac, and of detecting and dividing the constriction, is described under the general considerations. If the seat of the constric- tion be at the internal ring, it should be divided upward and outward to avoid the epigastric artery which runs along its inner border (Figs. 609, 4 and 610). In fact, in the oblique variety the incision upward Fig. 610.—Course of epigastric artery. and outward is always to be made irrespective of the situation of the constriction. The only fallacy that may arise is that of mistaking the direct for the indirect form. In recent cases this can hardly occur, but in those of long standing, where the traction upon the neck of the sac of the oblique form has drawn it inward in front of the point of the exit of the direct variety, it is quite difficult and often impossi- ble to distinguish between them. If the neck of an oblique hernial sac be dragged inward, it causes the epigastric vessels to be pressed di- rectly against its inner and also to encroach upon its upper and lower borders. Under these conditions, if the stricture be divided agreeably to directions often given—parallel with the course of the epigastric vessels—or even upward and slightly outward, these vessels will be in imminent danger of injury. If, upon the other hand, the protrusion be of the direct variety, and the incision be made upward and outward, under the impression that it is a displaced indirect form of hernia, the epigastric vessels will i; Fig. 611.—Djrect inguinal hernia. HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 397 then be exposed to peril (Fig. 611, 6). It is readily seen, therefore hat great caution should be employed in distinguishing between the two, prior to cutting the constriction. It is practically impossible to discrim- inate between them until the covering of the sac are examined. The oblique variety has for a covering the cremaster muscle, which can readily be distin- guished in an old hernia. This muscle never forms the covering of a direct hernia except when it passes to the outer side of the conjoined tendon ; then its coverings are similar to those of the oblique form. It therefore fol- lows, from the anatomical relations, that when the cremaster does not form a covering the constriction should be divided upward and inward—that is, away from the epigastric vessels. If it forms one of the coverings, then the constriction must be cut upward and outward, provided there be no evidence that it is a direct hernia which has escaped to the outer side of the conjoined tendon. This latter condition of affairs is fortunately rare, and this fact, when taken in connection with the location of the tumor at its incipiencv, should settle the question between the two. If, however, it be impracticable to settle the doubt, dull the edge of the knife by drawing it across a nail or stone, and then proceed carefully to nick the neck of the constriction in an upward direction. If the constriction be at the external abdominal ring, it matters little in which direction the cut is made; however, to simplify matters, the direction upward and out- ward should still be adhered to. The methods of examination of the contents of the sac and their reduction, together with the subsequent treatment, are sufficiently considered in the preceding pages. If the protrusion be incomplete, the treatment is similar, and the matter simplified by the inability to confound the direct with the indirect varieties of this form. Strangulated Femoral Hernia.—The protrusion in this instance escapes at the femoral or crural ring at the inner side of the femoral vein (Fig. 612), then passes along between the vein and Gimbernat's ligament, and the inner boundary of the femoral canal for about naif an inch, to the upper portion of the saphenous opening through which it escapes, and in many instances passes upward and rests upon the falciform process of that opening (Fig. 613). The tioo com- mon points of constriction are : Gimbernat's ligament, and the sharp border of the falciform process of the saphenous opening. The im- 398 OPERATIVE SURGERY. portant boundaries of the upper extremity of the crural canal are: within, Gimbernat's ligament, and without, the femoral vein, sur- Fig. 612.—Location of the femoral canal. rounded by its sheath. Throughout the course of this canal the femoral vein lies at the outer side. The distinctive coverings of this protrusion are : the cribriform fascia, crural sheath, and septum cru- rale, together with the subserous tissues. The important vascular relations are those of the femoral vein and the obturator artery. Tax- is should not be employed in femoral hernia as long as in inguinal, since the constricting influences are greater, and the neck of the sac much smaller. I must again refer to the fact that a femoral hernia, which extends upward toward Poupart's ligament, sometimes reaching above it, may be mistaken for one of the inguinal variety, and that the efforts at reduction are directed to returning it through the external abdominal ring, instead of pushing it downward, backward, and up- ward, as is necessary to effect a reduction. Operation.—The part should be washed, shaved, and disinfected ; patient placed on the back, thigh flexed and rotated outward, bladder HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 399 emptied, patient anaesthetized, and an incision made in the long axis of the tumor. The integument and superficial fascia should be care- Fig. 613.—Saphenous opening. fully divided, thus exposing the cribriform fascia, which in fleshy subjects is loaded with fat. This, with the glands connected with it, especially if the latter be enlarged, forms a mass often difficult to un- derstand. The glands should be pushed aside, and the remainder of the structure carefully divided. It can hardly be mistaken for any- thing but the omentum, or the deeper layer of fatty tissues. The absence of the sac will readily expose the fallacy of the former, and the nature of the latter will be soon recognized. The femoral or crural sheath comes next in order. It is dense, like the fascia transversalis, of which it is a prolongation, and might be mistaken for the sac did it not present those appearances of a dif- ferent character, which have already been described. The septum cru- rale, if the protrusion be large, will hardly form one of its coverings ; if it does, its texture will be much diminished in thickness, and some- what blended with the subserous tissue. It sometimes happens that the small lymphatic gland, which normally exists between the subserous tissue and the septum crurale, can be distinguished, which, of course, 400 OPERATIVE SURGERY. settles all doubts as to the identity of the tissues under inspection. The careful use of the knife and director soon exposes the sac with its characteristic appearance. It should be opened at the lower ex- tremity with the precautions previously enjoined, and the stricture sought for and divided. If it be, as is usual, at the free border of the falciform process, flex the thigh, rotate it inward, and then, if it is proper, and no further obstruction exists, the protrusion can be re- duced. If the constriction be at the free border of Gimbernat's liga- ment, this, too, must be nicked. It is necessary to remember, before Figs. 614, 615.—Course of obturator artery. with the Vein in its descent (Fig. 614), and is, therefore, out of danger, yet it not infrequently curves inward along the free margin of Gimbernat's ligament (Fig. 615), thus nearly encircling the neck of the sac, and is therefore in great danger of being cut. The knife should be made quite dull, and the ligament nicked superficially in several places. The tip of the little finger may then be inserted and the artery felt for ; if not discovered, the nicking may be repeated, or firm traction with the finger against the ligament may be made, so as to tear or stretch it. This vessel has been severed ten or twelve times during the operation, but in each instance the bleeding was controlled without a fatal result. Ligation and com- pression were the principal expedients resorted to. After the return of the protrusion, the wound is closed and dressed antiseptically. Femoral hernia? do not always follow the course just described; they take, though rarely, anomalous courses, sometimes appearing at the outer side, or behind the femoral vessels. They have been known to pass through Gimbernat's ligament. It is important to know that in all the anomalous cases the neck of the sac lies closely associated with the epigastric artery alone, or, together with the obturator, and troublesome and often fatal haemorrhages may be caused unless care is taken in dividing the constriction. Strangulated Umbilical Hernia.—If the symptoms be not urgent, it is recommended that taxis be continued longer in umbilical hernia than is considered admissible in other forms of hernial strangulation, owing to the greater death-rate attending herniotomy in this situation. In the employment of taxis the patient lies upon the back, with the OPERATIONS UPON THE ANUS AND RECTUM. 401 shoulders raised and the thighs flexed. The location and size of the opening can often be defined by the finger before the viscus is returned. The seat of the strangulation is usually at the upper border of the open- ing. The taxis pressure should be directed upward and backward to cor- respond to the line of its escape. The incision for the operation is made to suit the shape and size of the tumor. All the tissues are divided on a director, and the upper border of the opening sought for, since it is at this situation that the constriction is most frequently seated. If it be possible, the stricture should be divided without opening the sac, and the contents returned, if they be not gangrenous. If the stricture be without the sac and the contents in an uncertain condi- tion, a small opening, just large enough to admit of inspection, can be made through the sac. If the stricture be within, the only recourse is to relieve it through as small an opening in the sac as possible. If the intestine be gangrenous, the constriction must not be divided, for to do so will allow the wound discharges to run into the abdominal cavity, even though the intestine remain outside. Strangulated Obturator Hernia.—The viscus follows the course of the obturator vessels in its escape from the pelvis, and lies beneath the pectineus and obturator muscles. It is usually small and not de- tected during life. The incision for its relief is made over the tumor at the inner side of and parallel to the femoral vessels. The constriction has been found in the fibers of the pectineus muscle ; and it is usually neces- sary to divide some fibers of this muscle in order to expose the open- ing through which it has escaped. The relation of the obturator ves- sels to the neck of the sac varies, being equally frequent at the outer and inner sides; never in front, and occasionally behind it. If the constriction be found at the foramen, it will require much caution to divide it without implicating these vessels. CHAPTER XV. OPERATIONS UPON THE ANUS AND RECTUM. Examination of the Anus.—Place the patient in either one of four positions: 1, in the knee and elbow position ; 2, upon the back; 3, upon the right side, with the knees drawn upon the abdomen ; 4, or cause the patient to kneel upon a chair and lean over its back. The position most commonly employed is upon the back in the lithotomy attitude. The one, however, which is most comfortable and 26 402 OPERATIVE SURGERY. at the same time most delicate, is upon the side. It is hardly neces- sary to add that the surgeon should be familiar with the normal char- acteristics of the parts, not those alone relating to the appearances, but to their sensibility and density as well. On inspection, not only will the presence of the anal opening be noticed, but the wrinkled appearance of the contiguous integument, the condition of the blood- vessels bordering upon it, but also the white line at the muco-cuta- neous junction will be seen, which indicates the interval between the internal and external sphincters. The instruments necessary to prop- erly examine the anus and rectum consist of variously formed specula constructed for that especial purpose, which may often be wisely sup- plemented by those intended for vaginal examinations (Figs. 616, 617, Fig. 616.—Bivalve specu- Fig. &11.—Williams' rec- Fig. 618.—Allingham's rectal lum. tal speculum. speculum. and 618). Sims' speculum, or a simulated pattern of it, made by bending the handle of an ordinary tablespoon at a suitable angle, will be found to be of much use. Any form of speculum which possesses ample power of adjustment will serve the purpose well. Imperforate Anus.—This condition depends upon a layer of tissue of variable thickness which exists between the normal site of the ex- ternal opening and the lower extremity of the rectum. It may be simply a thin layer of fibro-cellular tissue, which by its projection in- dicates the nearness of the loaded bowel. In these cases, the emotions of the child may be noted by the movements of the interposed mem- brane, and a positive diagnosis can be made by a hypodermic puncture. If the septum be thin, a longitudinal or crucial incision, or even a OPERATIONS UPON THE ANUS AND RECTUM. 403 simple puncture, followed by the careful introduction of a well-oiled finger, will be a sufficient operative interference, especially if after- ward the extremity of a suitable sized rectal bougie be occasionally introduced. If the membrane be of sufficient density to interpose an obstacle after its division, it should be trimmed away, care being taken to not include the proper structure of the opening. Absence of the Anus (Fig. 619). —In this deformity all trace of the opening is absent; and the median raphe may extend continuously from the scrotum to the tip of the coc- cyx. The fibro-cellular interval may be thin or of extreme thickness. If thin, the previously detailed signs Fio. 619.—Absence of anus. of imperforate anus may be evident. If they be not present, the occlusion is then of considerable thickness, and may even involve the entire length of the rectum itself. The operation for its relief consists in first placing the patient, properly anaesthetized, in the dorsal position. Then introduce a sound into the bladder, if the patient be a male, into the vagina if a female, and make a vertical incision in the median line from just behind the scrotum or vagina to the tip of the coccyx, continue it cautiously upward and backward, shortening each succeeding cut, and carefully feel for the fluctuating extremity of the gut. It is sometimes located posterior to the central line and must be sought for near the hollow of the sacrum. During the entire progress of the dissection the situation of the vagina or urethra must be marked by the location of the sound previously introduced. When the dark-brown, fluctuating extremity of the gut is detected, the introduction of a hypodermic needle will settle all doubt. The gut-end should then be seized by a pair of strong toothed forceps (Fig. 620), and drawn firmly downward, while its con- nections with the surrounding tissues are separated by the scissors and fingers. As soon as the cul-de-sac is drawn down to a level with the external opening, pass two short ligatures transversely through the sides of the wound, one through its anterior and one through its pos- terior portion, transfixing the anterior and posterior portions of the bowel in their passage. Protect the raw surfaces with lint saturated with carbolized oil, then open the sac between the ligatures and allow its contents to escape ; after having thoroughly cleansed it, remove the lint, draw the ligatures through the opening in the bowel by means of a hook, cut and tie them, as in the operation for lumbar colotomy. 404 OPERATIVE SURGERY. The mucous membrane should be closely adjusted to the integument, in order to secure perfect union and prevent the contact of the raw Fig. 620.—Byrne's rectal forceps. surfaces with the discharges. If it be impossible to draw the end of the gut down to the external opening, it can be incised at its lower extremity, and the discharges allowed to escape over the lower sur- faces, which are kept opened by the use of the bougies ; or, the coc- cyx can be removed, as recommended by Verneuil, and the extremity of the bowel drawn through the gap and united to the integument as before. Fistula in Ano.—A fistula here, as elsewhere, is a sinus, which in this case leads into the cavity of an ab- scess located near to the rectum. It may be either complete or incomplete ; if of the latter variety, it may be an in- complete internal or external fistula (Fig. 621). The complete form is the most frequent. In the case of a sus- pected fistula, before making an exami- nation evacuate the bowel by a cathartic and an enema ; place the patient on the back or side, and introduce the well- oiled index-finger of the hand corre- sponding to the side of the patient pre- senting the external opening. The end of the finger will often detect a nipple- like projection in the bowel, indicating the internal opening. If a flexible probe be then introduced through the external opening, it can with a little care be carried into the lumen of the rectum (Fig. 622). Sometimes, Fig. 621.—.4, R. Anus and rectum. B. Complete fistula. C. Incom- plete internal fistula. D. Incom- plete external fistula. OPERATIONS ON THE ANUS AND RECTUM. 405 however, the end of the probe will be felt separated from the finger by only the thin mucous lining of the gut; this may be due to the inabil- ity to find the internal opening, or to its non-existence. In either case the thin wall should be perforated by the instru- ment, thus producing a complete fistula. It not infrequently happens that more than one opening, E, F, communicates with the original abscess (Fig. 623, D), and also that the mu- cous membrane is under- mined to a considerable ex- tent above a previously ex- isting abscess (Fig. 624, A). It is of importance to re- member that the introduc- tion of the finger and the probe often produces such a degree of contraction of the sphincter as to prevent the passage of the probe with- out great difficulty along the sinus into the gut; therefore the attempt to pass it should not be made until the muscular contraction ceases. It may be advisa- ble to paralyze the sphincter by over- distention before di- viding the sinus ; this causes the parts to remain at rest, adding to the com- fort of the patient and hastening re- covery. It can be accomplished by in- serting the thumbs through the anus back to back, flexing the first joints and withdrawing them, or by the use of a speculum designed for that additional purpose (Fig. 625). The accepted method of treatment, namely, that of laying open Fig. 622.—Probing a fistula. Figs. 623, 624.—Variations of fistula in ano. 406 OPERATIVE SURGERY. the sinus, can be practiced by direct incision, by ligature, or by the galvano-cautery. The first method is the one most commonly employed. For this purpose the bowel should be thoroughly evacuated by a brisk cathartic on the day preceding the operation, and be followed by light diet. On the day of the operation it should be thor- oughly cleansed by one or two copious enemata. Operation by Direct Incis- ion.—Place the patient on the back, give an anaesthetic, pass the finger into the bowel as be- fore described, introduce a grooved director through the sinus into the bowel; if the end can be turned out (Fig. 626), then divide the sinus upon it; if not, press it against the finger, and pass a probe- pointed bistoury along the groove into the bowel; after which, the director may be withdrawn, the point of the bistoury pressed against the finger (Fig. 627), and the sinus cut outward with the point thus protected. The finger may be replaced by a wooden director intro- duced into the bowel, and the division made upon it (Fig. 628). The Fig. 625.—Thebaud's dilating speculum. Figs. 626, 627, 628.—Dividing fistulas. scissors may be employed instead of the knife, either with or without the grooved director (Fig. 629). Whenever the depth of the sinus de- mands the division of the entire thickness of the internal sphincter, it should be done at right angles with the course of the fibers, to avoid, as far as possible, the danger of incontinence of flatus and fasces. While each sinus should be opened, still, when possible to avoid it, the sphincter should be divided in but one situation, in order that its integrity can be the better restored ; and, when practicable, a small portion of the circular fibers should be preserved with the same object OPERATIONS ON THE ANUS AND RECTUM. 407 Fig. 629.—Allingham's scissors and director. in view. It is not necessary to divide the walls of the abscess above the opening into the gut, since the drainage and loss of power due to the division of the tissues below permits a rapid healing of this portion. As soon as the sinuses are opened, their pseudo-membranous linings can be scraped or touched with a thermo-cautery, all hemorrhage stopped, the cut packed with oakum, marine lint, or iodoformized gauze, a T-bandage applied, patient placed in bed with limbs ex- tended, and morphia or opium freely given to re- lieve all irritation and to produce constipation of the bowels. The food should be light, and not of a nature likely to leave a residue. In ten days or two weeks make use of a mild cathartic in con- junction with a copious enema. Incision with Closure.—If the extent of the sinus will permit it, the entire track may be re- moved and the resulting wound closed by catgut sutures, carried deep enough to bring the walls of the wound in contact. Two sets of sutures may be employed ; one, a superficial set, which shall bring the borders of the mucous membrane to- gether, while the second should unite the deeper structures. In this manner union by first inten- tion may be secured, thus shortening the period of recovery and obviating all danger of fecal incon- tinence dependent upon the incomplete closure, which sometimes occurs when the cut is deep and is permitted to heal from the bottom. If, how- ever, there be a cavity at the upper end of the si- nus, or if any portion of the track be not dissected out, the recovery by rapid healing will be retarded if not entirely prevented. _ FlG 630—Allingham's Treatment by Ligaturing.—The elastic liga- ligature-carrier. 408 OPERATIVE SURGERY. ture is the only one worthy of consideration. It consists of a rubber cord about one tenth of an inch in diameter. This is carried through the sinus into the gut by an appropriate instrument (Fig. 630), the inner extremity drawn out through the anus and tied, after any integ- ument which might be included in its grasp has been divided, to pre- vent the pain and delay incident to the division of its peculiar struct- ure. A strong silk thread can be substituted for the more elaborate apparatus shown in Fig. 630. This, after being passed through the sinus and attached to the rubber cord, can be employed to carry it into position. It is sometimes difficult to tie a knot in the rubber cord securely. Still, this can be accomplished easily by tying the first half of the knot over a silk ligature placed at right angles to the course of the elastic one, and then tying the silk ligature firmly around the half-knot. This holds the elastic cord securely while the knot is completed. The elastic ligature will cut its way through in six or eight days. This method possesses some advantages over that by incision, among which may be noted that, in simple cases, little or no pain ia inflicted, and the patient can walk out-doors without any especial danger. Nervous persons will often submit to it when they will not to the knife. There is no bleeding, which is of advantage when the larger vessels may be implicated, or when an undue tendency to hemorrhage exists. It is the best method in phthisical patients, for manifest reasons. It can be employed in all cases where but a single sinus exists; if, however, a second be present, the result must of necessity be unsatisfactory, as this involves a repetition of the operation or the use of the knife. The galvano-cautery does not secure better results than incision, and is much more cumbersome in its application; still, it is useful when dangerous hemorrhage is apprehended. Surgical Anatomy of the Rectum.—The length of the rectum is from six to eight inches, the latter being the length of advanced life. It has vario.us curves. The first, an inch and a half in length, extends from the anus to near the prostate, and is directed upward and for- ward, a fact which should be remembered in the introduction of instruments. The second portion follows the curve of the sacrum, and is about three inches in length ; the greater portion of this is covered by peritoneum, it being reflected upon it at a point about two and one half inches above the anus in front, and about five inches behind, when the bladder and rectum are empty; if filled, the dis- tance is increased about an inch. The anterior surface of the lower part of this portion is intimately associated with the base of the blad- der, vesiculaB seminales, and prostate body in the male. In the female the posterior wall of the vagina is in front. The third curve extends OPERATIONS ON THE ANUS AND RECTUM. 409 from the middle of the third piece of the sacrum to the left sacro- iliac synchondrosis. This portion is almost entirely surrounded by serous membrane. The vessels having surgical associations with the rectum are the superior, middle, and inferior hemorrhoidal arteries. The first is the most important; it runs between the rectum and the sacrum, a little to the left of the median line, to within about four or four and a half inches of the anus. Its branches run parallel with the long axis of the bowel down to the anus, and can be best avoided by longitudinal incisions. For a rectal examination the patient is placed in one of the many positions previously cited. The bowel should be thoroughly emptied and cleansed prior to the attempt. One or two fingers, or even the whole hand, may be introduced, or the tube may be inspected through the various forms of specula. If the examination is made with the index-finger, it should be well oiled and inserted with a semi-rotary motion, allowing the remaining fingers to lie in the median line between the buttocks. In this man- ner, by the use of moderate force, the lower four or five inches of the organ may be examined. The introduction of the middle finger along with the index-finger will somewhat increase the range of examina- tion, especially if the patient be requested to bear down. The introduction of the whole hand must be done with great cau- tion in order not to lacerate the bowel or the peritoneum enveloping it. For this purpose the patient is placed upon the back, anaesthetized, bladder emptied, and the services of a person with a small hand, not exceeding eight inches in circumference, are enlisted. The hand should be well oiled, and a conical form given to it by applying the thumb to the palmar surface of the approximated fingers. The tips of the fingers are then inserted by a semi-rotary motion, which is slowly continued until the whole hand enters the bowel. After the entrance of the hand, the fingers are to be moved in various direc- tions to ascertain the caliber of the gut, and, at the same time, favor the circulation of the imprisoned hand. If the hand meets a narrowing of the bowel at a distance of three or four inches above the anus, but little force should be used, as the peri- toneum, which is connected with the gut in this situation and is the cause of the narrowing, may be ruptured. If the hand be small, it not unfrequently happens that the sigmoid flexure may be passed, the descending colon entered, and the kidneys, uterus, and great vessels may be examined through it. It is, however, extremely fatiguing to the examiner ; still, the discomfort experienced should not lead the surgeon to relax in the least the degree of caution necessary to the safety of the patient. Prolapsus Ani.—Prolapsus ani occurs in two distinct varieties : first, as a partial or complete prolapse of the mucous membrane alone 410 OPERATIVE SURGERY. (Fig. 631); second, as a prolapsus implicating the deeper tissues, often attended by invagination (Fig. 632). The aims in the operative treat- Fig. 631.—Prolapsus ani. Fig. 632.—Prolapse with invagination. ment of the former consist in producing adhesions of the mucous membrane to the tissues beneath it, and a narrowing of the orifice of the anus by stimulating the function of the sphincter. The adhe- sions may be established by clamping and destroving isolated portions of the mucous membrane, or by removing similar portions of it by the ligature or the galvano-cautery. If piles be present, they should be ligatured, as this will alone often effect a cure. The application of Paquehn's cautery, longitudinally or at isolated points, to the pro- lapsed part, after its return, is an excellent method of procedure, and this, when combined with rest in the horizontal position and the pro- duction of fluid evacuations, as adjuvants to the treatment, will usually effect a speedy and satisfactory cure. Operation.— The patient must be anaesthetized, placed in the knee- elbow position, the prolapse reduced, and the parts exposed by the Sims speculum. Then four or five longitudinal stripes about three inches in length are made with the point of a cautery at a dull-red heat at equal intervals apart, and terminating externally at the border of the true skm. The number, size, and depth of the eschars made will depend on the age of the patient and the severity of the case. In the mfant, two or three a line or two in width may be sufficient. The older the patient and the severer the case, the deeper should be the eschars.^ The possibility of reanimating the sphincter is somewhat uncertain, yet the medical expedients .directed to the restoration of paralyzed muscles may be employed with some success. The anus OPERATIONS ON THE ANUS AND RECTUM. 4H may be narrowed by removing elliptical-shaped pieces from the mu- cous membrane and uniting their raw surfaces ; and also, by linear eschars made in a manner similar to that for prolapsus ani. Expedients of this kind, while they frequently fail of curing, gen- erally give marked relief to the patient. The second or complete variety of prolapse exists in three forms : 1. In which the external surface is devoid of a sulcus ; in this, the prolapse follows as the result of the continuous traction exerted by long-standing prolapse of the mucous membrane. Peritoneum exists in the tumor, and sometimes also a loop of intestine (Fig. 633). 2. In which a sulcus exists at the base of the tumor, at the bot- tom of which the lining mem- brane of the gut can be felt as it is reflected from the invagi- nated protrusion. 3. In which the finger, when introduced into the anus beside the tu- mor, fails to detect any evi- dence of the reflection of the mucous membrane of the rec- tum upon the tumor, because the invagination is extensive, involving the colon, caput coli, and sometimes the ileum it- self. All three varieties must first be reduced ; sometimes this is accomplished with great difficulty, especially when an acute case is complicated with evidences of strangulation of the protruding portion. Place the patient in the knee-elbow position, and endeavor carefully to return the part first which escaped last, and, if necessary, the external sphincter can be divided. If this fail, renew the effort by reducing the part first that escaped first. If the case be a severe one, the mucous membrane of the protrusion can be painted with a solution of cocaine, and even an anesthetic may be given. To the treatment of the third variety of prolapse must be added the copious injection into the bowel of fluids or gases, the introduction of the hand, etc. The after-treatment of the first two forms of the second variety is substantially the same as that for the first variety, except it should be more vigorouslv and persistently applied, and the patient be con- FiG. 633.—Complete prolapse, with peritoneum. R. Rectum. B. Bladder. S. Sacrum. P. Pubes. U. Uterus. V. Vagina. CSP. Cavity of the peritoneal sac. 412 OPERATIVE SURGERY. fined to the recumbent position and be required to use a bed-pan. It is not advisable in any of the forms of prolapse to resort to the direct removal of the protruding portion by means of the knife or ligature until all other methods have been faithfully tried and have failed. In the tliird form of the second variety the question of laparotomy must be considered ; and the answer to the question as to whether it should be performed or not, will depend largely on the symptoms and conditions of the case. Its early performance, however, improves the prognosis for recovery. Cancer of the Rectum.—Excision of the rectum and colotomy are the only operative measures of radical importance employed in this disease. Rectotomy, or External Proctotomy. — Place the patient in the lithotomy position, empty the bladder, expose the posterior wall of the rectum by a Sims' speculum, and, with the Paquelin cautery, or with a knife, make an incision through the diseased mass at the pos- terior aspect of the gut, about four inches in length, carrying it downward through the sphincters. The ecraseur may be employed, introducing the chain by means of a trocar passed from the tip of the coccyx upward behind the mass, thence into the gut, and dividing the included structures slowly. Eectotomy is only a palliative measure, enabling the bowel to discharge its contents more readily and with less pain. Iodoformized dressings, combined with frequent cleansing, comprise the local after-treatment. Excision of the Rectum.—Excision of the rectum, either as a cura- tive or a palliative measure, is, at the present time, a generally accepted surgical procedure. It can be stated as a conservative precept, how- ever, that if the upper limit of the growth can not be easily reached with the index-finger, its removal should not be contemplated, owing to the contiguity of the peritoneum. Still, even under these circum- stances, if the mucous membrane be involved alone, the diseased structure can be stripped off without entering the peritoneal cavity. If contiguous viscera be involved, or the pelvic lymphatic glands be enlarged, the expediency of the operation is decidedly questionable. Prior to the operation the entire length of the intestinal tract should be thoroughly evacuated, and the rectum cleansed by antiseptic ene- mata. A large antiseptic sponge, with a string attached, is then pushed up the bowel beyond the disease, to prevent soiling the opera- tion field. The bladder is emptied, and a sound carried into it to guide the operator in making the anterior dissections. An anaesthetic is administered with the patient in the dorsal position, after which the position may be changed to conform to the convenience of the opera- tor. The entire operation should be conducted with strict antiseptic precautions. OPERATIONS ON THE ANUS AND RECTUM. 413 Volkmann's Method.—This surgeon has described three different operations, intended to meet as many different phases of the disease : 1. For Removal of a Circumscribed Growth.—Dilate the anus, pull down the diseased portion, and remove it by an incision so di- rected that when closed the caliber of the bowel will be diminished as little as possible. If the sphincter have been involved, its fibers should be united after the removal of the growth, and deep drainage provided. If the growth be above the sphincter, after uniting the borders of the wound, deep drainage must be made by allowing the tube to pass through or beneath the sphincter. 2. For Removal of a Growth involving the Circumference of the Bowel, but not the Anus.—Divide the anus forward into the perineum and backward to the tip of the coccyx, the latter incision extending to the lower limit of the disease. The morbid growth is dissected out by means of the knife, scissors, fingers, etc. ; the healthy mucous membrane above is carefully stitched to that below, and deep drain- age is provided behind and in front, and the antero-posterior prelimi- nary incisions are carefully closed. 3. For Removal when the Disease involves the Circumference of the Bowel, and Part of or the Entire Anus.—Make the preliminary in- cisions as in the second class, and carry a circular incision around the anus, outside of the sphincter, from which the dissection is carried upward parallel with the gut to the upper limits of the morbid growth, which is drawn down, the healthy mucous membrane above it stitched to the cutaneous border, and the disease removed. Deep drainage is then provided, the parts are carefully united, and the wound tam- poned with iodoform gauze. If, in case the structure of the bowel is to be cut transversely, as when the morbid growth is being completely separated, the healthy portion be transfixed and tied by several catgut ligatures before the final separation, all danger of hemorrhage from this source is avoided. Lately, Volkmann has recommended the entire removal of the exter- nal sphincter, whether it be diseased or not, as he believes the growth is less liable to return than when it is left. If it be found difficult to draw down the mucous membrane of the bowel sufficiently to readily unite it to the external cutaneous opening, it should be permitted to remain above, and the exposed surfaces below it sprinkled with iodo- form or naphthaline, and packed around with antiseptic gauze. A tube of suitable size to discharge flatus and even fecal matter may be then passed up and confined in position. By these simple expedients the raw surfaces may be kept quite clean. The prostate, and even the base of the bladder, have been removed in conjunction with the diseased rectal tissue, but there is little, if anything, to be said in support of this measure. Cripp's Method.— Make the posterior incision by passing a curved 414 OPERATIVE SURGERY. bistoury into the rectum and bringing its point out at the tip of the coccyx, cutting all the intervening tissue. Separate the parts suffi- ciently to put the tissue on the stretch, and make lateral incisions from the posterior cut around to the median line in front, on each side, either without or within the anus, according to the location of the disease. These cuts should reach into the ischio-rectal fossae, and each one be completed in its turn. The dissection is carried above the point of the disease in the usual manner, the bowel drawn down- ward, and the morbid growth removed with an ecraseur. Maisonneuve's Method.—A. circular incision is made around the anus, through the integument and subcutaneous tissue, and a long, strong needle, bearing at its point a ligature one foot in length, is passed upward through the external incision outside the bowel into the gut above the growth. The loop of the ligature is seized at the eye of the needle and drawn out of the anus, while the needle retraces its course, thus depositing a double uncut ligature, one end hanging by the anus, the other lying in the primary incision. A sufficient number of ligatures are thus deposited, at equal distances from each other, to include the entire circumference of the gut. A strong whipcord, about six feet in length, is now passed through the loops banging from the anus, leaving an interval of about ten inches be- tween each loop. The ligatures are then drawn outward by seizing the extremities in the external cut, thereby drawing the whipcord through the openings made in the bowel by the receding ligatures. Each loop of the whipcord is allotted in turn to an ecraseur, and the portion of the rectum included by it is cut through. Results.— The rate of mortality following this operation is from twenty to twenty-five per cent. The operation is a proper one, under favorable conditions, and will pro- long the life of eighty per cent of the patients, and effect a cure in a small proportion of them. Stricture of the Rectum.—Ordi- narily a stricture of the rectum is treated upon substantially the same principles as a stricture of the ure- thra : the repeated use of rectal bougies passed in the direction of its curvatures ; nicking its edges with a probe-pointed knife ; divul- sion, elastic distention, rectotomy, and, finally, if the stricture be high up, colotomy. Imperforate Rectum (Fig. 634). Fig. 634.—Imperforate rectum. __This form of occlusion varies iu OPERATIONS ON TIIE ANUS AND RECTUM. 415 thickness, and is usually situated within half an inch of the anus, which is normal. If the structure be thin, it will be influenced by the emotions of the child and depressed by the superimposed fecal accumulations. Operation.—A radi- ating incision, with its center corresponding to that of the obstruction, can be made through the tissues, the contents of the gut evacuated, the flaps trimmed off, and the opening main- tained by the occasional introduction of a well- oiled bougie. Some- times the occlusion is so thick as to raise the question as to the pres- ence or absence of the gut above. The sig- moid flexure may term- inate in a blind point, while the rectum below is marked by an impervious cord (Fig. 635). An attempt should always be made to find the blind extremity, which is done by intro- ducing a sound into the bladder and carefully seeking, by aid of the scissors and finger, for the cul-de-sac above. In doing this, the established relation which the rectum bears to the curve of the sa- crum must be carefully regarded, and the fibrous trace of the rectum sought after. If the abdomen of the patient be pressed upon, any existing tumor above will be made more distinct and tense. If the cul-de-sac be found, the diagnosis should be still further strength- ened by exploring it by means of a hypodermic syringe or a small aspirating needle carried into its posterior aspect. If fecal matter or offensive gases be detected, the blind extremity of the gut is drawn carefully downward toward the external opening, and held in this position by forceps or by a loop of thread passed through its apex while it is opened carefully, the incision into it being guided by the exploring needle, which is allowed to remain for that purpose. After the contents are evacuated and the parts are thoroughly cleansed, a sponge with a string attached to it is pushed up the bowel to prevent any further escape of fecal matter while the extremity of Fig. 635.—Rectum ending in blind pouch. 416 OPERATIVE SURGERY. the bowel is being sewed to the surface below—if practicable, to the cutaneous border. When this step is impracticable, the after-treat- ment should be the same as that following excision of the rectum. If the extremity of the bowel be not found, colotomy must be per- formed. Not infrequently the rectum communicates with the bladder, and even the glans penis, conditions which are determined by the fecal character of the urine. In these cases the bowel should be sought for, and, when found, drawn down and stitched as before, and the fecal canal kept open by the frequent introduction of a well-greased finger or a suitable bougie. The fistulous openings are closed with catgut, suitable drainage provided, and the contents of the bladder evacuated at short intervals, to prevent its distention during the heal- ing process. CHAPTER XVI. OPERATIONS ON THE URINARY BLADDER. The cavity of the bladder may be explored by catheters, sounds, and searchers; its outer surface by rectal and abdominal palpation. Catheters can be practically divided into the soft rubber, silk, gum- Fig. 636.—Mercier's Fig. 637.—Mercier's Fig. 638.—Self-re- Fig. 639.—nolt'a double elbowed elbowed catheter. taining catheter. self-retaining catheter. catheter. elastic, aud metal varieties. The first two varieties are extremely flex- ible, and are most innocent instruments in the clumsiest hands (Figs. OPERATIONS ON THE URINARY BLADDER. 417 636, 637, 638, 639, 642, and 643). It is sometimes necessary that a soft rubber catheter be provided with a guide in order to properly direct it as well as to overcome any slight impediment in its course (Figs. 640 s and 641). The gum-elastic and metal instruments are too fa- miliar to all to require a de- scription, except such of them as have been especially modified for distinct purposes. Introduction of a Catheter or Sound into the Bladder.—Select an instrument of a suitable curve and size ; place the pa- tient on the back, with the shoulders somewhat raised, and the thighs slightly flexed on the abdomen, and rotated outward to relax the abdominal muscles ; warm and smear the instrument 6 Fig. 640.— Fig. 641.—Otis' Keyes' catheter-guide. catheter- guide. Fig. 642.—Oli- vary gum cath- eter. Fig. 643.—Velvet-eye catheter. with oil or vaseline ; stand on the left side of the patient; grasp the penis with the middle and ring fingers of the left hand and raise it vertically. The catheter or sound is then taken lightly between the thumb, index, and middle fingers of the right hand and introduced into the meatus, held open by the left index-finger and thumb. The instrument and penis should now be carried close to the body in the 27 418 OPERATIVE SURGERY. line of the groin. The penis is then gently drawn over the instru- ment, which at the same time is carefully pushed, or allowed to enter by its own weight, into the canal. After about five inches of the instrument have disappeared, the outer extremity should be carried toward the median line of the body of the patient and elevated slowly to a vertical position, when its weight will usually cause the advancing end to pass beneath the pubes (Fig. 644), after which the upper extremity is depressed between the thighs, causing the point to enter the bladder (Fig. 645). Not infrequently the end Fig. 644.—Passing catheter. will hitch upon the triangular ligament as it passes beneath the arch of the pubes. This can be obviated by raising the point of the instrument at this situation by the finger pressed firmly against the median line of the perineum, accompanied by upward traction as the point is being advanced ; in a word, causing the instrument to hug the roof instead of the floor of the canal. The beginner is apt to carry the handle of the instrument between the thighs too soon, causing the beak to be reversed in front of the pubes. Un- OPERATIONS ON THE URINARY BLADDER. 419 der no consideration must violence be employed in introducing a catheter, ars non vis being an almost traditional axiom in this con- nection. The surgeon should always follow the advancing end of the instrument with the mind's eye, aiming to keep it in the axis of the urethral curve. The first approach of the instrument to the perineal Fig. 645.—Catheter entering bladder. portion of the urethra not infrequently causes a contraction of the muscles of this region, which interposes an effectual temporary obsta- cle to its advancement. If, however, the patient's attention be en- gaged in conversation or otherwise diverted from the procedure, while at the same time the end of the instrument is pressed continuously and carefully against the obstacle, it will soon give way and enter the bladder without further trouble. If it be a catheter, the flow of urine usually announces its entrance into the bladder. However, if the eye of the catheter be obstructed, or a sound be introduced, the exact situation of the instrument may be determined by rotating it on its long axis ; when, if the beak be in the viscus, its extremity will describe the arc of a circle around its shaft as a center; if not, then the shaft will describe a circle around its beak. If the bladder be empty or contracted, the impinging of the beak upon its walls may deceive the beginner and also cause the patient much pain. The in- troduction of the index-finger into the rectum will aid in guiding the instrument into the bladder, and determine the fact of its entrance as well. Hot fomentations to the abdomen, together with an anodyne and a ten-grain dose of quinine, should be employed if a urethral chill be feared. The injection into the urethra of a weak solution of carbolic acid and oil after the passage of the sound is thought to sometimes prevent urethral chills. 420 OPERATIVE SURGERY. Retention of Urine.—Retention of urine depends upon some ob- struction to its egress, located at the neck of the bladder, or in the course of the urethra; also upon paralysis of the muscular coats of the bladder, or upon both combined. The indications are met by overcoming the obstruction or restoring tone to the bladder. If the obstruction be due to stricture, and it be permeable, catheterization will effect ready relief. It is important to know, however, that the bladder should not be entirely emptied of its contents, but that only a sufficient amount of urine should be drawn to afford complete relief from all pain and tension. If it be completely emptied, its walls will collapse from want of support, causing conges- tion of its lining, and, in all probability, the catheter will be required at the next attempt at urination. If but a third or a half of the con- tents be withdrawn, the bladder will probably expel its contents properly at the next act of micturition. If it be impossible to intro- duce an ordinary catheter, even of a small size, recourse must then be had to the filiform bougies (Fig. 646) or whalebone guides (Fig. 647). /yosD ■» ---------------- S«t==3 -------------------------------------------------------------------- Fig. 646.—Filiform bougies. The latter are more commonly employed. The patient is placed in the dorsal position, an anaesthetic given, unless the bladder be much distended—as then there is danger of its rupturing during the strug- gles of the patient. If anaesthesia be necessary under such a circum- stance, it is advisable to relieve the bladder of some portion of the fluid by supra-pubic aspiration. If one be not v entirely familiar with the use of the whalebone guides and the retention catheter, local or gen- —--------—'v. eral anaesthesia is not advisable, as then the pa- tient's sensations can not be consulted, and great j harm might arise from their use. Vtn ,A>7 r , , Introduction of Whalebone Guides.—The ure- 1'iG. 647.—Gouley's . whalebone guides. thra is forcibly filled with sweet-oil by means ot a syringe, and the end of the penis grasped to re- tain it as long as possible, leaving sufficient room at the meatus for the introduction of a whalebone guide. The guide is carefully introduced, and if its point becomes engaged in a lacuna, it is with- drawn a little and again carried onward with a rotary motion. If it enters a false passage, it is allowed to remain there, while another guide is passed by its side. If a second enters the false passage, it is treated in a similar manner, and so on until four or six, or even more, are contained in the canal, some of which have the spiral and others OPERATIONS ON THE URINARY BLADDER. 421 the straight end foremost. Each one is then taken separately and pressed onward with or without the spiral twist, always remembering to use no force, else the small points may pierce the mucous membrane of the urethra, or enter and perforate Cowper's ducts. As soon as all the side openings are closed by the extremities of the guides, one guide will be found to have entered the stricture, and with a little coaxing will pass into the bladder, which is known by the painless ease with which it can be moved in and out. The others are then withdrawn, and the end of the one remaining is passed through the eye of a tunneled sound (Fig. 648), or, what is better, the tunneled catheter (Fig. 649). This guide serves to direct the passage of the instrument into the bladder, which should be done cau- tiously, as the guide may be cut by the eye of the instrument, causing it to double and lead the end of the catheter astray. The instru- ment is known to have entered the bladder if urine flows from it, or if its innermost ex- tremity can be turned from side to side. After the requisite amount of urine is withdrawn, a tunneled sound of larger size may be passed in a similar manner as the catheter, after which the guide can be taken out and an ordinary steel sound of small size carefully introduced to insure a channel of sufficient capacity to admit the ready entrance of an instrument thereafter. Aspiration of the Bladder.—The contents of the bladder can be removed by aspiration by introducing the aspirating needle into it above the pubes, at the point indicated for the passage of a trocar (Fig. 657). This, however, is a temporary measure only. The same can be said of tapping per rectum. These are important expedients to enable the surgeon to gain time for the performance of ^(Sii^^-wfl external perineal urethrotomy. Rupture of the Bladder,— Fig. 649.-Gouley's tunneled catheter and guide. Rupture OCCUrs Fig. 648.—Gouley's tunneled sound. 422 OPERATIVE SURGERY. most frequently on the posterior surface, involving the peritoneum, and allowing the urine to escape into the abdominal cavity. When the rupture occurs anteriorly, the extravasated urine infiltrates the perineum and the anterior walls of the abdomen. Free incisions to relieve the extravasation and the performance of cystotomy, together with the opening of the abdomen in the median line—laparotomy—to remove the urine contained in its cavity, are the practical operative procedures. Cystotomy.—This operation consists in opening into the bladder through the median line of the perineum, as in the median operation for stone. Place the patient on the back, evacuate the rectum, intro- duce a grooved staff into the bladder, and with a sharp knife make an incision in the median line about two inches in length, terminating about half an inch in front of the anus ; by repeated applications of the knife the staff is reached and the membranous urethra opened backward to the apex of the prostate. Introduce a small probe into the bladder by way of the groove in the staff, withdraw the staff cau- tiously, introduce the index-finger into the bladder along the probe as a guide, and distend the neck of the bladder sufficiently to cause the urine to escape as fast as it flows into the bladder. The prostatic structure must be well dilated, else it will soon return to its normal condition and require a repetition of the dilating process. The pros- tate may be incised on either one or both sides, as in lateral and bi- lateral lithotomy ; it is necessary to do so to maintain the patency of the opening for any length of time. Cystotomy is now quite frequently performed as an ultimate expedient in obstinate cystitis in both sexes. In the female the incision is made into the bladder through the vagina. Prognosis.—The operation implies about the same danger to life as the median operation for stone in the bladder. Digital Exploration of the Bladder.—This procedure is resorted to for the purpose of detecting encysted calculi, polypoid and other morbid growths, and to- settle many vexatious questions relative to the bladder cavity. It must of necessity be preceded by a prelimi- nary cystotomy. In order to properly accomplish the purposes of an exploration, anaesthesia to complete muscular relaxation is essential; the finger-tip must enter the bladder, which should be empty and be depressed by supra-pubic pressure. Instruments such as forceps, scoops, curettes, etc., of various sizes and patterns, can then be introduced into the organ to remove the offending agent. After the operation the bladder is washed out, and a large-sized cath- eter is introduced through its neck to drain it of its contents for four or five days, and the occurrence of hemorrhage carefully watched for. OPERATIONS ON THE URINARY BLADDER. 423 Prognosis.—The digital exploration of the bladder of itself im- plies no especial danger to the patient if the kidneys be sound, but cystotomy and removal of morbid growths, especially of a villous char- acter, by crushing or curetting, may, in the latter, give rise to severe if not fatal hemorrhage, or cause death from blood-poisoning. This operation is reported to have been performed frequently, but the re- sults are not sufficiently definite to enable one to estimate a percent- age, although they are such as to establish the entire justice of the measure in severe cases. Extroversion of the Bladder.—In extroversion of the bladder the anterior wall of the bladder and abdominal parietes are absent, while the posterior and inferior portion of the bladder protrudes through the opening in the abdominal wall on account of the pressure of the viscera behind it. Various measures have been attempted- to establish a more feasible channel for the escape of urine, none of which, how- ever, have afforded any practical benefit. Mr. Simon made an at- tempt to connect the ureters with the rectum, but with indifferent success. Floyd and Johnson attempted to establish a fistu- lous communication between the bladder and rectum by means of setons, but the patient died shortly after from peritonitis. The methods by auto- plasty are the most rational, and have in many instances afforded substantial 1 \, \ relief. Dr. F. F. Mau- ry's Operation. — Make a curvilinear incision, with the convexity upward, on each side, extending from the outer third of Poupart's ligament downward and inward below the scrotum to the middle of the perineum, at which point they become joined (Fig. 650). This flap, 1, is dissected upward over the scrotum to the root of the penis, which is slipped through a valve-like incision made at its base, thus permitting the urine to escape without coming in contact with the raw surfaces. A second or abdominal flap is now raised transversely across the abdomen, ex- tending upward from below the umbilicus. The lower flap, 1, is then turned upward to bring its cutaneous surface in contact with the mu- Fig. 650.—Maury's operation. 424 OPERATIVE SURGERY. cous surface of the bladder (Fig. 651, 2), and the cuticle is removed from all portions of it that are to be placed in contact with freshened surfaces. The edges of the lower flap are then beveled and car- ried under the upper flap, to which they are united by catgut su- tures. This method offers the best results in operations upon males. Bigelow dis- sected off the mucous membrane of the ex- posed bladder down to a line with the ure- ters, constructed lat- eral flaps from each inguinal region (Fig. 651, a, b), united them in the median line and above (Fig. 652), and thereby secured a perfect result. Wood's Method (Fig. 653).—This is best adapted to female subjects, and consists in mak- ing a central or um- bilical flap, a, and turning it down- ward over the blad- der, after which a flap is made from each groin, b, c, and carried inward over the everted central one and united in the median line to the other (Fig. 654). This arrangement brings the integu- mentary surface of Fig. 651.—Bigelow's method. Fig. 652.—Bigelow's flaps united. the central flap in contact with the mucous surface of the bladder, and the raw surfaces of the central and lateral flaps are apposed; the uncovered raw surface above being allowed to heal by granulation. Dr. Pancoast raised two flaps, one from each inguinal region, joined them together in the median line, and allowed the raw external surface to cicatrize. OPERATIONS ON THE URINARY BLADDER. 425 Fig. 653.—Wood's method. Fig. 654.—Wood's method. in position. Flaps Ayres covered the opening by turning down an umbilical flap with its raw surface uppermost; this surface, together with that from which it was taken, was covered by two broad flaps dissected from the abdomen at both sides, of sufficient width to fill the gap when joined together in the median line. Results.—Some fifty-five cases have been oper- ated upon by one method or another, with the sat- isfactory results of forty-three successful cases. Four were failures, and eight fatal. Puncturing the Bladder (Fig. 657).—Puncturing the bladder is done to relieve the organ from over- distention. It can be done above or below the pubes, and through the rectum. It may be performed with the ordinary curved trocar (Fig. 655), or with the aspirator, the latter be- ing the safer and more satisfactory. Above the Pubes (Fig. 657).—Place the patient Fig. 655.—Rectum trocar. Fig. 656.—Buck's rectum trocar. 426 OPERATIVE SURGERY. on the back ; outline the distended bladder by percussion ; explore the tumor with a hypodermic needle if a doubt exists as to its nature. Fig. 657.—Puncturing the bladder. Select a small straight or curved trocar, the latter being the better; make the skin tense about an inch above the pubis, and push the tro- car through the median line with its convexity upward. An initia- tory incision through the skin is often made with a sharp knife which permits the easier entrance of the trocar. An injection of cocaine may relieve the patient of the pain caused by the introduction of the trocar. Under the Pubes.—If the bladder be small and shrunken behind the pubes, or the prostate be too large to admit of the rectal puncture, the penis can be pulled downward, and a small curved trocar, with the concavity upward, passed just beneath the arch of the pubis into the viscus. Through the Rectum (Fig. 657).—Place the patient in the lithoto- my position ; introduce the left index-finger into the rectum ; locate the vesiculae seminales and base of the prostate ; place the end of the finger between the former, allowing it to rest upon the base of the prostate ; along the palmar surface of the finger, a curved trocar (Figs. 655 and 656) is then carried just above the base of the prostate, and OPERATIONS ON THE URINARY BLADDER. 427 pushed into the bladder; the canula may be tied in position, or a soft catheter substituted therefor, by passing it through the canula. The almost universal practice of using some form of aspirator, and the superiority of this instrument over the trocar, are fast consigning the latter to an honorable remembrance only. STONE IN THE BLADDER. This morbid condition is quite common, and usually is accom- panied by well-marked and characteristic symptoms. Sometimes, however, calculi of inordinate size, and with unusual asperities, are attended by only trifling man- ifestations. W^hen it is sus- pected that a stone may be in the bladder, the proof of its presence is sought by aid of a searcher. There are various patterns of this instrument (Figs. 658, 659, and 660). The one devised by Thompson is most commonly employed. It can be used for the double purpose of regulating the amount of water in the blad- der, by injection or by out- flow, thereby better accommo- dating the bladder-walls to the remaining function of this in- strument—sounding for stone. Sounding. — The time se- lected should be when the pa- tient is suffering the least from the bladder difficulty. If the patient be a child, an anaes- thetic should be given; if an adult, only when he is ex- tremely restless from the pain. Two or three ounces of a two- per-cent solution of cocaine have been employed success- fully in the bladder to relieve the pain and irritation of sounding and even of crush- ing. The urine of one or two hours collect in the bladder, or its equivalent, four or five ounces of warm water, should be injected before attempting the sounding. Fig. 658.— Fig. 659.—Lit- Thompson's tie's searcher. searcher. Fig. 660.—Gou- lev's searcher. secretion should be allowed to 428 OPERATIVE SURGERY. Place the patient on the back with the hips raised, the operator standing upon the right side. Introduce the searcher in substantially the same manner as that employed to introduce a lithotrite (page 429); then push it carefully to the posterior wall of the bladder, with the beak upward; withdraw it slightly to give easy play to the end, and then carefully turn the beak from side to side, until the lateral walls of the bladder are touched by it. This is done by rotating the instru- ment on its long axis between the thumb and finger. In this manner the whole inner surface of the bladder is examined, the instrument being withdrawn each time a sufficient distance to accomplish this object thoroughly. As soon as the beak comes in contact with the neck of the bladder it can be withdrawn. If the prostate be enlarged, the handle should be depressed, and the beak turned toward the floor of the bladder and rotated from side to side while it is being gradually withdrawn. This manoeuvre will be quite sure to detect the stone if it be lodged behind that body. If a stone be not detected, it is better to make a second and even a third examination before positively asserting that none is present. Five or ten minutes is quite sufficient time to employ at one sitting. If the presence of stone be detected, the number, size, and the proba- ble consistency should be determined. After the searching is com- pleted, apply warmth to the hypogastrium, give an anodyne along with ten grains of quinine, and keep the patient quiet. The ability to detect the "click" from small fragments by aid of the searcher is greatly enhanced by the attachment of the so-called " lithophone." This attachment can be extemporized by taking a piece of rubber tubing, twenty-five or thirty inches in length with an eighth- inch caliber ; double one end upon itself and place it against the handle of the searcher, allowing also the tubing continuous with it to lie along the handle, or push it into the open end of the handle of the searcher. The other extremity is then placed in the ear directly, or connected to it by the medium of an otoscope. The ability to detect fragments of an almost infinitesimal size is said to be thus attained. The washing process of litholapaxy may also cause the "click." Lithotrity, litholapaxy, and lithotomy are the only practical meth- ods of relief in the male. Lithotrity is the reducing of stone to fragments so minute as to allow of their easy escape with the urine through the urethra. The instruments used to effect the reduction are called lithotrites, of which there are several varieties (Figs. 661, 664, and 667). The ones devised by the ingenuity of Thompson, Bigelow, and Keyes are most frequently used. For this operation the patient should be in a good condition, and the urethra of suitable size to admit the lithotrites ; he is required to hold the urine for an hour or two, and is then placed upon the back with the pelvis elevated; the older the OPERATIONS ON THE URINARY BLADDER. 429 patient, the greater the elevation should be. An anaesthetic may be given, and should be administered if it be the intention to triturate the entire mass at one sitting; or, if the patient be irritable, or the bladder over-sensitive. Fig. 661.—Thompson's Fig. 663.—Non-fenestrated jaws. lithotrite. the right hand on the perineum, will cause it to enter this portion of the canal, when the handle of the instrument should be taken by the right hand, and allowed to fall slowly of its own weight between the thighs. If the instrument be now slightly pressed upward, its upper extremity will be found to be disengaged, and can be easily ro- 430 OPERATIVE SURGERY. tated upon its long axis. If the prostate be enlarged, it increases the length of the deepest portion of the urethra, and interposes an ob- stacle to its progress. The handle should not, therefore, be depressed so rapidly during the latter stage, and the instrument must be pushed farther upward. Under no consideration should any undue force be used. The weight of the handle is of itself sufficient, unless under proper control, to cause laceration of the soft urethral tissues. The instrument is pressed upward in the line of its entrance until it reaches the posterior wall of the bladder, unless its course be sooner interrupted by the stone, when the beak is turned from the stone and the male blade withdrawn ; then the separated blades are turned toward the stone, which is seized and fixed. The beak is now turned upward—care being taken to observe that the mucous lining of the bladder is not caught—and the fragment crushed. The blades are again separated and turned sidewise to catch the resulting fragments, which manoeuvre is continued until the sitting is completed. During the crushing, the female blade must be held firmly and remain entirely passive, and the blades should only be separated suffi- ciently to admit the stone between them. If the beak be not turned away from the stone before it is opened, the stone may be displaced by the separation of the blades. While it is true that, in a large ma- jority of cases, the plan of action just described will suffice, still, in those where the prostate is enlarged, or an excavation exists at the base of the bladder from another cause, it may become necessary to reverse the beak of the instrument, causing it to look toward the rec- tum. To do this properly, the handle of the instrument is depressed until the beak is elevated sufficiently to allow of its revolution with- out impinging upon the walls of the bladder. If the simple revers- ing of the instrument does not bring it in eontact with the stone, the beak should then be turned in various directions with care. Another manoeuvre, which in the case of small stones located behind the pros- tate will often prove successful, consists in drawing the reversed beak outward until it nearly touches the prostate, and then separating the blades by pressing the female blade backward until it strikes against the posterior wall of the bladder, the male blade being held firmly in position; raise the handle until the female blade rests lightly upon the floor of the bladder, then draw it forward to join the male blade, lightly touching the floor in its course. If a stone lies in the line, it will be touched, and, moreover, the mucous membrane will not be pinched. It is better that the blades be smooth in these reversed movements. During this antero-posterior manipulation the neck of the bladder should be carefully preserved from any unnecessary contact with the instrument. When the sitting is completed the blades must be screwed firmly together, that the instrument may be withdrawn with- OPERATIONS ON THE URINARY BLADDER. 431 out injury to the urethra. Each sitting, if without anaesthesia, should not exceed five or ten minutes; with it, a sitting can be prolonged until an ordinary calculus is reduced to fragments. The intervals of the crushing will depend upon the size of the stone, its hardness, and more frequently the effect of the crushing upon the patient. Inas- much as the conditions differ greatly, it is impossible to lay down Figs. 667, 668.—Keyes' modified blades. 432 OPERATIVE SURGERY. any stereotyped rules. Fig. 669.—Thompson's washer. The surgeon should not repeat the operation until the subsidence of the irrita- tion produced by the previous at- tempts. Villous growths of the bladder, and deformities which in- terpose a mechanical obstruction, are the principal contraindications to lithotrity. After the completion of the sitting the patient is given an anodyne, and hot fomentations are applied to the abdomen, and he is caused to remain in the recum- bent posture for twenty-four hours subsequent to the operation, even to the extent of lying on his side during micturition. Results.—The rate of mortality is about eleven per cent. Rapid Lithotrity, or Litholapaxy.—The crushing and washing out of a stone at a single sitting has supplanted the ordinary lithot- rity. Fig. 670.—Bigelow's washer. The instruments usually employed in this procedure are the litho- trites of Thompson or Bigelow, as shown in Figs. 661 and 664, the latter being in common use. The blades of lithotrites differ in their grinding surfaces from a simple roughening to a well-marked denticu- OPERATIONS ON THE URINARY BLADDER. 433 lation. The blades of Bigelow's instruments present appearances pe- culiar to themselves (Figs. 665 and 666). The instrument used by Fig. 672.—Otis' washer, inverted. Dr. Keyes is of a stronger pattern than is usually employed, provided with a large wheel at the end, that a greater force quickly applied. The blades are fenestrated (Figs. 667, 668), and are so constructed that they can not clog. The operator should possess lithotrites of two or three sizes and of different patterns, to enable him to comply with the demands of in- dividual cases, as modified by the hardness and size of the stone, size of the urethra, etc. For crushing large and hard stones, a fenestrated blade should be employed. If the stone be small and friable, the blades may be roughened only, with the 28 and is may be Fig. 673.—Bigelow's evacuating 434 OPERATIVE SURGERY. male blade much the smaller. A non-fenestrated or " scoop " litho- trite can be used to crush the smaller fragments. The larger and harder the concre- tion, the stronger should be the in- strument employed. In addition to the in- struments for crush- ing, the operator must be provided with an evacuator or washer. The Thompson washer is admirable (Fig. 669), and the latest pattern by Bigelow leaves but little to be desired in this respect (Fig. 670). Otis' washer is sim- ple, cheap, and effi- cient (Figs. 671, 672). The evacuating- tubes of Bigelow (Fig. 673), or their modifications, com- plete the outfit. The spiral-tipped tube of Warren (Fig. 674) and the straight, open-ended one of Keyes (Fig. 675), are thought to fa- cilitate the discharge of the detritus, while in the latter instance es- pecially the lining membrane of the urethra is not exposed to injury from a fragment lodged in the eye of the instrument during its with- drawal from the bladder. The size of the tube commonly employed varies from 16 to 18, English scale. The contraindications to the operation are of a limited number. It is not admissible, if the bladder be sacculated and affected by cystitis, or if it be ulcerated, or intolerant of the presence of instru- ments. Repeated and severe chills following the introduction of in- struments into the urethra and bladder contraindicate the operation. If the organ contain morbid growths, or, if the patient be feeble, es- Fig. 674.—Warren's spiral-tipped evac- uating catheter. Fig. 675.—Keyes' straight tube and guide. Fig. 676.—Keyes curved tube and guide. OPERATIONS ON THE URINARY BLADDER. 435 pecially if the stone be large and hard, crushing should not be at tempted. The preparatory treatment consists in alleviating all symptoms de- pendent upon the existence of the stone, and in preparing the urethra for receiving the instruments by increasing its size if necessary, and subduing any undue sensibility of it. Operation.—An assistant, besides the one to administer the ether, must be present to empty the washer and adjust it. The bladder should contain four or five ounces of fluid, which condition is best obtained by causing the patient to retain the urine for two or three hours prior to the operation; or, if it be empty, a similar amount of tepid carbolized water must be injected. If the contents of the bladder be offensive, empty it and wash it out with a tepid solution of borax, a drachm to the pint, before beginning the opera- tion. The patient is placed on the back, complete anaesthesia secured to insure perfect quiet, pelvis elevated, thighs slightly flexed and rotated outward. The method of introduction of the lithotrite, and the process of catching and crushing the stone, are similar in this operation to the ordinary method, except that the crushing process is interrupted by the introduction of the evacuating catheter as soon as the stone is well broken. This may be within five or ten minutes after the intro- duction of the lithotrite, depending, of course, upon the success at- tending the efforts of the operator. A well-oiled evacuating catheter is then passed down to the prostatic urethra, and the washer is at- tached while it is in this situation to avoid the entrance of air into the bladder. The air in the catheter while it is thus located will, if water be forced gently into it, pass upward through the water in the washer and remain in the air-trap above, after which the evacuating- tube is carried on into the bladder. If, now, the elastic, half-filled bulb be alternately compressed and expanded, the changing current thus produced will wash the fragments from the bladder, and their weight will precipitate them into the glass receiver beneath. If all the fragments be not removed—which can be ascertained by the intro- duction of a searcher—the process of crushing is again resorted to, and the resulting comminutions treated as before until the entire stone is removed. The last fragments not infrequently elude the grasp of the instrument, and, were it not that they can be heard to strike the evacuating catheter when the water is drawn upward, their existence might not be known. If the curved tube be used, the beak should be turned from side to side to present its eye to different aspects of the bladder, while the square-ended tube of Keyes is passed just beyond the neck of the bladder, and its exter- nal extremity is well lowered between the thighs. It is better some- 436 OPERATIVE SURGERY. times to allow these fragments to remain until the patient has re- covered from the operation, and then seek for them again, than to continue indefinitely the attempt to secure the last one at the first sitting. Very small fragments which escape detection are not infre- quently passed with the urine within four or five days after the oper- ation. The limit of time to which the first crushing may be prolonged is not an arbitrary one ; an hour or two is not unusual, and even a longer time may be employed. However, an hour is a safe rule to adopt. After the operation the patient is kept quiet in bed and well wrapped ; if retention occurs, it is relieved by a catheter. Sequels.—Litholapaxy has various sequels —rigors, retention of urine, cystitis, impaction of stone in the urethra, pyaemia, atony of the bladder, suppression of urine, etc.—all of which should be treated on general principles. Under ordinary circumstances the patient will be up and around at the end of a week or ten days. Results.—The rate of mortality is about three and one half per cent. Combined Crushing and Evacuating In- strument.—The idea of the possible utility of such an instrument suggested itself to me some time since, after a somewhat annoying effort on my part to seize the " last fragment," the existence of which could be easily and quickly demonstrated by the characteristic click against the eye of the evacuating cath- eter during the washing-out process. I also recalled the fact that, on other occasions, the suction-force of the washer had been tempo- rarily arrested by the closure of the eye of the evacuating catheter by a fragment of calculus. The male blade of an ordinary lithotrite is modified to fit the anterior or concave wall of the ordinary evacuating catheter, which is lined with a brass tube. The washer can be easily connected with the catchers of the in- strument, as shown by the cut (Fig. 677). It is not expected that this instrument can supplant the lithotrite. The idea is to crush Fig. 677.—The author's ^ • , ,, „ , . , -, ■• » ,, „ i;fi, combined instrument the stone at the first introduction oi the ntn- OPERATIONS ON THE URINARY BLADDER. 437 otrite as effectually as practicable, and to introduce the combined instrument instead of the ordinary evacuating catheter. By means of this the detritus is removed from the bladder, and such of the re- maining fragments as are caught in the throat of the instrument are crushed and likewise removed. It thus becomes possible to avoid the interchange of instruments incident to repeated crushings. With an assistant to manipulate the washer, the operator can devote his entire attention to crushing the fragments caught in the throat of the instrument. When applied to an extemporized bladder it worked admirably, and seemed to require only the perfecting influences of repeated and practical applications to create for it a place among the recognized appliances for the performance of litholapaxy. Perineal Lithotrity.—A stone may be crushed by gradual or rapid lithotrity through an opening in the perineum. Perineal lithotrity has, as yet, been rarely adopted as a primary method of treatment. Fig. 678.—Dolbeau's method, first step. but rather as an expedient to facilitate the removal of a stone too large to be removed through the incision made for the purpose of a simple lithotomy. It has been advocated as a substitute for lithotomy, because the crushing and the use of the washing apparatus can be 438 OPERATIVE SURGERY. Fig. 679.—Dolbeau's method, second step. substituted for the incision through the deeper parts. Still, the with- drawal of an ordinary sized stone can hardly compare, in point of Fig. 680.—Dolbeau's method, third step. 99 OPERATIONS ON THE URINARY BLADDER. 439 danger, to the repeated introduction of instruments and the necessary prolongation of the operation of crushing through an open wound. However, it is, without doubt, an expedient which should be more fre- quently adopted, especially for the removal of large stones through an opening too small to admit of their safe withdrawal. Fig. 681.—Gouley's lithoclasts. Professor Dolbeau systematized this method. The incision is made through the perineum, as in median lithotomy, after which the dilata- tion is divided into three steps, the dilator of Mr. Dolbeau being emploved The first step consists in the dilatation of the tissues down to the groove in the staff (Fig. 678) ; the second, the dilatation of the tissues nearly through the neck of the bladder (Fig. 679); 440 OPERATIVE SURGERY. third, the withdrawal of the staff and carrying the dilator in suffi- ciently to thoroughly dilate the neck of the bladder (Fig. 680). The dilatation in all the steps must be done carefully, and in ac- cordance with the resistance encountered. After it is completed a lithoclast (Fig. 681) of suitable size is introduced, and the stone fragmented, after which it comes away with the urine. A small reverse current of carbolized water thrown into the bladder will wash the fragments out. The results, while very satisfactory, are not equal to those of litholapaxy. Lithotrity in the Female. —The absence of the prostate body, and the shorter and larger urethra of the female, combine to secure a more complete emptying of the bladder, and also lessen the liability in the female to the formation of vesical calculi. A stone in the female bladder can not be grasped with the same facility as that in the male, owing to the difference in the normal shape and sur- roundings of the bladder, and to the pathological modifica- tions to which its cavity is subjected, due to its connec- tions with the uterus and va- gina, and their physiological and pathological variations caused by child-bearing and its sequels. The greater lia- bility to a sacculated base requires that the instrument be reversed more frequently than in the sterner sex. The operation can, however, be readily per- formed, and, aside from the slight variations in the manoeuvres neces- sary to catch the stone, differs but little from that in the male. Lithotomy.—Lithotomy is the operation for the removal of stone from the bladder by cutting. The varieties of incision in common use Figs. 682, 683.—Dolbeau's dilator. OPERATIONS ON THE URINARY BLADDER. 441 are classed as the lateral, median, and bilateral, together with the occasional employment of the supra-pubic method. Lateral Lithotomy.—-Lateral lithotomy is employed in preference to the median, when the stone is too large to be easily removed through Fig. 687.—Blunt gorget. Fig. 688.—Scoop and conductor. the dilated prostate. The instruments necessary for the operation are a staff of suitable size, with the proper curve and a deep groove upon its convexity which approaches its right lateral aspect as it nears the extremity of the beak (Fig. 684); a bistoury with a stout blade and handle, a solid shank, a sharp point, and a cutting edge of about two inches in length ; a probe-pointed knife—the one devised by Bliz- ard being the best—and, if the perineum be deep, due to obesity, the gorget may be selected ; forceps of various sizes and shapes to seize the stone, one of which should be arranged with crossed handles to avoid stretching the parts about the neck of the bladder when the stone is grasped. It is likewise well to be provided with a small lithoclast, for the purpose of breaking those stones too large to be extracted with 442 OPERATIVE SURGERY. safety ; a scoop to dislodge the remaining fragments of stone (Fig. 692), and a syringe to wash from the bladder any small fragments that Fig. 689.—Straight Fig. 690.—Curved Fig. 691.—Dol- Fig. 692.— forceps. lithotomy forceps. beau's lithoclast. Luer's scoop. may remain (Fig. 693). Davidson's syringe can be used, but is less satisfactory than one designed for the purpose. The chemise or shirted canula (Fig. 694) is useful to control hemorrhage. At least five assistants should be present. To one of these the staff should be intrusted ; the lower limbs may be held by two others, either with or without the limbs being confined by the anklets (Fig. 695). The hands and feet may be bandaged together satisfactorily for the pur- pose. Of the remaining assistants, one should attend the instru- ments, and the other the sponges, etc. The more modern device for separating the lower limbs and exposing the perineum will be of great service (Fig. 696). Operation.— Shave and disinfect the parts, empty the rectum with OPERATIONS ON THE URINARY BLADDER. 443 an enema, administer an anaesthetic, draw the patient down to the edge of the table, and confine the extremities. The staff is then in- troduced and the stone found ; a diagnosis which should be verified by others present. If the stone be not detected, the staff should be withdrawn, and its presence and location determined by the searcher. These points must likewise be confirmed by others. If the stone be not found at all, the operation must be deferred. The principal as- sistant, who holds the staff, should sat- isfy himself that the sound touches the stone, although it is not necessary that it be pressed against it during the opera- tion. The holder of the staff should stand at the patient's left and press it firmly beneath the pubes with the right hand, while the integu- Fig. 693.—Van Buren's debris syringe. 694.—Chemise cath- eter. ment of the perineum is made tense by drawing up the. scrotum with the left. The convexity of the staff is easily felt in the perineum. If the perineum be thin the groove may be distinctly defined. Some sur- geons have advised that the staff be pressed against the perineum instead of the pubes, to bet- ter define its out- line. However, it is a matter of little importance which course is taken, so long as the pubes Fig. 695.—Pritchard's anklets and wristlets. 444 OPERATIVE SURGERY. is hugged by the instrument while the incision is being made into the bladder. The surgeon should sit upon a low stool, and, before begin- ning the incision, carefully map out the location of the bulb, and the point where the incision is to begin, also determine the outlines of the rami and tuber ischii. He then introduces the index-finger of the left hand into the rectum, locates the apex of the prostate, and determines its relations to the sound. The finger is withdrawn, disinfected, and the groove in the staff again located. The incision is commenced a little to the left of the median raphe, from an inch and a quarter to an inch and a half in front of the anus. The point of the knife is made to enter the groove at the second or third cut, being guided by the nail of the in- dex-finger of the left hand. The perineal incision is made from three to three and a half inches in length, and carried obliquely downward, midway between the tuber ischii and the verge of the anus (Fig. 708, b). The urethra is then freely opened, and the probe-pointed bistoury substituted for the scalpel; or, the blunt extremity of the Blizard's knife is engaged in the groove—when, the surgeon, taking the han- dle of the staff in the left hand, lowers it somewhat, and holding it firmly carries the knife toward the bladder, depressing its handle OPERATIONS ON THE URINARY BLADDER. 445 slightly to correspond to the curve of the staff. If he>were to push the knife downward and backward without depressing its handle, the point would leave the staff and pass behind the bladder, a fact which would not be discovered until the withdrawal of the knife and the at- tempt to pass the finger into the bladder. As soon as the end of the knife is stopped by the termination of the end of the groove in the staff, its handle is depressed, the edge turned still more, and the deep tissues severed from within outward by its withdrawal, care being taken to make the incision through the prostate more horizontal than that of the perineum (Fig. 697). The flow of urine which follows assures the operator of successful entrance to the bladder. It is recommended to press the point of the scalpel firmly against the groove in the staff with the right hand, seize the staff with the left, depress the handle of the staff and the knife at the same time, to the same extent, and thus convert them for the moment into one in- strument which is pushed into the bladder. This course is often fol- lowed, and will prevent the escape of the point of the knife from the groove. It is more difficult, however, to properly lateralize the knife in its passage through the pros- tate in this than by the former method; besides, it is much less elegant. The purified in- dex-finger of the left hand is now passed carefully into the bladder along the staff, which is then withdrawn. The neck of the bladder is dilated by the finger, the stone reached, and its diameter estimated, if it has not been done before. If it exceeds an inch in diameter, the right side of the prostate should be nicked by introduc- ing a knife along the finger. The forceps are now passed in as the finger is withdrawn, and the stone carefully grasped in the short diameter. If one blade of the forceps be pressed upon the floor of the bladder, and the instrument opened, the stone will often roll properly within its grasp. However this may be, un- usual caution must be employed not to bruise the contracted walls of the empty viscus. If the stone be grasped in its long axis it should be dropped and the direction corrected by the finger carried into the bladder The change in direction may sometimes be accomplished by Fig. 697.—Lateral incision of prostate. 446 OPERATIVE SURGERY. carrying two^ fingers into the rectum, separating and pressing them upward against the bladder, thereby compressing its sides and creat- ing a furrow running antero-posteriorly, into which the corresponding long axis of the stone will drop. When properly grasped it is with- drawn by steady traction made in the line of the incision through the perineum. Lateral movements can be made with direct traction. If inordinate traction be deemed necessary for its removal, it should be crushed, after which it can be easily extracted. Too great traction may tear off the neck of the bladder, or lacerate the tissues beyond the limits of the prostate; still, tearing is safer than extensive cut- ting, since the plexus of veins is less liable to be injured by it. As soon as the calculus is removed, its surface is examined for facets, which indicate the presence of still one or more calculi in the bladder. Having removed all the calculi, irrigate the bladder with tepid car- bolized water to remove all blood-clots and whatever detritus may be present. If earthy matter exist in the bladder, it may be necessary to remove it with a scoop. If the stone be encysted, it is very difficult and often impossible to remove it. It may be grasped with the for- ceps with or without nicking the confining structure ; in either in- stance great care and judgment must be exercised. If arterial hemor- rhage occur, it may be checked by ice-pressure, by the devices pre- viously illustrated, or by the ligature ; if these fail, the serrefine forceps (Fig. 54) may be clasped to the bleeding point and allowed to remain. The tying in of a tenaculum, or acupressure, will check it; venous hemorrhage may be controlled by the chemise catheter or some other similar expedient. After the operation place the patient in bed with a rubber cloth beneath the hips, separated from the body by cloths, to collect the urine and indicate the occurrence of hemorrhage. The temporary introduction of a catheter or drainage-tube into the blad- der through the wound in the perineum is not commonly practiced. Give light and stimulating diet, alkaline drinks, and treat all sequelae on general principles. Results.—The rate of mortality ranges from six to ten per cent. OPERATIONS ON THE URINARY BLADDER. 447 The operation just described is the one usually employed. There are, however, instrumental modifications which, in the opinion of some, may deprive it of the little danger that may arise even with a care- ful adherence to the details. The instrument devised some years ago by Dr. Smith, of Baltimore, and successfully employed by him and others (Fig. 698), is worthy of mention. It consists of a rectangular staff with a well-rounded angle, and is deeply grooved on its horizontal portion, and provided with an indicator attached to the shaft by means of a hinge. The indicator is likewise rectangular and ter- minates in a lance-shaped blade. The indicator can be adjusted by sliding it up and down the staff; or various sizes of the instrument may be employed to meet indi- vidual differences. The staff is introduced and held by an assistant in the usual man- ner, and the cutting extrem- ity of the indicator is ap- plied to the median line and pushed through the tissues, until it lodges in the groove of the staff. The probe- pointed gorget is then passed into the groove and lodged in the channel on the staff, along which a cut is made into the bladder. A probe- pointed bistoury may be sub- stituted for the gorget. The single and double lithotomes (Figs. 699 and 700) have their advocates. They are, how- ever, in a small minority when compared with the number of adherents of the scalpel and grooved staff. Median Lithotomy.—Me- dian lithotomy is applicable to cases having one or more small stones half an inch or so in diam- eter, and in advancing puberty. In this method there is less danger from hemorrhage, much better control of the urine from the first, and the wound heals rapidly. If the stone be larger than was anticipated, Fig. 699.—Dupuytren's double lithotome. Fig. 700—Hutchinson's lithotome. 448 OPERATIVE SURGERY. the temptation to use violence during the extraction is great. It is claimed that this method may be followed by stricture of the urethra, ^ Fig. 701.—Little's lithotomy staff. Fig. 702.—Mar- koe's staff. Fig. 703—Rectangu- lar staff. and also that the mouths of the seminal ducts are more likely to be injured than by the other methods. The general precautions to be employed in all q forms of lithot- omy are men- tioned more fully in connection with the lateral opera- tion. Fig. 704.—Little's director. The instruments required are the staff, director, and knife. The staffs vary somewhat in the shape and depth of the grooves. The OPERATIONS ON THE URINARY BLADDER. 449 ones devised by Drs. J. L. Little (Fig. 701) and T. M. Markoe (Fig. 702) leave nothing to be desired. The rectangular variety (Fig. 703) can be used in lieu of the curved one, although it is rarely employed in this country. The director devised by Dr. Little is an admirable instru- ment (Fig. 704), but is by no means essential to a successful operation. Fig. 705.—Little's lithotomy bistoury. A stout, straight, sharp bistoury, double-edged at the point (Fig. 705), for making the perineal incision, makes the especial outfit complete. Operation.—Confine the patient in the lithotomy position (Fig. 696) ; intro- duce the staff, placing the end of the beak in contact with the stone ; pass the left index-finger into the rectum, and locate the apex of the prostate just where the staff enters it; introduce the point of the knife into the median line of the perineum half an inch in front of the anus (Fig. 708, a), with the long cutting edge uppermost, and push it carefully upward to the apex of the prostate, guided by the finger in the rec- tum, into the groove of the staff. The knife is advanced sufficiently toward the bladder to nick the apex of the prostate, after which it is carried forward to di- vide the membranous portion of the ure- thra. The external incision should be from one and a quarter to one and a half inch in length, care being taken to avoid the bulb of the urethra. The director is then passed into the bladder along the staff, and the neck of the bladder moder- ately dilated by separating the two. The staff is then withdrawn, and the index- finger of the left hand carried* through the neck along the director with a semi- rotary motion to complete the dilatation. The forceps are then introduced, the stone caught at its short diameter, and removed by steady, gradual traction, which may be accompanied by rocking movements, but never by a ro- tation of the instrument on its long axis while grasping the stone. 29 Fig. 706.—Wood's staff and bisector. 450 OPERATIVE SURGERY. Various instruments have been devised to dilate the prostate in this and other methods calling for the procedure (Figs. 682 and 683), all of which an- swer the purpose well, but are by no means essential Fig. 707.—Wood's bisector. to the safe per- formance of the operation. After the removal of the stone, stop all hemorrhage, seek for any remaining calculi, wash out the bladder, place the patient in bed with the limbs extended, administer an anodyne, and maintain quietude. Bilateral Method.—The preliminary preparations, the precautions, and general arrangements in this are similar to those necessary in the other methods. The special instruments are the grooved staff, and the bisector, so intimately associated with the name of the late Prof. James R. Wood (Figs. 706 and 707). Operation.—Make a semilunar incision across the perineum, three fourths of an inch in front of the anus, beginning midway between the anus and the tuberosity on the right side, and terminating at a similar point on the opposite side (Fig. 708, c). The convexity of the cut is directed forward. The several tissues are divided down to the membranous ure- thra, which is opened and the beak of the in- strument inserted in such a manner as to cause the beveled edges of the bisector to be up- permost. After moving the beak backward and forward, to be certain it Fig. 70S.—External incisions in perineal lithotomy. is well lodged in the groove, it is then firmly pressed against the groove of the staff, and, with the staff held firmly, it is carried into the bladder. They may be, practically, converted into a single instrument by pressing them firmly together and carry- ing them both in at the same time, being careful to depress the handle of each to the same degree. Fallacies.—The bisector may be carried behind the bladder if any tissues exist between the groove and its probe-pointed extremity, or if the handle be not depressed to conform with the long axis of the staff. The anterior wall of the rectum may be cut. Avoid this accident by OPERATIONS ON THE URINARY BLADDER. 451 inserting the index-finger of the left hand into the bowel when the primary incision is being made, and drawing the anterior wall back- ward while the cut is being completed. TJie results obtained by this method in the hands of Dr. Wood were equal to, if not better than, those previously given in connection with the other methods of cutting for stone. Nelaton's Modification.—Nelaton modified the first step of the bilateral method, with the view of lessening the danger of cutting the bulb and the wall of the rectum. He introduced the left index-finger into the rectum, placed the end of it against the apex of the prostate, and steadied the anterior border of the anus with the thumb of the same hand. He then made a semilunar incision in front of the anus, the extremities of which were four fifths of an inch from the opening, and the greatest convexity three fifths of an inch from it. The dissec- tion was continued, layer by layer, the wall of the rectum and the bulb being carefully avoided, until the membranous urethra was reached and opened, and the cutting instrument introduced. The same object was accomplished through a transverse incision an inch and a quarter in length, with its center located three fifths of an inch in front of the anus. Medio-Lateral Operation.—This method was devised by Buchanan, of Glasgow. The instruments necessary are a rectangular staff with a broad groove in its left side, and a narrow, straight knife with a long edge. The staff is introduced, and the prominent staff-angle adjusted to cor- respond to the muco-cutaneous junction on the anterior verge of the anus in the median line. The instrument is then firmly held with the handle inclined toward the abdomen, and the tissues are penetrated by the knife, held horizontally and with the edge turned to the left, until the groove in the staff is reached (Fig. 709); then the knife is pushed forward into the bladder upon the staff. As it is withdrawn, an incision three fourths of an inch long is made downward and outward toward the fore part of the tuber ischii. This incision is completed by being continued directly downward about half an inch. If necessary, it can be extended. Results.—A little over ten per cent are reported to have died after operations by this method. Fig. 709.—Medio-lateral method. 452 OPERATIVE SURGERY. Medio-Bilateral Operation. —This method was brought to the notice of the profession by Civiale, and has since been championed in this country by Dr. W. F. Briggs, of Nashville. The staff for the median method is introduced with the patient placed in the usual position ; the rectum is drawn backward by the finger, and an incision made through the median line into the staff an inch and a half in length, beginning about half an inch in front of the anus. The lithotome (Fig. 710, a) is then introduced into the groove, car- ried into the bladder, the blade expanded half an inch, and the instru- ment withdrawn, enlarging the wound on either side a quarter of an inch throughout. The wound is then dilated and the stone removed in the usual manner. If too large, it may be crushed. The author has modified Briggs' instrument somewhat by introducing an inde- pendent guiding stem, which leaves the cutting blades uninterfered with during the withdrawal of the instrument from the bladder (Fig. 710, b). Results.—Prof. Briggs reports his mortality as at the rate of one in thirty-seven cases operated upon. These are certainly astonishing results. Supra-Pubic Lithotomy.—The supra-pubic or high operation was done first by Frere Come, about 1560. Since this time it has found favor at several epochs, and is now again being strongly advocated by prominent surgeons. The various relapses of the method depended, without doubt, more upon the determination of its exponents to make it an exclusive operation, than upon its own intrinsic defects. The following are a few of the many conditions said to call for this method : Great prostatic hypertrophy; inability to extract the stone through the perineum on account of its size ; encysted stone, large stone with a contracted bladder surrounding it firmly; imper- meability of the urethra. The practical objections to it may be limit- ed to these two—operation on an obese patient, and one with a con- tracted bladder containing a small stone. The possibilities of urinary extravasation—which is rare—and of cutting the vesico-abdominal reflection of peritoneum, are the practical dangers. OPERATIONS ON THE URINARY BLADDER. 453 Operation.—Place the patient on the back, and anaesthetize to complete insensibility to overcome the contractility of the bladder. This is first washed out, and then moderately distended with a warm four-per-cent solution of boric acid. The amount injected will de- pend on the capacity as well as the irritability of the organ ; usu- ally six or seven ounces will suffice. The rectal balloon is next introduced—the ordinary colpeurynter will do—and distended with warm water sufficiently to raise the bladder well above the pubes. An incision three or four inches in length is then made in the median line, commencing just above the pubes. The various tissues are divided down to the linea alba, which is cut through and the interspace between the pyramidal muscles is sought for. If it be not found, the muscular fibers should be separated, when the fatty layer on the transversalis fascia and the fold of peritoneum will make their appear- ance. Divide the fat, draw up the peritoneum with the finger, and, after passing a strong ligature through each side of the bladder and looping it, to provide a means to control the opening to be made into it, open the bladder with a bistoury, in the median line. The hemor- rhage, which may at first be severe, subsides as the bladder contracts and empties itself. Introduce the finger into the bladder and locate the stone. The forceps are now introduced into the bladder along the finger, the stone seized and removed. If it is necessary, enlarge the opening ; it should be extended downward. Examine the bladder for remaining calculi, and cleanse the wound. Some surgeons sew the wound in the bladder with catgut, carried down to but not through its mucous membrane. The abdominal wound is then closed with deep and superficial sutures, and dressed antiseptically. The bladder should be evacuated once in two or three hours during the first three days; after this it may be done less frequently and at the end of a week dis- continued. It is strongly recommended—and justly, too, it seems to me_t0 leave enough of the visceral and abdominal wounds open to admit the introduction into the bladder of a long drainage-tube, and, by keeping the patient on the side, thus avoid the use of the cathe- ter. The use of the drainage-tube is open to the objection, however, that a small amount of urine will escape beside it, in spite of the great- est care. It is also advised to sew the lips of the visceral wound to the borders of the abdominal wound, thus to surely prevent urinary extravasation. Opposed to this last plan is the possible effect—as yet uncertain—on the functions of the bladder of the union of its walls with those of the abdomen The wound should always be dressed with antiseptic care, irrespective of the method employed. The opening through the linea 454 OPERATIVE SURGERY. alba may be made with the aponeurotome (Fig. 711), or by the ordi- nary scalpel. The sonde a dart (Fig. 712) may be introduced into the bladder and its trocar pushed through the anterior wall, thus serv- ing as a good guide. The hooked gorget (Fig. 713) is useful to hold up the bladder, and keep the wound open while the stone is being removed. Results.— The rate of mortality as reported by some is about one in four. These estimates are, however, deceptive, since they relate principally to the results gained by this method when employed under unfavorable circumstances. A rate of one in eight or nine is now attained. Fig. 712.—Sonde a dart. Fig. 713.—Hooked gorget. Fig. 714.—Gross' dilator. LITHOTOMY IN THE FEMALE. Aside from the method of crushing, a stone may be removed from the bladder of the female by rapid dilatation of the urethra, or by urethral and vesico-vaginal lithotomy. The method by dilatation is performed with the aid of the finger or an instrument (Fig. 714) espe- cially designed for the purpose. A calculus an inch or more in diam- eter can be removed in this manner without unfavorable results. The operation of lithotomy is not difficult of execution in the female. OPERATIONS ON THE PENIS AND SCROTUM. 455 Operation.—Introduce a broad-grooved director into the bladder, pass upon it a straight probe-pointed bistoury, and cut directly up- ward toward the symphysis pubis. Follow the incision by dilatation, and then remove the calculus with forceps. If greater space be re- quired, the cut may be extended downward and outward toward the tuber ischii. This method is modified by combining the two preceding methods as follows : first dilate the urethra, then divide either its anterior or posterior wall as best suits the indications of the case, and remove the stone. The vesico-vaginal method consists in simply connecting the vagina with the cavity of the bladder by a longitudinal incision made in the median line of the vagina, the length varying according to the size of the stone. A grooved staff is introduced into the bladder, the position of the groove ascertained by the finger, and the tissues between the finger and the groove are divided by a scalpel or scissors. The sequel which con train dicates the vesico-vaginal method is the formation of a chronic fistula. It is claimed that the w7ound can be made to heal completely if the parts be frequently irrigated, so as to prevent phos- phatic deposits. Tepid water acidulated with nitric or hydrochloric acid will aid materially in the prevention of the deposit. A solution of the acetate of lead—one grain to the ounce of warm water—is also highly extolled for this purpose. CHAPTER XVII. OPERATIONS ON THE PENIS AND SCROTUM. Hydrocele.—This morbid condition may be treated by tapping (which is palliative), and by incision, excision, and injection. Tapping is a simple process, requiring for its performance a small trocar and canula, or an aspirating needle, or an instrument of a simi- lar nature. The patient is caused to sit upright on the edge of a chair with the limbs separated, the enlargement is seized by the left hand, and the tissues made tense on its anterior surface. The testicle is care- fully located, and the course of the scrotal vessels as carefully avoided. The instrument, guarded by the end of the finger (Fig. 715), is quickly plunged into the scrotum at about the junction of its middle and lower thirds. As the fluid escapes, the end of the canula is turned away from the testicle, and the tumor is compressed carefully to expel the entire fluid collection. After the fluid is removed the scrotum is suspended, and the patient kept quiet, otherwise inflammation of the sac mav occur, which, while it may lead to a radical cure, will not be 456 OPERATIVE SURGERY. welcome, as it causes much pain and confines the patient to bed. It will be necessary to repeat the operation in five or six months. Fallacy.—The testicle may be punctured by the trocar, unless the exact location of the fluid has been determined by transmitted light. Incision.—In this operation the sac is laid freely open on the ante- rior surface, and the wound dressed from the bottom. It heals in from four to six weeks, and is seldom followed by a return of the disease. It is of especial efficacy when it is de- sired to examine the pathological con- dition of the testicles, with the view of determining the relation of a sus- pected morbid process to the fluid collection. Volkmann incised the tis- sues under antiseptic precautions, and stitched the sac to the scrotal incis- ion. This operation, like the preced- ing one, has been followed, though rarely, by a return of the disease. Excision.—In this method a por- tion of the sac is cut away on either side of the primary incision. As a modification it allows a freer escape of the discharges, and prevents the protrusion of the rigid tunic, but otherwise makes no practical difference. The external incisions in the preceding methods may be made either long or short; the former is the better, as it affords more suitable drainage. The wounds, after all of these operations, may be treated anti- septically with most satisfactory results. Incision with Excision.—This method differs but little from the one last mentioned, and is, in my opinion, the best operative proced- ure for the radical cure of hydrocele. A long incision is made into the tunica vaginalis, under the bichloride douche, and the condition of the testis ascertained. The rigid protruding borders of the divided tunic are then excised in the direction of the long axis of the external incision, and the remaining portions stitched by catgut to the sub- cutaneous scrotal tissues at the borders of the long incision. A drain- age-tube is introduced, the scrotal wound closed, and the scrotal flaps quilted together by catgut sutures to prevent the contractions of the dartos from disturbing the union, the whole is then dusted with iodo- form, and surrounded by antiseptic gauze. Prognosis.—The wound usually heals completely, in a week or ten days, under the primary dressing, without any suppuration ; and the probability of a return of the disease is very remote. Fig. 715.—Tapping hydrocele. OPERATIONS ON THE PENIS AND SCROTUM. 457 Injection.—The fluids recommended are numerous, among which iodine, sulphate of zinc, and carbolic acid are preferred at the present time. The instrument required in the performance of the operation is the rubber injection-bag, in addition to the ordinary trocar (Fig 716) The trocar is introduced and the fluid drawn off. The Eac is then seized, together with the scrotal tissues, to prevent the escape of the extremity of the trocar from the cavity of the sac, and the medicated fluid is thrown in by means of the gum bag. If the tincture of iodine be used, it may be diluted with three or four parts of water. Three or four ounces of' the mixture is quite sufficient to come in contact with the entire surface. It should be re- tained for five or ten minutes, until the patient complains of pain, and then allowed to escape through the canula. If the pure tincture be used, a drachm or two injected in the same manner, and allowed to re- main and become absorbed, is quite sufficient. If the sac be small, fifteen or twenty drops may be thrown into it by a hypodermic syringe, without the previous removal of the fluid. If the sulphate of zinc be used, a solution composed of a drachm of the salt to the pint of water is of sufficient strength. A drachm or two of a ten- to fif- ty-per-cent solution of carbolic-acid crystals in glycerine may be injected and allowed to remain. This plan is strongly advocated at the present time by competent observers. The after-treatment in these cases consists in putting the patient in bed, suspending the scrotum, and keeping lead and opium applied to it, with anodynes to allay pain. For obvious reasons, the congenital hydrocele should not be treated radically until its communication with the abdominal cavity is closed. Accidents.—If care be not taken, the fluid may be thrown into the connective tissue of the scrotum instead of the sac. If the canula slip out after the fluid is withdrawn, a fresh puncture must be made, since the previous opening will be closed by the contraction of the Fig. 716.—Rubber bag for injecting. 458 OPERATIVE SURGERY. dartos. Suppuration, sloughing, etc., which rarely follow, should be treated upon general principles. The results following all of the enumerated methods of operation are flattering; yet failures are not unknown in the best. Castration.—Castration is an operation simple of performance and free from danger. Shave and disinfect the parts; place the patient upon the back and administer an anaesthetic. Make an incision in the long axis of the tumor, beginning just below the external abdominal ring and extend it to the lower extremity of the scrotum. The tis- sues are carefully divided on a director down to the cord, which should always be cut off short, if the operation be done for malignant dis- ease. The three arteries accompanying it should be tied separately with catgut ligatures. If any doubt exists as to their having been properly secured, the cord should be isolated and transfixed by a needle armed with a strong catgut ligature, each half tied separately, and the cord divided. If it be divided low down, each vessel can then be tied separately. In cases where it is divided high up, it must be secured before its division, otherwise it may retract and seriously com- plicate the final treatment. After the division of the cord, the testicle can be easily removed from the enveloping tissue by means of traction and an occasional use of the scissors. All bleeding is then stopped, a small drainage- tube is inserted into the lower edge of the wound, which is united by fine catgut or carbolized silk, and the wound is dressed antiseptically. If hemorrhage of the cord occurs afterward, the dressing must be removed and the wound opened, and enlarged if it be necessary in order to secure the bleeding vessels. Circumcision.—When phymosis or a simple redundancy of the foreskin exists, circumcision, or some modification of this operation, Tig. 717.—Henry's phymosis forceps. Fig. 718.—Fisher's phymosis forceps. should be performed. The instruments especially designed for the purpose consist of the variously formed clamps (Figs. 717, 718), a grooved director, and probe-pointed scissors (Fig. 719). The patient is placed on the back and an anaesthetic administered, or a cocaine OPERATIONS ON THE PENIS AND SCROTUM. 459 solution injected into the prepuce, unless a determination is expressed to endure the pain without it. The object of the operation is not to remove the foreskin so as to leave the entire glans penis exposed after fe Fig. 719.—Taylor's phymosis scissors. recovery, but to allow sufficient integument to remain so as to afford the protection characteristic of the normal prepuce. The situation of the base and apex of the glans should be determined, and with a pen or pencil an oblique line drawn corresponding to the direction of the base of the glans, about midway between it and the apex, upon the integument. The foreskin is then drawn downward, placed between the blades of the clamp, with the line just made correspond- ing to the lower border of the blades, care being taken to not include the glans in its grasp (Fig. 720). The clamp is tight- ened and the distal por- tion severed by a sweep of the scalpel. The clamp is now removed, and the integument retracts to or a little behind its previous location. The mucous membrane which still covers the glans (Fig. 721, a) is slit up on a grooved director, along the dorsum, b, and trimmed symmetrically on either side, not even with the integument, c, but near enough to it so that when it is turned over and its free borders are stitched to the skin, a vermilion border, d, at least a third of an inch wide, will be formed. Before the sew- ing is done, the mucous mem- brane should be stripped off the glans to a point behind the coro- na, after which it can be returned Fig. 721.—Steps of circumcision. and its border joined to the integ- Fig. 720.—Clamping foreskin. 460 OPERATIVE SURGERY. ument by a continuous horse-hair suture. If the mucous membrane grasps the glans too tightly, endangering the occurrence of paraphy- mosis, it must be slit on the dorsal surface up to its point of reflection, after which the borders are joined as before described. The complete division along the dorsal surface will permit the prepuce to accommo- date itself to the varying dimensions of the penis that not infrequent- ly occur during the process of healing. Another admirable method (Keyes), which is intended to meet the same indications, is represented by Fig. 722. In this the mucous membrane is not slit up, but both it and the integument are shaped to correspond to the out- lines 1, 2, 3, and 4, 5, 6, after which the former is re- flected backward and joined to the integument, so that 1 shall correspond to 4, 2 to 5, and 3 to 6. This plan does not, however, insure the same freedom as the long dorsal slit just described. If the phymosis be not at- tended by an elongation of the foreskin, a cure may be effected by slitting it upward on the dorsal surface to the base of the glans. The ear-like projections on either side are then trimmed off, and the mucous and cutaneous borders stitched to each other (Fig. 723). Cullerrier well accomplished the purpose in this con- dition by subcutaneously dividing the mucous mem- brane in three or four places by means of blunt-pointed scissors, the blunt point resting upon the glans, while the sharp one was passed between the membrane and the integument. If the prepuce be short, and the case not an aggravated one, the mu- cous lini?ig can be stretched, and even torn asunder, by introducing the blades of dressing-forceps be- tween the glans and foreskin and expanding them, after which the foreskin can be drawn backward and retained until healing is completed. In all the methods of operating, the after-treatment is di- rected to modifying the inflammation and prevent- ing the occurrence of an erection of the penis. For this purpose, cold applications, large doses of bromide of potassium, and anodynes are recom- mended. It is now a favorite method to sew the borders of the wound with a continuous suture of fine catgut, dust it with iodoform, and surround Fig. 722.— Keyes' modifi- cation. Fig. 723.—Dorsal slit. the organ with iodoform gauze. The catgut sutures are allowed to remain until ab- sorbed. In one case I now recall, local and general medication combined were not sufficient to control or hardly mitigate the tendency to erec- tion ; yet this tendency was effectually controlled by employing a OPERATIONS ON THE PENIS AND SCROTUM. 461 nurse to watch the penis while the patient slept, with instructions to awaken him at the first indication of an erection. Paraphymosis (Fig. 724).—In this condition the foreskin is im- movably lodged behind the corona glandis, so as to cause great con- gestion and oedema of the parts if not relieved (Fig. 725), and the con- dition may even termi- nate in gangrene and sloughing. The reduc- tion may be accom- plished as follows : Oil the parts well, and administer an an- aesthetic, if necessary; grasp the penis behind the constriction with the thumb and fingers of the left hand, and the glans with the tips of the thumb and fingers of the right; press the glans with the latter gradually to reduce the swelling, then draw the constriction forward with the left, while the glans is gradually forced through it with the thumb and fingers of the right (Fig. 726). If the constriction be not Fig. 724.—Paraphymosis. Fig. 725.—Results of the constriction. *f*ib Fig. 726.—First method of reduction. Fig. 727.—Second method. 462 OPERATIVE SURGERY. Fig. 728.—Third method. great, and the oedema aud congestion be slight, this manipulation will soon effect the reduction. When the part is corrugated and much swollen by long-standing severe constriction, followed by inflammation and plastic oedema, it will be found necessary to sever the constriction on the dorsal surface by a sharp-pointed, curved bis- toury. In all cases where much oedema exists, acu- puncture should be per- formed, and the fluids squeezed through the open- ings before reduction is at- tempted. Other methods of grasping the penis are rec- ommended to effect the re- duction of the foreskin (Figs. 727, 728). After reduction, thor- oughly cleanse and disinfect the parts ; place the patient in bed, with the penis resting upon the abdomen, and dress with cooling antiseptic lotions. Amputation of the Penis—Old Plan.—Place the patient on his back and give an anaesthetic, cause an assistant to retract the integu- ment somewhat, transfix the corpora cavernosa transversely by an acupressure-pin to prevent retraction of the stump, embrace the penis behind the seat of the disease by a clamp (Fig. 729) inclined slight- ly forward, and re- move the projecting portion with a large scalpel, by cutting ob- liquely downward and forward ; secure all the bleeding points, draw out the mucous membrane of the ure- thra, divide it trans- versely, and stitch it to the integument at four different points, to prevent its contraction into the canal. If the cavernous bodies bleed too freely, the hemor- rhage can be checked by acupressure. If the amputation be made too near the pubes to permit the application of the clamp, a tape or cord, carried behind the pin, may be substituted. Hilton's Modification consists in dividing the spongy body about a fourth of an inch in front of the cavernous portion, splitting it longi- tudinally, and uniting the lateral flaps to the integument as before. Fig. 729.—Bodcnhamer's clamp. OPERATIONS ON THE PENIS AND SCROTUM. 4(53 Humphrey's Modification consists in dissecting up the skin of the penis, and turning back a circular flap about half an inch in length, dividing the corpora cavernosa on a level with the attachment of the flap, and cutting the spongy body at least half an inch longer than the preceding, and attaching the integument to its extremity. If the amputation is to be made close to the symphysis, two acci- dents must be guarded against, viz., retraction of the stump and infil- tration of the scrotum with urine. If a stout ligature be passed through the fibrous sheath of the penis, a little above the point of proposed section, the first accident will be obviated. The infiltration can be prevented by dividing the scrotum entirely through, in the line of the urinary canal, and uniting the borders of the integument to those of the urethra, thus forming two scrotums, with the urinary opening between them. Extirpation of the Penis (Gouley).—Anaesthetize the patient, make a curvilinear incision on either side of the root of the penis, beginning in the median line, about one inch and a half above the level of the pubes, and ending a little below the peno-scrotal junction. The cavernous bodies are exposed and transfixed with a large knitting- needle, or with a suitable substitute ; the urethra is transfixed by a smaller one on the same plane, and the penis is amputated an eighth of an inch in front of them. After all the bleeding points are secured, the urethra is found and a grooved staff introduced through it into the bladder. A sharp-pointed scalpel is then carried through the perineum and lodged in the grooved staff, and all the tissues, in- cluding the scrotum, divided from behind forward. The urethral cut is about an inch and a half in length, and the cutaneous one three inches. The urethra is now detached from the cavernous bod- ies, and these bodies, together with their crura, are dissected away, after which the borders of the urethra are united to those of the perineal wound. CONGENITAL MALFORMATION OF THE URETHRA. The urethra may be absent or occluded ; it may be extremely small or bifid ; the external opening may be higher or lower than normal, and even double ; its walls may be deficient above or below, consti- tuting epispadias and hypospadias. Epispadias is sometimes com- plicated by separation of the symphysis pubis and exstrophy of the bladder. Hypospadias results from a deficiency in the floor of the urethra. The opening may exist in the glans or in the penile or scrotal por- tions. The first form is the most frequent and the least important. The scrotal is the next m point of frequency, and the most important of all. When the deficiency is in the anterior or balanic portion, the following operation will give satisfaction : 464 OPERATIVE SURGERY. Fig. 730.—Gouley's method. Gouley's Method (Fig. 730).—Make two longitudinal cuts, 2-3 and 2-3, far enough apart to leave ample material for the new urethra ; make 4-5 and 4-5 a fourth of an inch out- side ; remove the integument of the spaces bounded by these incisions ; leave undis- turbed the skin and mucous membrane in- cluded between the incisions 2, 3 at 1, 10; slide the loose skin at the root of the penis and of the scrotum forward, making it double upon itself until 3, 3 is brought to 2, 2, and the denuded surfaces are brought in accurate apposition, making the angle of the fold at 7, 7. The first suture is taken at 6, 6, passing through the upper flap from within (beneath) outward, and the lower flap or border, 2, 3, from without inward; before tying, pass the suture of the opposite side in the same manner; tie both, cut the ends short, leaving the knots inside the new ure- thra ; introduce sutures along the external borders, uniting 3, 5, 9 to 2, 4, 8. The newly formed meatus is trans- verse, its under lip being the fold of the skin from 10, formed by the apposition of the points 3, 3 to 2, 2. If the opening be in the penile portion, and the organ bent downward, the curve must first be relieved by subcutaneous section of the tissues while the penis is forcibly extended. If transverse incis- ions of the skin be needed to aid in overcoming the de- formity, they will be found to assume a longitudinal as- pect when the or- gan is straight- ened, and can then be united by su- tures. When the defect is in the penile portion, the following method is worthy of trial: Anger's Method (Fig. 731).—Make an incision on the left side of the penis, from the glans to the scrotum, 1, 2, half an inch from the median line, also incisions at 1, 3 and 2, 4; the flap thus formed, a, is dissected up, its base being attached near to the median line, 3, 4. A second longitudinal incision, 5, 6, is made at the right side of the Fig. 731.—Anger's method. OPERATIONS ON THE PENIS AND SCROTUM. 465 median line, near to it, and of the same length as 1, 2, with lateral incisions an inch and a half long at each extremity, 5, 7 and 6, 8. The flaps are raised, a sound introduced into the urethral groove, and the first flap, a, turned over it, bringing the integumentary portion in contact with the urethral sound. Independent sutures, each armed with a needle, are passed through the free margin of the first flap, a, and outward through the base of the second flap, b, and fastened by shot pressed around them. The remaining flap, b, is then placed upon the raw surface of the first, a, and fastened to the margin of the first incision, 1, 2. The sound or catheter is then removed, and only intro- duced thereafter to evacuate the bladder. Duplay's Method (Fig. 732).—This operation can be divided into three steps: 1, if the penis be incurved, it is straightened and a new meatus made; 2, the missing wall of the urethra is restored ; 3, the old and new portions are joined together. The penis is straightened by making transverse subcutaneous in- cisions through the restraining bands while the organ is being extend- ed ; if the integument be too taut to admit of the proper rectification of the organ, it, too, must be severed, the resulting cuts united in the long axis of the penis, and the penis confined in the corrected posi- tion a sufficient time to permit the healing of the wound before the second step of the operation is attempted. The first step is completed by freshening, and, if necessary, deep- ening the urethral groove at the situation of the proposed meatus, and uniting its raw surfaces by silver wire or carbolized silk around a sound or gum catheter as in Thiersch's method (Fig. 736). Second Step.—Two longitudinal incisions are made, 3, 3, extend- ing from the glans to near the abnormal opening, one on each side of the urethral groove, at a distance from each other equal to half the circumference of the proposed urethra, a dimension which can be ascertained by measuring the gum catheter over which the flaps are to be reflected. From the ends of these a transverse incision is made toward, but not quite to, the median line. The flaps, 1 and 2, are 30 466 OPERATIVE SURGERY. dissected up and turned inward over a gum catheter, 3 (transverse sections), and their margins fastened together in the median line by fine sutures. The outer flaps, 4 and 5, of the longitudinal incision are dissected up sufficiently to permit them to be easily drawn over the reflected ones, 1 and 2, when they, too, are united in the median line by interrupted or continuous sutures. Unite the anterior ex- tremities of all the flaps to the raw borders of the glans, thus com- pleting the anterior portion of the tube. Third Step.—Freshen the edges of the abnormal opening, 6, and unite it to the posterior extremities of the flap by a double row of su- tures. Szymanoivski's Method (Fig. 733).—Make an incision, 1, 1, near the edge of the fistula, extending half an inch beyond it; dissect up a flap bounded by the dotted line; make a curved incision, 2, 2, on the opposite side, its length being a trifle less than that marked on the dotted line upon the other side, but otherwise of sufficient width to cover the fistula and reach the dotted line when turned upon it- self ; scrape the cuticle from the flap 2, 2, and dissect it up to the edge of the fistula; arm each end of a fine carbolized silk suture with a small curved needle ; pass these two needles from the epidermic sur- face, about a quarter to a sixth of an inch apart, through the edge of the curled flap (Fig. 733, b), introducing them from within outward —corresponding to the dotted line—through the base of the flap formed by the straight incision ; after passing a sufficient number of these sutures—one every quarter inch—draw the curved flap beneath the straight one into the space formed by the separation of the latter OPERATIONS ON THE PENIS AND SCROTUM. 467 Fig. 734.—Nelaton's method. so that its edge will correspond to the dotted curved line (Fig. 733, c), and secure them over a piece of quill or cork. The inner edge of the straight flap is now united to the outer edge of the curved one, and the opera- tion is completed. Epispadias. — Epispadias results from a deficiency in the roof of the urethra. The ability to secure as satisfactory results in this as in the preceding deformity has not yet been attained. Nelaton's Method.—A ligature is passed through the prepuce, which is drawn over the end of the penis and held during the op- eration. An incision, 1 and 2, is then made along each side of the urethral gutter at the junction of the skin and mucous membrane, beginning at the prepuce and ending at the abdominal wall (Fig. 734). The external lip of each incision is dissected outward about a sixth of an inch and allowed to remain continuous with the skin ; the inner lip of each is likewise slightly detached. A third flap, 3, is marked out upon the abdominal wall, its base being located immediately above the abnormal urethral orifice, between two ver- tical incisions, which are connected above by a transverse one ; this flap should be as broad as and a little longer than the penis, and be dissected from above downward. It is then turned downward upon the dorsum of the penis, the raw surface being uppermost (Fig. 735, 3), and the cuticle forms the roof of the new urethra. The borders of the flap, h h, are now united by sutures to the inner lips of the incisions on the dorsum of the penis (Fig. 734, g g), the con- tact being made as broad as pos- sible. The abdominal flap is now re-enforced by a scrotal one (Fig. 735, //), which is limited above by a curved incision circumscribing the under half of the penis at the peno-scrotal junction, and below by a curved incision located the length of the penis below the upper one, each extremity remaining continuous with the integument on the outer surface (Fig. 735, e). Fig. 735.—Nelaton's method. 468 OPERATIVE SURGERY. This flap is dissected up, the penis slipped under it, and its raw sur- face apposed to the abdominal one already in position. The outer borders of the scrotal flap are now united to the borders of the external flaps, 1, 2, found by the primary incisions made along the urethral gutter. Thiersch's Method.—This method comprises four distinct steps, and requires several months for its completion. A fistulous opening should be established in the perineum to jier- mit the escape of the urine before any of the steps are taken. First Step.—Formation of a meatus and that portion of the canal occupying the glans. A deep incision (Fig. 736, 1) is made along each side of the urethral groove, in the glans, and the surface of the outer lips of each incision is pared, a a, 2, and they are drawn around a sound or cath- eter, brought in contact with each other, and united by sutures or hare-lip pins, a (Fig. 736, 3). Second Step.—Formation of the urethra. Make an incision through the skin and subcutaneous tissue at the edge of the urethral gutter at the right side, 3, 3 (Fig. 737); also a short transverse cut outward from each end, 3, 4. Make a second in- cision on the left side parallel with the preceding one half an inch ex- ternal to the edge of the gutter, 1, 1, and a transverse one at each ex- tremity, 1, 2, extending inward to the border of the groove. The flap, a, is dissected up, making it as thick as possible. The flap on the right OPERATIONS ON THE PENIS AND SCROTUM. 4(59 side, b, is also raised. The flap, a, is now turned over to form the roof of the new channel, its raw surface being uppermost. Several sutures should be passed through it near to its free margin, in the manner previously shown (Fig. 731), thence through the base of the flap b, and fastened by a quill or shot attachment. The flap b is then drawn across the former so that their raw surfaces are in contact throughout, and its free margin, 3, 3, joined to the outer side of the incision, 1, 1, by sutures. Fourth Step.—To close the posterior portion of the canal. This opening is closed by two flaps, one taken from each groin. The left flap is shaped like an isosceles triangle. Its base is located at the left half of the opening, and when turned downward forms the roof of the new urethra. The right flap is quadrilateral, its base being located at the right external abdominal ring ; its raw surface is placed in contact with the raw surface of the fellow, and its borders are united by sutures to all contiguous borders. After the healing is completed, the perfection of the canal can be tested by temporarily closing the perineal fistula by the finger during micturition. If sat- isfactory, the perineal fistula should be permanently closed. ACQUIRED URETHRAL DEFECTS. The walls of the urethra may suffer loss of substance, producing a fistula. The caliber of the canal may be diminished, causing strict- ure, either of which usually depends upon acquired causes. Before attempting an operation for the closure of a urethral fis- tula, the caliber of the canal should be made as near to its normal size as possible by appropriate treatment of the strictures and such other obstructions as may exist. Urethroraphy.—This operation is employed to close a small ure- thral fistula, not exceeding a fifth of an inch in diameter if it be cir- cular, and one fourth if longitudinal. If reasonable success is to be attained, it is necessary that careful attention be paid to every detail. Before beginning the operation empty the bladder, and if necessary administer an anaesthetic. Operation.—A sound is introduced into the urethra and the handle given in charge of an assistant. The edges of the opening are care- fully pared obliquely, and when completed should present a funnel- shape appearance, the apex corresponding to the mucous opening of the canal The wound is then closed longitudinally by means of a fine wire, horse-hair, or antiseptic silk, carried down to, but not through, the mucous lining ; the intervals between them being °The patient should be kept quiet and given alkaline and demul- cent drinks, and the urine drawn with a catheter. It is a wise pre- 470 OPERATIVE SURGERY. caution to inject oil into the urethra before the introduction of the catheter, to protect the cut as much as possible from any urine that might come in contact with it. Urethroplasty.—Urethroplasty is employed to close larger open- ings than those within the domain of urethroraphy. If flaps be dissected upon either side of the opening, and drawn together and joined in the median line, imperfect union is very apt to result on account of their thinness and median contact. To over- come this, it has been proposed to pass a sheet of thin rubber above the flaps to protect them from the urine during the healing process (Fig. 738). If, for this sheet-rubber, thin rubber-skin, separated from the cut surfaces by a strip of Lister gauze, be substituted, the irritation will be lessened and the prospect of success correspondingly increased. Nelaton's Method (Fig. 739).—The edges of the opening are first pared, and then the integument is detached subcutaneously for about an inch around it by entering a long, thin knife-blade through a transverse cut just below the opening (Fig. 739). The liberated integument is then joined in a longitudinal fold along the median line by means of quilted sutures. Dieffenbach, instead of dissecting subcuta- neously, raised two parallel longitudinal flaps and fastened the middle of their raw under surfaces together by sutures passed through leather supports at each side. Two or three rows of sutures can be used instead of this. Delpech dissected up a single flap, drew it across the fistula, and fastened it to a raw surface prepared on the opposite side. Ar- laud made two transverse flaps, one in front and the other behind the fistula, about an inch and a half in width. The anterior one was dissected up toward the glans about three fourths of an inch, and the posterior one back over the scrotum, until it could be easily drawn forward, so as to cover the fistula. The cutaneous surface of the an- terior portion of the scrotal flap was fresh- ened and the flap drawn forward so as to cover the fistula, and the an- terior flap drawn backward over it and united by sutures. Rigaud (Fig. 740) closed a large fistula at the peno-scrotal junc- Fig. 738.—Urethroplasty. Fig. 739.—Nelaton's method. OPERATIONS ON THE PENIS AND SCROTUM. 471 tion by the method employed by Nelaton in the treatment of epispa- dias. A quadrilateral median flap, with its base adjoining the open- ing, was taken from the scrotum, turned forward over the fistula, and its raw sur- face covered by two flaps taken from the sides and drawn together so as to meet in the median line. Szymanowski suggested that the cuta- neous surface of the reversed flap be blis- tered instead of scraped. This meth- od is not as reliable, however, as the former. External Perineal Urethrotomy, some- times called perineal section, is employed in the treatment of intractable strictures, especially when accompanied by a urethral fistula located in the perineum. It may be performed Fig. 740.—Rfcaud's method. Fig. 741.—Gouley's beaked bistoury. either with or without a guide. The former is not a difficult opera- tion, while the latter is frequently an extremely perplexing one. The instruments essential for the operation are an ordinary scalpel, also Fig. 742.__Gouley's grooved and tunneled catheter staffs. one with a sharp point and a long, thin blade, the beaked bistoury of Gouley (Fig. 741), whalebone guides, a grooved and tunneled catheter staff (Fig. 742, a, b), ordinary sounds, a gum catheter, small probe, grooved director, c, spatula, tenacula, two strong ligatures, each armed 472 OPERATIVE SURGERY. with a curved needle, and the usual instruments for controlling hem- orrhage. Syme's grooved staff (Fig. 743) is objectionable, in that its point may get into a false passage and the stricture be missed. Moreover, its introduction through the stricture is more difficult than that of the whale- bone guide, and attended by greater danger to the soft parts. If the ordinary small-sized grooved staff employed in lithotomy can be introduced, nothing better need be asked for. Operation with a Guide.—Evacuate the bowel, shave and cleanse the perineum, administer an an- aesthetic, fill the urethra with olive-oil, and intro- duce a whalebone guide into the bladder in the manner before described (page 420); over this pass the grooved and tunneled catheter staff down to and through the stricture, if it can be done readi- ly ; if not, allow its beak to rest against the ob- struction, carefully supported by an assistant, who at the same time raises and holds the scrotum. The patient is now placed in a lithotomy position, and the limbs supported by an assistant upon either side. The surgeon, sitting upon a low stool facing the perineum of the patient, introduces the left in- dex-finger into the rectum to ascertain the condi- tion of the membranous and prostatic portions of the canal. A free incision, from an inch to an inch and a half long, is then made in the median line of the perineum, extending from the base of the scrotum to within half an inch of the anus, through the integument and fascia. The grooved instrument is carefully located by the finger, and the urethra brought into view by repeated cuts in the same line. The nail of the index-finger assures the surgeon of the location of the groove, and the ^grootedlSff6'8 urethra is divided upon it. Two silk ligatures are now passed, one through each border of the divided urethra, and are then looped and given in charge of the assistants, who are instructed to carefully draw the lips of the wound apart (Fig. 744). This important step exposes the mucous wall of the urethra completely, enabling the operator to follow its course by carefully observing the continuity of its structures. The staff is now withdrawn sufficiently to show the black guide, then the beaked bistoury is introduced in its course, and the stricture, together with about half an inch of the canal immediately behind it, is di- vided in the median line. OPERATIONS ON THE PENIS AND SCROTUM. 473 «. u fudmiSS10U of a grooved director or a small gum catheter through the opening into the bladder, followed by the flow of urine assures the surgeon that he has located the proper channel; or, after Fig. 744.—Borders of incision drawn apart. the division of the stricture, the tunneled catheter staff may be passed along the whalebone guide into the bladder and the stylet withdrawn, when the diagnostic urinary stream will appear. The instruments are now withdrawn from the urethra, and the ordi- nary sound of suitable size is introduced into the neck of the blad- der, through the urethra, to determine the complete freedom of the passage. Operation without a Guide.—After all efforts to introduce a whale- bone guide into the bladder have failed, pass the tunneled catheter staff over a whalebone guide along the urethra as far as it will go without using violence ; then place the staff and guide in charge of an assistant, as before. Make an incision of the usual length directly in the median line down to and through the urethra into the groove at the end of the staff; pass the silken loops through the borders of the incised urethra as before; check all hemorrhage, withdraw the staff slightly, and examine to see if it be located in the urethral tube. The lips of the urethral incision are now drawn well apart, and the 474 OPERATIVE SURGERY. operator, whose patience, care, and knowledge must now be well tested, endeavors to introduce a whalebone guide or a fine probe or grooved director through the stricture into the bladder by way of the perineal incision. If the effort be successful, the remainder of the operation is simple, and consists only in dividing the stricture with the probe-pointed bistoury from above downward as before ; usually, however, no anterior opening can be found, or one may be detected which leads away from the median line, showing the existence of a false passage. In either case the plan of the operator must be the same. Keep in the median line. If, after a patient search, no direct orifice be found, it is often possible to detect it, by making moderate pressure above the pubes on the bladder, which will frequently cause a few drops of urine to escape from the obscure opening in the perineal cut, into which a whalebone guide or a fine director can be inserted, and usu- ally passed into the bladder. If the pressure accomplishes nothing, then the surgeon feels for the opening in the triangular ligament, through which the urethra normally passes, and cuts toward and even ■ through it if the urethra can not be found before. As he cuts he re- peatedly seeks for the orifice, and closely examines for a continuation of the fibrous mass in the line of his incision with the tissues compos- ing the walls of the urethra. In the obscure division of the amalga- mated perineal tissues, the surgeon is also guided by the established relations of the normal urethra to the arch and rami of the pubes, to the tuberosities and rami of the ischium, and, still more important, the relations to the rectum. The careful cutting and searching are continued until an opening is found which leads into the bladder. The tissue barring the passage is cut, and a small gum catheter is passed along the probe or director into the organ. This is followed by the welcome flow of urine. The catheter is then withdrawn, the canal dilated with the little finger, and all constricting bands at the roof and floor of the urethra are severed. A steel sound the size of the canal is then introduced into the bladder through the urethra several times until its uninterrupted entrance is assured. Increase the size of the meatus and divide by internal urethrotomy all obstinate strictures in front of the perineal opening. Examine the bladder for stone, and, if found, remove it; stop all bleeding; place the patient in bed with hot fomentations to the abdomen ; elevate the scrotum to prevent infiltration ; administer anodynes and demulcents, and keep the patient quiet. The major portion of the perineal wound may be closed by antiseptic sutures carried deeply, leaving, however, sufficient room for the introduction of a large flexible catheter, through the neck of the bladder. The wound should be dressed antiseptically. The catheter should be allowed to remain in position for four or five days, unless its presence causes some degree of vesical irritation. Suit- OPERATIONS ON THE PENIS AND SCROTUM. 475 able-sized sounds should be passed every two or three days for a con- siderable time at a later period. Results.—In eight thousand cases of external urethrotomy a little over five per cent died. Internal Urethrotomy.—The division of strictures by cutting in- struments introduced into the urethra is called "internal urethroto- my." It is usually limited to strictures of the penile portion, although sub-pubic and even those of the membranous portions may be divided. The number, size, location, and extent of the obstructions should be determined before their division is attempted. For this purpose, bulbous bougies and urethrometers have been devised. The me- tallic bougie of Otis (Fig. 745), and also the non-metallic forms (Fig. 746), meet the indica- tions admirably. If it be the intention of the operator to distend the canal to its fullest capacity, and if the meatus be undersized, it should be slit up before the stricture is divided. =*» Fig. 746.—Non-metallic bougies. Fig. 747.—Civiale's bistouri cacne. The slitting can be easily done by means of the bistouri cache of Civiale (Fig. 747). After prop- erly distending the meatus, it is introduced with the cutting surface downward, and quickly with- drawn. The ordinary probe-pointed bistoury, or a straight-edged one, with the end guarded, will accomplish the purpose perfectly. The lips of the cut will unite unless they be kept sepa- rated by lint or cotton, or by the occasional in- troduction of a large-sized sound. The location, number, and size of strictures can be determined by the introduction of bulbous bougies. One of large size that will slip through the meatus is selected, oiled, and passed down the canal until arrested The distance in the canal is noted on the handle. It is then withdrawn, and the size of the bulb measured by the familiar scale. 745.—Otis' bougies a boule. 476 OPERATIVE SURGERY. The surgeon next ascertains the size of the one that will pass the obstruction, and so on, recording the location and size of each obstruc- tion in its turn until the bladder is entered. The urethrometer of Otis (Fig. 748) is constructed on a principle calculated to give practically accurate measurements. The unexpanded blades of the extremity of the instrument, B, are covered by a small rubber cap or closed tube, C ; the instrument is oiled and carried, closed, through the last obstruction, if possible, when the extremity is expanded by a screw at the outer end until-it fills the urethra, the capacity of which is noted upon the dial ; it is slowly withdrawn while the expanded extremity is regulated to accommodate the varied dimensions of the canal, the caliber and location of which should always be noted. By this simple though ingenious method the surgeon is enabled to locate quite correctly the seat of the obstacle he is to treat. The re- maining instruments required are the urethrotome, and a double-barreled catheter, to apply an iced-water current to the canal. Urethrotomes, like other instruments designed for spe- cial purposes, vary in many important particulars. Those, however, of greatest practical utility were devised by Otis and Peet (Figs. 749, 750, and 751). Each bears upon its handle a scale which enables the operator to ascertain not only the size but the distensibility of an obstruction. Either of these instruments, when taken in connection with the urethrometer, enables the surgeon to divide the strictured portions until the scale on the dial or handle of the cutting instrument indicates that the strictured por- tions of the urethra correspond in size to the dimensions of the normal portions, as indicated by the dial of the urethrometer. Operation.—An anaesthetic or cocaine solution is em- ployed, and the patient is placed upon the back. Then a well-oiled instrument is introduced, and the extremity concealing the blade is carried beyond the obstruction, which is dilated by turning or depressing the screw at the end until the strictured tissues are made tense, when the knife is withdrawn sufficiently to divide the stricture freely. The action of the instrument is then reversed and the knife pushed back into its hiding-place, and the instrument again dilated to note the effect of the incision upon the caliber of the stricture. If it still be below the standard, as indicated by the urethrometer, the blade is again applied to it. In this manner each constriction can be divided and the tube made of a uniform diameter throughout. If two or Fig. 748.— Otis' ure- thrometer. OPERATIONS ON THE PENIS AND SCROTUM. 477 more strictures have a common, or an almost common, diameter, they can be cut simultaneously by drawing the knife along the course of Figs. 749, 750.—Otis' urethrotomes. Fig. 751.—Peet's urethrotome low, a large-sized sound can be introduced, and the penis bandaged to it. Cold may be applied by means of a stream of iced-water con- ducted through a double-barreled catheter. It is sometimes necessary 478 OPERATIVE SURGERY. to make pressure on the perineum, in conjunction with other expedi- ents. The necessity for this is extremely rare. Following urethrot- omy the patient must be kept quiet in bed for three or four days, with a light diet and open bow- els ; demulcent and alkaline drinks are often advisable. A sound may be passed every third day un- til the wound is healed. Very few patients perish as the Fig. 752.—Tapping the urethra. direct result of in- ternal urethrotomy, and when carefully done upon proper cases, an unfavorable result need not be anticipated. Tapping the Urethra (Cock).—In a distended bladder from impass- able stricture this is a feasible operation. The patient is placed in the lithotomy position, and the left index-finger introduced into the rec- tum, and its tip pressed against the apex of the prostate (Fig. 752). A double-edged knife is then plunged into the perineum, in the median line, the point being directed to the tip of the finger, and caused to open the urethra in front of the prostate, behind the stricture, by a slight lat- eral motion. As the knife is withdrawn, the dimension of the wound may be increased anteriorly. A grooved director is then carried into the bladder through the opening, and a catheter passed upon it to re- lieve the distended viscus. The opening may be made through the an- terior wall of the rectum when objections exist to the perineal puncture. CHAPTER XVIII. MISCELLANEOUS OPERATIONS. Tapping the Pericardium.—If the pericardium be hyper-distended by fluid, or contain pus, and the attending symptoms denote danger- ous heart failure from pressure, the accumulated fluid may be removed by tapping or by aspiration through the trocar of Fitch. The instrument devised by Dr. Roberts, of Philadelphia, who has MISCELLANEOUS OPERATIONS. 479 given much attention to the subject, is well adapted to the purpose mentioned. The principal operation should be preceded by an explor- atory puncture with a hypodermic syringe. The arteries to be avoided are the mammary and intercostal; the former rests upon the costal cartilages, about a half inch from the outer border of the sternum, the latter run along the lower border of the ribs. The point of the instru- ment should be directed away from the apex of the heart, since the latter moves from left to right and from behind forward at each pul- sation. Operation.—Place the patient diagonally upon the left side, with the shoulder and chest raised. Insert the instrument through the fifth intercostal space, an inch or an inch and a half from the left border of the sternum, close to the upper border of the sixth rib, using great care to prevent the entrance of air. Results.— Nearly forty per cent of the patients have recovered after the operation. Extirpation of the Breast.—The breast is removed to eradicate growths of a malignant and non-malignant character. If malignant, the entire gland must be extirpated. If non-ma- lignant, only such tissues as are involved in the growth need be removed. If the growth be malig- nant or of a doubtful character, all of the en- larged lymphatics in its vicinity should be taken away. Indeed, it is wise under these conditions to remove the entire axillary system of lymphatic glands, even though but one or two have become slightly enlarged. The shape and extent of the growth will modify the outlines of the incisions. If it be irregular, some other form rather than the estab- lished elliptical cut may be employed (Figs. 753 and 754). Operation.—Wash and asepticize the part and its immediate sur- roundings ; shave the axilla if the examination of the contents be con- templated ; place the patient on the back and administer an anaes- thetic. Raise the arm to make tense the fibers of the pectoralis major ; assume a position relative to the patient which will be most convenient for making the inferior incision first (Fig. 755). A scalpel of large size is now selected ; the breast pressed upward and supported by the left hand, and the inferior incision made in the direction, if possible, of the fibers of the pectoralis major. It should extend down to the pectoral fibers, and the breast should be reflected upward from them by traction with the hand, aided by the scalpel when necessary. As Figs. 753, 754.—Incisions for removal of the breast. 480 OPERATIVE SURGERY. soon as the under surface of the tumor is raised, the upper incision is made and the growth removed. The amount of hemorrhage is some- times quite ex- tensive ; still, it can be easily kept under control if an assistant fol- lows the course of the knife with an antiseptic tow- el, making firm pressure on the bleeding points. Two towels are required, one for each incision. After the removal of the growth, the towels are cautiously raised from below upward, and the bleeding points secured by serresfines as soon as seen. Any remaining portions of the morbid growth which may be attached-to the pectoral fascia, muscle, etc., should be removed, even at the complete sacrifice of the parts with which they are con- nected. The vessels should be ligated with catgut. If any enlarged glands exist in the axilla, or along the border of the great pectoral muscle, they should be removed at once, together with all of their associates, irrespective of their size. The wound must be properly drained at its most dependent part, united with silver wire or carbol- ized silk, and otherwise treated antiseptically. Results.—The rate of mortality from removal of mammary growths and their axillary complications is about seventeen per cent. How- ever, this mortality is offset by the fact that the operation adds twelve months to the life of the patient, and when thoroughly performed cures about nine per cent (Prof. S. W. Gross). The mortuary results from limited extirpation alone are practically the same as those following complete removal. It often happens that the skin is too extensively diseased to admit of the formation of a suit- able flap. The wound should then be allowed to heal by granulation. Extirpation of the Axillary Glands.—This operation is often neces- sary when the lymphatic glands located therein become enlarged, either primarily or secondarily, from malignant growths. In fact, it is wise to " clean out" the space whenever one or more of these glands is enlarged from this cause, even though the enlargement be slight and of recent date. Whenever an axillary gland is found to be enlarged, not only should this be removed, but likewise the entire series should be removed, together with the connective tissue supporting them, simultaneously with the removal of the contiguous malignant growth. MISCELLANEOUS OPERATIONS. 481 Location of the Glands.—These glands are normally of compara- tively large size, are from ten to twelve in number, and are surrounded by loose areolar tissue. There are three chains of them : one, surround- ing the axillary vessels, which receive the lymphatics from the arm ; another, but smaller one, runs along the lower border of the pectoralis major muscle, and receives the lymphatics from the mammary gland and the front of the chest; the last chain is located along the poste- rior border of the axilla and receives the lymphatics from the back. There are, in addition also, two or three larger so-called subclavian lymphatic glands, that are located beneath the clavicle, through which the axillary and deep cervical glands communicate with each other. Location of the Vessels.—If a line be drawn through the center of the long axis of the axilla, the important vessels and nerves will be located within the anterior half of the space. It, therefore, follows that all deep incisions should be made within the posterior half, the nearer to the posterior border of the axilla the safer. Operation.—The parts should be always shaven and scrubbed be- fore the operation. The operation may then be performed either by extending into the axilla the incision for the removal of the primary growth, or by means of an independent one. If the latter plan be adopted, make an incision in the long axis of the axilla just in front of the axillary border of the scapula through the integument and fas- cia, then with the fingers and the handle of the scalpel cautiously dis- connect and remove the areolar tissue and glands. The large veins must be carefully avoided, not so much on account of the hemorrhage that may result if they be injured, as from the danger of the entrance of air, due to the respiratory action. When the removal is completed, wash the space thoroughly with an antiseptic solution, introduce drainage-tubes, bring the arm to the side of the chest, and dress anti- septically. Keep the patient quiet, so that union by first intention may be secured if possible ; for, if the wound heals by granulation, there is danger of obstruction of the circulation, and crippling of the movements of the arm from cicatricial contraction. If it be found to be impossible to remove the malignant growths from around the vessels, the question of amputation at the shoulder- joint is to be taken into consideration. Extirpation of the Parotid Gland.—The complete removal of this gland is one of the most difficult operations in surgery, especially when its relations are changed by a morbid malignant growth, impli- cating its structure. Contiguous Anatomy.—-The space in which this gland is located is deep, narrow above, broader below, and modified by the movement of the lower jaw. It is bounded above by the zygoma ; below, by a line extending from the angle of the inferior maxilla backward to the sterno-mastoid muscle ; in front, by the posterior border of the ramus 31 482 OPERATIVE SURGERY. of the jaw ; behind, by the external auditory meatus and mastoid pro- cess. The gland is separated from the submaxillary region by the stylo-maxillary ligament, and from the deeper tissues by the styloid process, and the ligaments and muscles connected with it. Prolonga- tions of considerable size extend from its deep surface inward, one in front and the other behind the styloid process, the former passing be- hind the mastoid process and sterno-mastoid muscle, the latter to the back part of the glenoid fossa. The external carotid artery passes through the gland from below upward, dividing into its terminal branches before its escape. Superficial to this artery there is a venous trunk formed by the union of the temporal and internal maxillary veins ; to this trunk the internal jugular is connected by a small branch that passes through the gland structure. The facial nerve and its branches traverse the gland from behind forward and receive a communicating branch from the great auricular in its substance. Im- mediately beneath the floor of the space lie the internal carotid artery and internal jugular vein, along with the spinal accessory, glossopha- ryngeal, and pneumogastric nerves. Lymphatic glands lie over the parotid, and their enlargement may be mistaken for that of the gland itself. Contraindications to Extirpation: immobility of the tumor, and a malignant growth implicating the structure of the gland. Operation.—Place the patient upon a suitable table, in a good light, with the shoulders elevated and the head turned to the opposite side. Make an incision from the zygoma along the central line of the tumor to its lower border. If necessary, this one can be supplemented by one or more extending from it at right angles. The integument- ary flaps are freely reflected to expose the growth. The tumor should be raised from below upward, and held by a volsella. This will raise the external carotid from its bed. when it must be isolated and tied between two ligatures. The vessels that enter or escape from the tu- mor at this point should be treated in the same manner. The tumor can now be raised upward, and its separation from the deeper tissues continued by means of the fingers or handle of the scalpel; the former are the better. The separation of the growth from the floor of the space must be done gently and with great caution, on account of the contiguity of the internal jugular vein and the other important vessels, and the nerves located there, which, if the growth be a large one, will be pressed upon by it, and may become adherent to it. It is scarcely possible to avoid division of the facial nerves if the growth be com- pact. If it be soft and spongy, the integrity of the nerve may be pre- served by a careful use of the fingers or director. The upper extrem- ity of the gland is last removed. This step of the operation is neces- sarily attended with considerable hemorrhage, which is, however, easily MISCELLANEOUS OPERATIONS. 483 controlled. After the removal, unite the flaps, establish drainage, and dress antiseptically. Results.—This operation has been done upward of one hundred and ten times. When done for malignant growths, the disease has almost invariably returned within six months. The dangers to life from the operation itself, when carefully performed, are not imminent. Paracentesis Thoracis.—This operation is done to remove a fluid accumulation from the chest cavity. The instruments employed for the purpose should be one of the many forms of aspirators (Figs. 580, 581). If one of these be not available, the ordinary trocar and canula can be used, due heed being given to the danger of the admission of air into the pleural cavity. The intercostal space through which the trocar should be introduced will depend upon the amount of fluid in the cavity. As a rule it may be stated that the intercostal space selected should be three or four inches above the lowest limit of abnormal dullness. The instrument is introduced nearest to the upper border of the rib, midway between its sternal and vertebral extremities, or on a line with the inferior angle of the scapula. It is often very difficult, on account of obesity, to determine the numerical relations of the ribs. The elevation between the first and second bones of the sternum corresponds exactly to the articulation of the second costal cartilages. The nipple in the male is located usually between the fourth and fifth ribs. If the nipple be normally located, a line carried horizontally from it around the chest will pass over the sixth intercostal space in the line of the axilla ; if the arm be raised, the first visible digitation of the serratus magnus is attached to the sixth rib. The inferior angle of the scapula covers the seventh rib, therefore the first intercostal space below it is the seventh. The eleventh and twelfth ribs can be felt in corpulent per- sons outside the erector spinae, sloping downward. If any one of the intercostal spaces below the seventh be selected, the diaphragm may be punctured if the trocar be inserted incautiously. Operation.—Prop up the patient in bed, or, if able, allow him to sit astride a chair with his arms resting on its back, and his head sup- ported by them. The thickness of the walls of the chest and the presence of fluid must first be determined by the introduction of the needle of a hypodermic syringe. All the instruments and the surface at the point of proposed puncture should be well carbolized. The integument over the intercostal space through which the puncture is to be made must be drawn upward, since, as the fluid escapes from the chest, the space will descend : if this be not done, the puncture through the skin will soon be above the intercostal space. A knowl- edge of this fact is of immense importance if a permanent opening is to be established, as in empyema. If the puncture be made in the vicinity of the diaphragm, the point of the instrument must be di- 484 OPERATIVE SURGERY. rected upward and inward. Locate the seat of the proposed puncture and make a small incision through the skin with a lance, with or with- out the use of cocaine, insert the end of the instrument, and as soon as the point is fully engaged in the tissues, extract the air if it be connected with an aspirator, and push it quickly in, guarded by the index-finger laid along its side. If the instrument become closed by false membrane or floating fibrin, the obstruction must be removed by a small wire passed through its lumen. The pulse and the sensations of the patient must be consulted during the evacuation to avoid, if possible, sudden syncope. Death is rarely directly due to this oper- ation. Perforation of the Antrum.—When fluid accumulations occur in this cavity, they can be removed by the trephine, or by the ordinary bone-drill passed into it through its anterior wall, or into its floor through the socket of the first permanent molar tooth, being careful that the drill does not perforate the floor of the orbit. The cavity is then washed out and the opening maintained by the introduction of a gold tube, if practicable, until the function of the mucous membrane is restored. OPERATIONS UPON THE NOSE. Plugging the Posterior Nares (Fig. 756).—This is done to arrest obstinate epistaxis. The tampon or plug can be made of sponge, lint, Fig. 756.—Plugging posterior nares. Fig. 757.—Bellocq's canula. or of suitable cloth, and should be of a proper size to closely fit the posterior naris, which in the adult is about three fourths of an inch long and half an inch wide. The plug is made by tying a strong ligature around the middle of the material selected for the purpose and suitably arranged, cutting the ends of the ligature short, and pass- ing beneath it on opposite sides of the plug two equally strong liga- MISCELLANEOUS OPERATIONS. 485 tures, which are looped around and firmly tied to the first one. The canula of Bellocq (Fig. 757), with the spring withdrawn, is then car- ried along the floor of the nostril to the posterior wall of the pharynx, when the movable rod is projected and curves forward into the mouth.' The extremities of the loop at one side of the tampon are passed through the instrument and down through the meatus by returning the central rod and withdrawing the instrument. The tampon is now carried into position by pulling upon the strings aided by the finger carried behind the soft palate. Sufficient traction is made upon it to forcibly close the naris, and the strings in front are tied around a plug of a similar material, which closes the anterior open- ing. The plug should be well carbolized before its introduction, and, if need be, can be wet with astringent solutions. It should be removed at the end of forty-eight hours, which can be easily done by pulling on the strings remaining in the mouth while it is forced back- ward by an instrument introduced through the floor of the nostril. If the canula of Bellocq be not available, a long, flexible probe, an ordinary gum catheter, and even common wire, may be utilized. Sometimes a string is carried through the nostril by means of the can- ula and attached to the plug, instead of being tied to it before the canula is in- troduced. Removal of Nasal Polypi. — If the growths or pedicles be small, they can be quite readily removed by forceps (Figs. 758 and 759) or the snare. If the forceps are to be employed, the patient should sit in a chair, exposed to a strong light, with the head supported by an assistant, and, after spraying the nares with a strong solution of cocaine, the attachment of the growth is seized, and it is twisted off by turning the instrument several times on its long axis. If the growth be attached to a turbinated bone, it may be necessary to pull away some of the bone structure before the tumor can be re- moved. If the growth be situated far back or hang down into the Fig. 758.—Curved Fig. 759.— nasal polypus for- Straight na- ccps. sal polypus forceps. Fig. 760.—Nasal polypus canula. 486 OPERATIVE SURGERY. fauces, it may be detached by the finger passed behind the soft palate. If this fail, it may be snared (Figs. 761, 762, 763). The wire, either Fig. 761.—Sexton's snare. Fig. 762.—Codman & Shurt- lcff's snare. =*o o Fig. 763.—Jarvis' polypus snare. with or without the canula, is passed along the floor of the nose, and the loop passed over the tumor (Fig. 764), by aid of the finger Fig. 764.—Removing polypus. if necessary ; the loop is tightened and the growth severed (Fig. 765). If the growth be fibrous and not accessible by the previously men- tioned methods, it can then be exposed by opening the nasal cavity. MISCELLANEOUS OPERATIONS. 487 Fig. 765.—Double canula in position. The cavity of the nose may be exposed if the nose be turned upward after detaching it on both sides through the ahe and at the junction of the nasal bones with the nasal processes of the supe- rior maxillae, and in the median line to the septum. After the removal of the growth the parts are re- stored to their normal po- sition, and the edges of the wound united. If this method be not deemed ad- visable, the nose can be turned downward by mak- ing a U-shaped incision down to the bone, the convex portion of which shall cross the root of the nose between the eyes and extend downward at each side of the nose to the outer borders of the alae (Fig. 766, a). The bones are then sawn through in the line of the incision, the septum liberated at their under surface, and the nose turned downward, so as to expose the interior surfaces to ob- servation and manipulation. If the growth be a large one and greater space be necessary, the incision can be modified, as shown by the dotted line b, and the bones lying in their course sawn through as before described, care being taken to avoid the roots of the' teeth. After the removal of the growth the parts are replaced and confined in position by su- tures, dressings, etc. Naso-pha- ryngeal polypi can sometimes be removed by this method (Oilier). Langenbeck's Method.—Make an incision from the junction of the nasal with the frontal bone vertically downward in the median line of the nose to the upper border of the cartilages of the alae, thence outward upon the cheek (Fig. 767, a). Dissect off the triangular flap, leaving the periosteum ; sever the alar cartilage from the nasal bone, and with bone nippers sever the nasal bone from its fellow. Also in the same manner separate the nasal process of the superior Fig. 766.—Lines of incision. 488 OPERATIVE SURGERY. Fig. 767.—Langenbeck's lines of incision. maxilla from its body, then the entire upper part of the nasal cavity can be exposed by raising upward the quadrilateral plate of bone. After the tumor is re- moved, the bone can be returned and fast- ened in its proper position. If the tu- mor be still larger, it may be attacked by an opening through the hard palate (Ne- laton, Fig. 768). Nelaton's Method (Fig. 768).—Make an incision in the medi- an line, through the soft palate down to the bone ; continue it forward, along the posterior half of the hard palate ; two oth- ers are now carried obliquely outward on either side from the anterior extremity of the incision along the hard palate, to the alveolar pro- cess ; these flaps, including the periosteum, are reflected outward, the hard palate perforated and cut away, the periosteum and mucous membrane of the floor of the nose turned aside, the septum removed if necessary, and the tumor will be exposed to view and can be removed. The periosteal flap of the hard palate should be returned to the normal position, and stitched after the growth is removed. The cut through the soft palate can be joined subsequently. If the growth be a small one, but one side of the hard palate need be attacked. Naso- pharyngeal polypi may be advantageously reached by this method. Removal of Naso-Pharyngeal Polypi.— Langenbeck's Method. — Make a slightly curved incision with the convexity down- ward, extending from the ala of the nose to the malar bone and as far backward as the middle of the zygoma. A second incision is made, beginning near to the center of the root of the nose, and, pass- ing along the inferior margin of the orbit, it joins the former near the middle of the malar bone (Fig. 767, b). These incisions should extend Fig. 768.—NSlaton's method. MISCELLANEOUS OPERATIONS. 489 through the periosteum down to the bone ; the soft parts, however, are not to be raised. Separate the masseter muscle from the malar bone, divide the buccal fascia, depress the inferior maxilla, and pass the fin- ger, if possible, into the posterior nares by carrying it through the ptery- go-maxillary fissure into the spheno-maxillary fossa, thence through the spheno-palatine foramen, all of which passages may have been dis- tended by the morbid growth. A small key-hole saw is passed by the same route, and the superior maxilla divided from behind forward ; the extremity of the saw is covered by the end of the index-finger, car- ried into the pharynx through the mouth, to protect the tissues from being injured by it. The zygomatic process of the temporal, frontal process of the malar, and orbital process of the superior maxilla are sawn through to the lachrymal bone. The superior maxilla can be divided in the line of the superior incision of the soft parts, thus leav- ing the orbital process intact. The osteo-cutaneous flap is now raised by an elevator carried beneath the malar bone and slowly lifted upward and inward toward the nose, the bones and soft parts of which form a hinge to the flap at that side. If the saw can not be passed into the posterior nasal cavity even by the aid of a grooved director, the lips of the incision of the soft parts may be drawn asunder and the bone sawn from without inward and before backward. Either incision exposes polypoid growths of the pharynx admirably for manipulation. The operation is usually attended by quite se- vere hemorrhage, which, however, can be controlled readily by press- ure and an occasional ligature. After the removal of the growth, the parts are adjusted and confined in position by sutures, etc. If the growth to be removed be a large and va cular one, a preliminary tra- cheotomy should be done. If it be malignant and very vascular, and have a large attachment, I deem it a wise precaution to tie both exter- nal carotids prior to removal. The dangers from hemorrhage will be lessened by this measure, and, moreover, the diminished vascularity of the parts will hinder the redevelopment of the growth. Results.—The rate of mortality from this method is less than twenty-five per cent, and depends more on the removal of the growth than upon the steps necessary to reach it. The mortality is greater when the operation is done through the hard palate than when per- formed by means of the displacement of the upper jaw. Cheever's Method.—In this both superior maxilla? were removed, owing to the large size and central situation of the growth. • He made an incision from near the inner canthus on each side of the nose down- ward along the natural furrow, around the alae to the median line of the lip, which he divided. These flaps were reflected upward and outward as far as the malar prominence, and the body of each supe- rior maxilla was sawn from behind forward to the middle meatus of the nose ; the septum and vomer were cut with scissors ; the jaws were 490 OPERATIVE SURGERY. then depressed and the tumor removed ; after which the bones were replaced and wired in position. The loss of blood was not great, but the patient died on the fifth day from exhaustion. The excision of the entire upper jaw may be practiced for the re- moval of these growths, or only the portion below the line of the orbital floor may be removed. The superior maxilla can be raised and turned outward on a hinge formed by the zygomatic process of the malar bone and the contiguous soft parts, by dividing the bone in the line of Ferguson's incision (Fig. 243, b), the upper portion of which, for this purpose, should be extended to the malar bone. The maxillae are separated by sawing through the hard palate and alveolar process, and the nasal bone is disconnected from the superior maxilla by severing its connections with bone-forceps. The osteo- cutaneous flap can then be raised and swung outward. If necessary, the soft palate may be divided. After the removal of the growths the parts, including the soft palate, are adjusted and joined by su- tures. With the view of avoiding as far as possible the division of the ter- minal filaments of the superior dental nerve, and obviating the loss of function incident thereto, Langenbeck recommended that a curved incision be made, crossing the cheek about midway between the angle of the mouth and the lower border of the orbit, beginning near the lower end of the nasal bone and extending downward, outward, and upward so as to avoid the Stenon duct. The flaps are dissected from the superior maxilla and it is removed through the opening made in the soft parts. If the whole bone is to be removed, the integ- rity of the superior maxillary nerve can be still further preserved by removing it from the infra-orbital groove by the aid of a fine, sharp chisel. The removal of a growth of any great size from the posterior nares or pharynx, especially the latter, will be attended, if its attachment be extensive, by the entrance of a large amount of blood into the pharynx and trachea ; it is, therefore, wise to do a preliminary trache- otomy so that the lower extremity of the pharynx may be closed by sponges, or otherwise tamponed. If the shoulders be elevated and the head allowed to fall far backward, the blood can be removed from the dependent portion of the pharynx as fast as it collects; this posi- tion, however, impedes respiration by over-extending the muscles that act on the os hyoides. If a preliminary tracheotomy be done, the anaesthetic must be administered through the tube. The apparatus devised for this purpose by Trendelenburg (Fig. 769) may be used entire, or only the inhaling portion attached to the ordinary trache- otomy-tube can be employed ; the latter plan is generally to be pre- ferred, since the rubber tampon attached to this tube often causes bronchial irritation when inflated; moreover, if it become ruptured MISCELLANEOUS OPERATIONS. 491 during the course of an operation, or be imperfectly distended, blood may enter the trachea unawares. Fig. 769.—Trendelenburg's trachea tampon. Deviation of the Septum Nasi.—It not unf requently occurs that both the bony and cartilaginous portions of the septum are deflected to such an extent as to seriously interfere with breathing through the nose during attacks of coryza, and likewise impart a distinct nasal twang to the voice. This deformity may or. may not be associated with ex- ternal modifications of the nasal symmetry. In either case the indi- cation remains the same—to overcome the deformity and to maintain the corrected relations of the parts until recovery takes place. Operation.—-The deformity can be overcome by grasping the ab- normal septum between the blades of forceps especially designed for the purpose (Fig. 770), which are thrust into the anterior nares and closed upon the de- formed septum, and held for a few mo- ments with suffi- cient firmness to press its irregulari- ties into a normal position. The re- sistance is still fur- Fig. 770.—Adams' rhinoplastos forceps. ther overcome by cautiously turning the forceps from side to side on their long axis. The pressure exerts a crushing and compressing in- fluence on the septum, causing it to assume or admit of its being pressed into a normal position. The retentive apparatus is a specially constructed clamp (Fig. 771), which is screwed into position while grasping the septum. The instrument retains the parts thus rectified until the reparative processes necessary to their permanency shall take place. The clamp can be permitted to remain in position two or three days, not tightly screwed—for this would cause ulcera- tion—but closely enough to exert a gradual controlling influence. This indication can likewise be well met by introducing rubber 492 OPERATIVE SURGERY. Fig. 771.—Adams' clamps. Fig. 772.—Ivory plugs. tubes of proper size and length, surrounded by oiled lint, into each nostril ; these tubes by their elastic pressure answer the pur- poses of the clamp, and at the same time permit air to pass unob- structed through the nostrils. After three or four days either of the preceding appliances should be replaced by ivory plugs (Fig. 772), which are pushed into each nostril and worn at night only. It is true that this treatment is annoying and even attended by positive discomfort, yet the almost as- sured good result will amply re- pay the patient for the affliction incurred. In addition to this, other operations are recom- mended, such as the removal of the inferior turbinated bone on the side of the deflection ; punching the septum, to establish a com- munication between the closed and the unclosed nostril. Neither of these rectify the deformity, and both are open to objections, the former of a physiological, the latter of a pathological nature. The removal of the projecting cartilage and its mucous membrane is like- wise commended. The removal of the deformed septum together with a portion of the superior maxilla (Post), accomplished by sepa- rating the side of the nose from the cheek, turning the nose over, and thus gaining access to the obstruction, constitutes an opera- tion having a severity out of proportion to that of the primary diffi- culty ; and, moreover, it may be followed by an unsightly scar. It is recommended that the meatus be burred out (Wagner) by means of the dental engine. The results which he reports certainly give strong testimony in favor of the suggestion. The deformed portion of the septum may be sawn off on a plane conforming to that of the remain- ing portion by first applying a strong solution of cocaine to it, then removing the deformity with a narrow fine saw constructed especially for the purpose. This plan is followed by Professor Bosworth, and it appears to me preferable to burring or punching the septum. BRONCHOTOMY. This expression includes three distinct operations—laryngotomy, tracheotomy, and laryngo-tracheotomy, the first two of which are still further classified. These operations are comparatively easy in the adult, especially if the neck be long and the landmarks well devel- oped. In the infant and the child, and before puberty—the periods MISCELLANEOUS OPERATIONS. 493 of life when they are most demanded—the performance is most diffi- cult, owing to the shortness of the neck, obesity of the patient, and the rudimentary condition of the land- marks. The thyroid cartilage, which is well marked in the adult, constitut- ing a prominent point of reckoning, is scarcely discernible in the child, and in the infant it is impracticable to de- termine its location by physical exami- nation. The cricoid cartilage is a far better guide by which to determine the comparative relations of the parts. It is the distinctive cartilage of the laryn- geal group, and, irrespective of age, it can be felt as a firm, round ring, much more prominent than the cartilaginous rings of the trachea, which lie imme- diately below it. The crico-thyroid space, through which in laryngotomy the deep incision is made, is located immediately above the cricoid carti- lage, between it and the thyroid (Fig. 773). It is situated at the bottom of the first groove-like depression above the cricoid cartilage. The crico-thy- roid membrane is composed of yellow elastic tissue, and is, therefore, of a yellowish appearance, and is often dotted by openings for small vessels. When incised it will retract, owing to its resilient nature ; hence all hemorrhage should be stopped before it is opened—if the urgency of the case will per- mit. It is not difficult to locate the guides in the dead subject under ordinary circumstances ; but, in the living, when they are be- ing jerked upward and downward by the efforts at respiration, it is a matter of great difficulty, and may be impossible. The only artery normally in the line of the operation of laryngotomy that need be re- spected is the crico-thyroid, which runs along the upper border of the space, resting on the membrane of the same name. It is troublesome, not from the amount of blood it contains, but from its relation to the opening in the membrane, through which a small amount of blood may pass into the tube. The vessels causing the greater annoyance —especially if the patient be much cyanosed—are the small venous trunks which run across the tracheal and laryngeal region, without any definitely established relationship, and which return their blood chiefly into the superior thyroid veins (Fig. 774). The anterior jugular veins will be troublesome, unless the median line be adhered to closely. It Fig. 773. —External cartilages of the larynx, a. Body of hyoid bone. b. Thyroid-hyoid membrane, c. Thy- roid cartilage. d. Crico-thyroid membrane, e. Cricoid cartilage, f. First tracheal ring. g. Isthmus of thyroid body. 494 OPERATIVE SURGERY. is unnecessary, I trust, to allude to the well-known relation between the larynx and the large vessels of the neck. The thymus gland in Fig. 774.—Surgical anatomy oflarynx and trachea, a. Thyroid cartilage, b. Crico-thyroid membrane and artery, c Cricoid cartilage, d. Superior thyroid vein. e. Inferior thy- roid vein. f. Arteria innominata. h. Thyroid body. the very young deserves respectful consideration, as will hereafter appear. The choice of anaesthetics to be given in operations where the respiratory function of the larynx is involved is a matter entitled to some consideration. For instance, if ether be given to oue who has no laryngeal irritation or obstruction, the frequent spasm of those parts is familiar to all. If to this be now added the deficient aeration of the blood, due to a laryngeal obstruction, together with the in- creased tendency to spasm, dependent on laryngeal disease, then is the danger of asphyxia greatly augmented. Chloroform may be given with but little danger of causing spasm ; if ether be administered, it must be commenced very gradually, to avoid as much as possible the occurrence of laryngeal spasms. In many instances the pressing na- ture of the case will not permit the expenditure of the time necessary to produce anaesthesia. In those cases presenting marked cyanosis the sense of pain is much blunted, and the operation should be done without anaesthesia. The instruments suitable for these operations are quite numerous, yet the absence of any one or more of them is not to be considered a reason for its non-performance when demanded. When necessary, a pocket-knife, a hair-pin, or a toothpick, can be extemporized to advantage, thus preventing the death of the patient unaided because a tracheotomy-tube is not obtainable. MISCELLANEOUS OPERATIONS. 495 Tracheotomy Instruments.—Two scalpels should be at hand, one sharp and the other probe-pointed (Fig. 775) ; also an ordinary grooved director, retractors (Figs. 776 and 777), and small spatulse, to draw aside the tissues, and tracheotomy-hooks, to fix the trachea during its Fig. 775— Fig. 776.— Fig. 777.— Fig. 778.—Lan- Fig. 779.—Trousseau's Probe-pointed Retractor. Tenaculum- genbeck's dou- trachea dilator. scalpel. retractor. ble hook. incision (Fig. 778). The hook illustrated is the best in use, because the line of the cut can be made between its blades, and the center line of Fig. 780.—Chassaignac's trachea dilator. 496 OPERATIVE SURGERY. the trachea is therefore better assured. There are various forms of tracheotomes, which should not, in my opinion, be.substituted for the sharp-pointed bistoury, because they are much less surgical in their Fig. 781.—Silver trachea tube. Fig. 782.—Hard rubber trachea tube. inception and far more dangerous in their use. Dilators, too, are quite numerous and varied in pattern. Trousseau's (Fig. 779) and Chas- saignac's (Fig. 780) are fair representatives of them, and will answer the purpose admirably. The borders of the tracheal opening can always be easily drawn apart by the common tenacula or by two of the ordinary grooved directors with aneurism-needle attachments. Trache- otomy-tubes of various forms are employed. Figs. 781 and 782 repre- sent those in every-day use, the latter being of hard rubber. The bivalve trachea tube (Fig. 783) is an admirable instru- ment, since it can be introduced through the opening in the trachea much more readily than the ordinary blunt-ended pat- tern, and can be afterward quickly opened by the introduc- tion into it of the companion tube (Fig. 784). Fig. 785 repre- Figs. 783, 784.—Bivalve trachea tubes. sents forceps for the removal of foreign bodies. A long feather, With the tip of the brush remaining, should be at hand to insert into the trachea through the tube, to create the irritation sometimes neces- sary to cause the expulsion of the tracheal mucus. A so-called trachea aspirator has been devised to remove mucus and blood from the trachea (Fig. 786). It is used as follows : After the insertion of the trachea tube, place the thumb on the air-hole of the barrel; apply the soft rubber cup over the tube, and withdraw the piston, when the mucus and blood will enter the barrel. It has not infrequently happened that a patient is unable to expel the blood and mucus on account of stupor or weakness, and the lips of the operator were used to clear the trachea. MISCELLANEOUS OPERATIONS. 497 This is obviously a hazardous procedure, if the patient have syphilis or diphtheria. The possession of the tracheal aspirator will be wel- comed as prefera- ble under all cir- ajjj=- A serviceable /^t^ ~**^^N. ^^m—*^ instrument for M^ ^^53jjiaj|jjja^^'^ the purpose of re- /m ^^^^^_ moving blood, |f(j ^*^*m '-^^ etc., from the f j trachea-tube, and FlG. ^.-Trachea forceps ^^ even from the trachea itself, can be quickly extemporized by attaching to the nozzle of an ordinary two-ounce rubber syringe a soft piece of "rubber tubing Fig. 786.—Trachea aspirator. five or six inches in length. The unattached end of the rubber tubing is inserted into the trachea-tube or into the trachea itself ; the piston of the syringe is withdrawn somewhat quickly, and the fluid sucked up. If the suction be made too quickly, the tube will be collapsed and inoperative. Large portions of membrane have been drawn from the bronchial tubes in this manner. Laryngotomy.—Place the patient on a table with the shoulders elevated, head thrown back, and neck exposed to a strong light. At least three assistants are required, especially if an anaesthetic be given. Locate the cricoid cartilage, support the larynx firmly between the thumb and finger of the left hand, then make an incision through the integument an inch and a half in length in the adult, terminating at the lower border of the cricoid cartilage, and divide the fascia on a director ; divide the connections between, and separate the borders of the sterno-hyoid muscles with retractors, push aside the veins and con- nective tissue, and the crico-thyroid membrane will be seen. If the case be not urgent, check all haemorrhge before opening the larynx. If otherwise, open it at once, when the entrance of air and the resump- tion of the respiratory functions will dispel the cyanosis and check the bleeding. The larynx is seized and held firmly by a tenaculum while the opening is made through the crico-thyroid membrane transversely alono- the upper border of the cricoid cartilage to avoid the crico-thyroid artery, that runs along the upper border of the membrane, near the thy- 32 498 OPERATIVE SURGERY. roid cartilage, and also to remove the tube as far as possible from the vocal cords. The whistling of the ingoing air, succeeded by an expul- sive cough—which ejects the mucus, blood, and other matters—follow Fig. 787.—Opening the trachea. quickly after the incision. If the operation be performed for the re- moval of a foreign body, it may at this time be expelled, or become lodged near the opening, when it can be removed by forceps. If the operation be performed for laryngeal diphtheria, the tube should not be inserted until all loose membrane has been ex- pelled, and such as may be within reach of the forceps has been pulled away. If blood escape into the opening from the oozing vessels, the pressure of the tube upon the lips of the wound will serve to check it, and for this reason it may be introduced early. The tube is carried carefully in while the borders of the opening are held apart with the orthodox retract- or, or by means of two blunt artery-needles or tenacula, after which it is fastened in position by means of tapes carried around the neck and tied behind (Fig. 788). If the opening be too small, it may Fig. 788.—Tube in position. MISCELLANEOUS OPERATIONS. 499 be increased by division of the cricoid cartilage (crico-laryngotomy). The size of the tube is a matter of great importance, since if it be too large it will be difficult to introduce and be followed by ulceration. For patients four years and under, a tube with a caliber of a fourth of an inch is sufficient, in those four to eight years of age, one third of an inch, and about one half an inch for an adult. The soft parts above and below the tube are closed by antiseptic sutures, the patient is then placed in bed and caused to breathe air saturated with warm vapor from which all floating particles of dirt should be excluded. The tube is carefully watched to prevent it from becoming closed, and occasionally removed and cleansed. Too great emphasis can not be laid upon the necessity of instantly relieving the sudden occlusion of the tube due to false membrane. For this reason, a momentary in- attention, as leaving the room, etc., may prove fatal to the patient. After three or four days the tube may be removed and the patient allowed to breathe through the opening for a few hours, when the tube must be again inserted ; later in the case it may be inserted only during the night. As soon as the patient can breathe well, the tube should be entirely removed, the opening closed and cleansed, and the soft parts joined by a suture. If antiseptic gauze (not bichloride) or adhesive plaster be placed between the surface of the neck and the flanges of the tube, the danger of irritation of the soft parts by these portions of the tube will be obviated (Fig. 788). Tracheotomy is the operation usually performed upon children, owing to the small size of the crico-thyroid space. It is the preferable operation in all instances when the incision should be made as far as possible from a contagious local disease. It may be done in three situations —above, below, and behind the isthmus of the thyroid gland ; the one below the isth- mus is to be preferred. The upper portion of the trachea is quite superficial, while the lower is from half an inch to an inch in depth, depending upon the shortness of the neck and the obesity of the patient. The lower portion recedes, following the curve of the spinal column. The vascu- lar structures in this portion are far more important and numerous than in other parts of its course ; the inferior thyroid veins (Fio-. 789), and their communications, pass in the course of the incis- ion* the arteria thyroidea ima when present runs along the center of the'trachea ; the arteria innominata, especially in the child, runs ob- liquely across it, at the root of the neck from left to right. The isth- 500 OPERATIVE SURGERY. mus of the thyroid covers the second, third, and often the fourth rings of the trachea ; above it is seen the communicating branch between the superior thyroid veins (Fig. 774, d); the thymus gland, which attains its full size at two years, encroaches upon the space from below up- ward with each labored respiratory act, and may be incised. It is sometimes difficult for the beginner, when surrounded by the turmoil incident to the operation, to be certain of the location of the trachea. If the index-finger be inserted into the wound, the trachea will roll un- der it, and be felt ascending and descending beneath its extremity, and, when sufficiently isolated, the rings can be seen and felt. The inex- perienced operator is also likely to make the opening at one side of the median cut, which makes it difficult to introduce the tube, causes it to bind after introduction, and not infrequently, if the tissues overlap the cut before its introduction, causes air to be forced between their planes, creating local emphysema. If the knife be inserted too far, the posterior wall of the trachea will be divided. Operation below the Isthmus.—Place the patient as for laryn- gotomy, and, if practicable, administer an anaesthetic. Finally, sup- port the trachea in the median line of the neck and make an incision in the median line, extending from the cricoid cartilage to within half an inch of the top of the sternum ; divide the fascia on a director; cautiously separate and pull aside the sterno-thyroid and sterno-hyoid muscles, thus exposing the deeper cervical fascia, beneath which are located the inferior thyroid veins (Fig. 789,13) supported by connective tissue. This fascia should be torn asunder by a blunt instrument, and pushed aside along with the veins and connective tissue beneath, which will expose the trachea. The blunt ends of two ordinary directors can be utilized for separating the fascia, or instruments especially devised for dry dissections can be employed. Throughout the entire opera- tion the tissues must be drawn asunder as fast as separated, by means of blunt hooks or other form of retractors, to afford ample exposure of each succeeding part. As soon as the trachea is reached and all hemorrhage checked, it is seized by a hook—the double one of Lan- genbeck being the best—drawn forward to near the surface of the wound, firmly held, and three or four rings of the trachea divided ex- actly in the median line from below upward, by a sharp-pointed knife (Fig. 787). Then the dilator is introduced, and the tube inserted and confined in position after the tracheal mucus and blood have been expelled. All incisions, except the primary one, must be di- rected upward to avoid the great vessels at the root of the neck. The opening in the trachea should be long enough to admit the easy ex- pulsion of all false membranes and foreign bodies (even an inch in length is not too much for this purpose), and must likewise readily admit the trachea tube. Operation above the Isthmus.—Make an incision of the usual MISCELLANEOUS OPERATIONS. 501 length, its center corresponding to the lower border of the cricoid car- tilage ; divide and carefully separate the tissues as before ; the loop of communication between the superior thyroid veins must be carefully drawn upward ; the fascial attachment between the isthmus and the cricoid cartilage divided, the isthmus pulled downward and drawn for- ward by a blunt hook, when the trachea can be opened beneath it from below upward, and the tube inserted with the same precautions as before. Operation through the Isthmus.—This is hardly of enough prac- tical importance to be entitled to a detailed consideration, since the opportunities afforded above and below it will be sufficient. If, how- ever, this position be selected, the isthmus should be divided between two ligatures to avoid the probability of troublesome hemorrhage. It sometimes happens that the isthmus is small or too illy developed to be troublesome after its division. Laryngo-tracheotomy.—In this operation the larynx and trachea are both opened by a continuous incision, which is usually made to increase the space, that foreign bodies and false membrane may be re- moved. The incision through the cricoid cartilage and upper rings of the trachea is then secondary to the opening of the larynx. Before the primary incision is extended, the communicating branches of the superior thyroid veins should be pulled downward, the lower border of the cricoid exposed, its fascial connection to the isthmus severed, and the isthmus drawn downward and forward as before. Rapid Laryngo-tracheotomy (Saint-Germain).—It is sometimes necessary to open the larynx very quickly ; therefore it is quite proper to mention some of the points connected therewith, that the surgeon may be prepared to act with dispatch combined with great caution. Operation.— With the patient placed in the usual position for tra- cheal operations, the surgeon locates the thyroid and cricoid cartilages and the space between them. Then, standing on the right side of the patient, he seizes and pushes forward the larynx by pressing the thumb and index-finger between it and the vertebral column, thereby making the integument tense. At the same time the index-finger locates the lower border of the thyroid cartilage. A straight, sharp- pointed bistoury is then seized between the thumb, index, and middle fingers, its back upward, with the middle finger so placed that the knife can not penetrate to exceed half an inch in depth. While thus held, its point is quickly entered at the nail of the index-finger and the blade is carried downward with a sawing motion, dividing the crico-thyroid membrane, cricoid cartilage, and one or two rings of the trachea. The opening through the integument should equal m length the one made in the larynx and trachea. The dilator is introduced, all bleeding checked, and the tracheal tube placed in position. Saint- 502 OPERATIVE SURGERY. Germain up to 1877 had operated by this method ninety-seven times, with but three cases of hemorrhage, and one in which the posterior wall of the trachea was cut. If the tube be too large, too loose, or too angular, it is liable to cause erosions and ulcerations of the trachea, which may extend through it and implicate the vessels at the root of the neck, causing fatal hemorrhage. The method of opening into the trachea by a sin- gle incision is fraught with danger, and should not be attempted ex- cept the neck of the patient be long and thin, and not even then unless the exigencies of the case call for it. The division of the tissues down to the trachea by means of thermo- or galvano-cautery has many advo- cates ; it is not, however, the adopted practice of this country. The searing of the tissues is said to prevent or lessen hemorrhage, and likewise to obviate the inoculation of the incision by contagious germs. This is not altogether true, since the large veins which might be oth- erwise avoided are burned asunder and too often cause severe hemor- rhage, which is not easily controlled because of the difficulty of prop- erly securing the charred extremities of the vessels. The resulting cicatrix is more disfiguring than that following other methods. It is advised in bronchotomy for diphtheria and acute affections of the air- passages that the tube be dispensed with, since it can only prove a source of local irritation, and obstructs the exit of false membranes and the secretions. As a substitute, the borders of the tracheal open- ing can be kept drawn asunder by passing looped ligatures through them (Martin), which are united to each other behind the neck. The patient must be carefully watched with this appliance, since if the head be turned the opening may become closed. If this prove trouble- some, an elliptical piece can be removed from the anterior surface of the tube. If the piece removed exceed a third of the diameter of the tube, fatal stenosis may follow its closure. Results.—But few perish from the direct results of the preced- ing operations. Bronchitis, pneumonia, hemorrhage from ulceration through the trachea caused by the tube, and primary hemorrhage from wounds of the vessels at the root of the neck, or from any ab- normally large erico-thyroid artery, constitute the leading causes of death directly due to the operation. A deeply cyanosed patient, in the tonic stage of anaesthesia, may die, especially if blood be allowed to enter the tracheal opening. In this contingency the blood must be removed at once, and artificial respiration be resorted to. Tracheoto- my in diphtheria is undoubtedly a most feasible operation, and should be performed early, before cyanosis is well established. Dr. Monti, of Vienna, in his recent work on "Croup and Diphtheria," records 12,736 tracheotomies for diphtheria alone, with 3,409 recoveries, or nearly twenty-eight per cent. It is estimated that twenty-five per cent of these cases have been saved which otherwise would have died. MISCELLANEOUS OPERATIONS. 503 About twenty-seven and a half per cent perish after bronchotomy for the removal of foreign bodies. Intubation of the Larynx.—It appears to be proper in this place to consider a plan of treatment of laryngeal obstruction which has of late attracted more than usual attention, especially in connection with the apparatus devised for the purpose by Dr. O'Dwyer, of this city (Fig. 790). "The numbers on the scale (Fig. 790, d) indicate the Fig. 790.—O'Dwyer's instruments for intubation of the larynx, a. Mouth-gag. b. Introducer, with larynx tubes, c. Extractor, d. Scale. years for which the corresponding tubes are suitable. For instance, the smallest tube when applied to the scale will reach to the first line, marked 1, and is intended to be used up to the age of twelve or fifteen months; the size marked 2 is suitable for the next year, 3 and 4 for these years, and so on. When the proper tube is selected for the case 504 OPERATIVE SURGERY. to be operated on, a fine thread is passed through the small hole near its anterior angle, and left long enough to hang out of the mouth after the introduction of the tube, its object being to withdraw the tube should it be found to have passed into the oesophagus instead of the larynx. " The obturator is then fastened tightly to the introductor, to pre- vent the possibility of its rotating while being inserted and passed into the tube. "The following is the method of introducing the tube, which is done without the use of an anaesthetic : The child is held upright in the arms of a nurse, and the gag (Fig. 790, a) inserted in the left angle of the mouth, well back between the teeth, and opened widely; an assistant holds the head, thrown somewhat backward, while the op- erator inserts the index-finger of the left hand into the mouth to ele- vate the epiglottis and draw the bone of the tongue forward, and at the same time direct the tube into the larynx. " The handle of the introductor (Fig. 790, b) is held close to the patient's chest in the beginning of the operation, and rapidly elevated as the canula approaches the glottis. The tube is then pushed down- ward, without using much force. The tube is then detached. The joint in the shank of the obturator is for the purpose of facilitating this part of the operation. As soon as the obturator is removed, and it is ascertained that the tube is in the larynx, the thread is with- drawn, but at the same time the finger is kept in contact with the tube to prevent its being also withdrawn. " It is important that the attempt at introduction be made quickly, as respiration is practically suspended from the time that the finger enters the larynx until the obturator is removed. It is, therefore, under the circumstances, much safer to make several abortive attempts than one prolonged effort, even if successful. "For the purpose of removal, the patient is held in a similar posi- tion, except that the head is not inclined backward, or very slightly so, and the extractor (Fig. 790, c) passed into the tube guided by the index-finger of the left hand, which also fixes the epiglottis, and is brought in contact with the head of the canula. Firm pressure with the thumb is then made on the lever above the handle while the tube is being withdrawn. If secondary dyspnoea supervenes at any time, the tube should be removed and a larger one substituted. These tubes will also prove valuable as dilators in chronic stenosis of the larynx or trachea." It is recommended by Dr. O'Dwyer that preliminary practice in the introduction and removal of the tube be had upon the cadaver when this means of gaining experience is feasible. The removal of the tube is more difficult than the introduction, on account of the trouble of inserting the blades of the extractor into the open upper MISCELLANEOUS OPERATIONS. 505 end of the tube while more or less completely hidden from view by the natural position of the surrounding soft parts. This part of the operation becomes especially troublesome when the patient offers any opposition to the attempt, and it may become necessary under these circumstances to administer an anaesthetic before the tube can be safely removed. > Prognosis.—The rate of mortality in laryngeal obstruction when treated by this method is not as yet well established, although it ap- pears thus far to compare favorably with that following either of the varieties of bronchotomy. This plan certainly offers especial advan- tages for the treatment of stenosis of the larynx from other causes and for the relief of those cases of acute stenosis for which the friends of the patient refuse tracheotomy as a means of relief. Foreign Bodies in the Bronchi.—It is advisable to endeavor to ex- tract a foreign body located in either bronchus rather than to trust to nature to expel it. Its site should be carefully determined by auscul- tation—it is more frequently located on the left side—before the open- ing is made in the trachea. After this, if a flexible probe be passed through the opening in the lire of the suspected bronchus, it may be easily detected. The foreign body may be grasped by forceps of a proper shape and size, or a wire with a hooked extremity may be passed beyond it, and withdrawn, thus displacing or removing the obstruction. A loop of surgical silver wire, as suggested by Dr. J. L. Little, can be pushed past it, turned somewhat and withdrawn with the best of results. In any instance no harm can be done by this simple agent. Half an hour is quite sufficient time to continue the manipulation. Thyrotomy.—This operation consists in dividing the thyroid car- tilage exactly in the median line, together with the crico-thyroid and thyro-hyoid membranes when additional room is desired. Morbid growths and foreign bodies in the larynx, below the false vocal cords, which threaten death from asphyxia and can not be removed through the mouth, demand its performance. It is wise to anticipate the dan- ger that may arise from the passage of blood into the trachea, by pre- liminary tracheotomy, especially if the tumor be a large or a very vas- cular one. Operation.—Place the patient as for tracheotomy ; administer an anaesthetic ; make an incision an inch and a half in length in the median line, extending from the hyoid bone downward ; divide the fascia on a director ; separate the sterno-hj-oid muscles, and with a grooved director press aside the tissues beneath, and expose the angle of the thyroid cartilage. If the patient be a child, this will be some- what difficult to discern, even after the exposure ; still, the center of the notch at the upper and lower borders of the cartilage marks the extremities of the line of the incision to be made. The cartilage is 506 OPERATIVE SURGERY. held firmly by a tsnaculum, and the division made exactly in the me- dian line, with a sharp-pointed knife, down to the mucous lining within. If it be divided at either side of the median line, the origin of the corresponding vocal cord will be cut. After all hemorrhage is checked, the mucous lining is divided and the lips of the cartilage wound separated by hooked retractors, and, if need be, the incision extended through the membranes above and below. The obstruction is then removed and the cartilage accurately apposed and united by fine catgut. The soft parts are then united and treated antiseptically. If the cartilage be not accurately joined, the functions of the vocal cords will be impaired, owing to their abnormal relations to each other. If the cartilaginous ridge be nicked transversely before its division, it can be accurately apposed thereafter by joining the carti- laginous borders on the line of the nicks. Results.—Nearly eight and one half per cent die from the opera- tion. Sub-hyoid Laryngotomy, or Pharyngotomy.—This operation is ad- missible for the removal of foreign bodies and morbid growths situ- ated high up in the air-passage, and for the relief of abscesses at the base of the epiglottis. Operation.—Place the patient as for laryngotomy ; administer an anaesthetic, and make an incision an inch and a half or two inches in length transversely along the lower border of the hyoid bone, with its center in the median line. The integument, fascia, platysma, and the inner portions of each sterno-hyoid muscle, and finally the thyro- hyoid, are divided on a director. The only vessel contiguous to the incision is the superior thyroid artery, which runs along the upper bor- der of the thyroid cartilage, parallel with the incision. As soon as the thyro-hyoid membrane is cut, the epiglottis will project through the opening, and must be drawn aside, when the tumor will be ex- posed to view. After the removal of the growth, the wound is closed and dressed antiseptically. The majority of the conditions calling for this operation can be satisfactorily treated through the mouth. Prognosis.—The operation itself implies no unusual danger to the patient. Laryngectomy.—The removal of the entire larynx is not a difficult operation if the surrounding tissues be not involved by the disease. Operation.—Make a vertical incision in the median line from the hyoid bone to the second ring of the trachea; free the sides of the larynx from its muscular attachments without opening into it; draw the trachea forward with a hook and separate it transversely from the larynx; a siphon-tube of vulcanite is then introduced, or the Tren- delenburg tampon, to prevent the entrance of blood, and at the same time afford a proper channel for the use of the anaesthetic. If there be much oozing of blood, the head may be lowered to cause it to flow MISCELLANEOUS OPERATIONS. 507 from the trachea, when the posterior and upper connections of the larynx are severed. The oesophagus must be carefully located, or it may be cut. The tissues should be separated by the fingers when pos- sible, aided by blunt-pointed scissors. The amount of hemorrhage is trifling and easily controlled ; the branches of the superior and in- ferior thyroid vessels furnish the principal bleeding points, and these should be tied and divided between two ligatures before the growth is separated from its connections. The after-treatment consists in keep- ing the parts thoroughly cleansed, and regulating the temperature of the room, together with careful attention to the tracheal tube. It often happens that in addition to the larynx the hyoid bone, base of the tongue, pharynx, and oesophagus, are involved in a malignant growth. The first step under these circumstances is to introduce the tampon canula of Trendelenburg, or a substitute, through which the anaes- thetic is administered. Make a transverse incision through the skin from the inner edge of one sterno-mastoid muscle to the other, pass- ing half an inch above the hyoid bone ; from this carry a second one vertically downward along the median line of the trachea to the in- cision made to open the trachea ; turn the flaps outward ; remove all large glands in the vicinity ; divide the muscular attachments to the hyoid bone ; tie the lingual and superior thyroid arteries ; excise the tongue below the disease, along with the palato-pharyngeal arches if necessary, carefully avoiding the external carotid arteries, when it is possible ; if not, draw them forward along with the pharynx and divide them between two ligatures; cut the lingual and hypoglossal nerves. The larynx is now separated from the trachea by cutting the latter just below the cricoid cartilage ; a canula is introduced into it; the parts are thoroughly washed with a carbolized solution ; the flaps placed in contact with the raw surfaces without sutures, and the wound sprinkled with iodoform. If the oesophagus be divided, its lower extremity must be kept open and so placed that it can be protected from the entrance of discharges, and become an available channel through which to nourish the patient. Results.—The prognosis of complete extirpation is better than the partial. In speaking of the results, Prof. S. D. Gross says : " Of thirty-seven complete excisions, nineteen recovered and eighteen died, at periods varying from ten to sixteen days, the cause of death in twelve having been pneumonia. Of the entire number thirty were for carcinoma, of which sixteen perished from the effects of the operation ; seven died of the recurrence of the disease in from four to nine months ; one died from an accident, and six were still living." After the extirpation of the larynx, its place may be supplied by an artificial appliance which, although ingenious, serves as a poor substitute for the normal parts. _ . Cohen, of Philadelphia, in a paper on "Does Excision of the Lar- 508 OPERATIVE SURGERY. ynx tend to the Prolongation of Life?" gives the results of sixty-five complete operations, over forty of which were done for carcinoma. Without entering into the details of the cases, it is sufficient to add that Dr. Cohen is of the opinion that tracheotomy and simpler means give a much better chance of prolonging life. Removal of a Goitre (Watson).—When the patient is in danger of suffocation, it is admissible to attempt the removal of the growth, which is done in the following manner : Operation.—The patient is placed in the dorsal position with the head situated so as to afford the best opportunity for breathing ; care- fully administer an anaesthetic ; make a free incision in the median line from the upper part of the growth to the sternal notch ; divide all the tissues on a director in the line of the incision down to the capsule; draw aside the muscles covering the growth if its size will permit; if not, cut them transversely on a director ; secure all bleed- ing points as fast as seen ; separate the cervical fascia from the capsule of the tumor with the fingers, down to the thyroid arteries, which must be ligatured. All fibrous connections between the capsule and the fascia should be tied before they are cut. The capsule can now be opened and its attachments to the growth severed by the scissors. If the capsule be opened before the arteries are ligatured, the hemor- rhage will be profuse and the ability to control it limited. After all hemorrhage has ceased, the wound is closed with catgut sutures, drained, and dressed antiseptically. Results.—The chance for the life of the patient is flattering. Since the plan of operation just described has been practiced, less than seven per cent have perished from it. The operation has been performed about three hundred and forty-five times since 1877. Recently, when done with antiseptic precautions, a large proportion have proved suc- cessful. Total extirpation is no more fatal than incomplete. Kocher has pointed out the fact that, if the thyroid body be removed before adolescence, cachexia followed by idiocy of the patient are common sequels. Arthrectomy.—The performance of this operation is limited sub- stantially to the knee-joint, and consists in forming a flap by a serrr- lunar incision, similar in its outline to the one employed in excision of the knee. The flap is reflected upward, and the capsule opened at each side of the patella and its ligament, or the patella may be sawn across and the fragments turned upward and downward. The re- mainder of the operation consists in the careful removal of all the diseased portions of bone, cartilage, synovial membrane, and liga- ment, with scissors, scoops, etc. The most difficult part of the operation is the removal of the pos- terior portions of the semilunar cartilages and the synovial membrane at the posterior part of the joint. Much time and patience are neces- MISCELLANEOUS OPERATIONS. 509 sary to faithfully meet the indications of this operation. After all hemorrhage has ceased, the entire cavity, including the upper syno- vial pouch, must be thoroughly cleansed and drained, and an anti- septic dressing applied to the limb. Prognosis.—The results thus far do not warrant the belief that this operation can be employed as a suitable substitute for excision, except, perhaps, in those cases where suppuration is slight, disease of the bone superficial and circumscribed, and when no constitutional vice is present. Wiring the Patella.—The generally accepted opinion that this operation is a justifiable measure in selected cases, and under suitable conditions, requires that its modus operandi be given some attention. Operation. — An incision is made transversely across the joint from one condyle to the other, passing between the fragments of the bone and freely ex- posing the joint-cavity. All blood-clots and bony asperities are removed from the broken borders of the fragments. The lacerated tissues about the joint are trimmed away and the blood-clots turned out. The fibrous tissues at the broken borders of the bone are trimmed off closely. Every form of blood and for- eign substance must be removed from the joint-cavity, especial care being tak- en to cleanse the upper synovial pouch and the posterior aspect of the joint. Drainage should be made through the posterior wall at each condyloid depres- sion, carefully avoiding the nerves and vessels in the popliteal space. The frag- ments are then drilled (Fig. 791), and one or more wire sutures introduced (Fig. 792). The joint-cavity is again thoroughly cleansed, all hemorrhage checked, and the fragments placed in contact with each other, the sutures tightened, their ends twisted together, cut short and turned inward from the surface (Fi°- 793). The cut borders of the capsule of the joint are united independently by a continuous suture of fine catgut, after Fig. 791.—French bone-drill. 510 OPERATIVE SURGERY. which the superficial tissues are joined by catgut of a larger size. Horse-hair drainage may be made at the sides between the tissues joined by the two rows of sutures. The antiseptic douching should be continuous during the entire operation. The external dressings are applied, and the limb is immovably fixed in an extended position. After a week or ten days fresh dressings are applied, and the drainage agents removed ; if suppuration has not occurred, one redressing may suffice. Yet it is better to again redress the limb after a week or so, when, if the wounds be healed, the limb can be confined in a plaster- of-Paris splint and the patient permitted to move around. The op- eration may be performed at any time during the first week or ten days after the injury. If the fracture be compound, it should be wired at once. In an old case, when the quadriceps extensor tissues have become contracted and atrophied, a V-shaped incision through its structure may be necessary in order to bring the freshened edges of the fragments in contact. The olecranon process, when fractured, may likewise be wired. The wire sutures need not be removed at all unless they cause trouble. Silk-worm gut is sometimes employed for this purpose, instead of the silver wire. Results.—Prior to 1883 the patella had been wired forty-nine times, of which two of the patients died, one of pyaemia and one of exhaustion. Besides these, six cases resulted in suppuration and an- chylosis. During the last two years upward of a hundred and forty cases have been reported, in a few of which suppuration has occurred, and in two or three death has followed. In my opinion, this measure should not be employed except for other reasons than that of the existence of a simple fracture of the bone, because I do not believe that it is good surgery to expose a patient to the contingencies of suppuration, amputation, anchylosis, and even death, for the better rectification of an injury, which at its worst has no tendency to ter- minate fatally, and almost invariably results in a serviceable limb when treated by the ordinary methods. Movable Bodies in Joints.—Movable bodies in joints not infre- quently become a source of so much annoyance that the comfort of MISCELLANEOUS OPERATIONS. 511 the patient, as well as the usefulness of the limb, demand their re- moval. Ordinarily these bodies appear at intervals at some point cor- responding to the external line of the articulation, where they can be easily felt, and where they will remain until displaced into the articu- lation again by movements of the joint or by manual manipulation. Operation.—An attempt to remove these bodies should not be made except under strict antiseptic precautions. The patient is given an anaesthetic, or, if the object be a small one, an injection of cocaine may be employed instead. After the movable body is fixed firmly in position by passing into it through the superficial tissues a sharp- pointed awl-like instrument, an incision is made directly down upon it, all bleeding checked, and the synovial lining of the joint is carefully opened sufficiently to permit the introduction of a strong pair of sharp-toothed forceps, by which the movable body is grasped and care- fully drawn through the incision in the soft parts. If it be adherent to the deeper joint-structure, it may be either pulled or cut away. The wound is closed by two rows of sutures, one of fine catgut, that unites the borders of the synovial membrane and its subjacent tissue, the second completely unites the remaining tissues. A few strands of horse-hair or catgut introduced between the tissues united by the two rows of sutures are sufficient for suitable drainage. The limb is now dressed antiseptically and immovably fixed in the extended position. At the end of four or five days the dressing is removed, drainage agents withdrawn, and the limb redressed as in the first instance. If the drainage agents are composed of a material that can be absorbed, one dressing may suffice for the entire treatment of the case. If the foreign bodies be not accessible during their wanderings, it may become necessary to open the joint in front by a free incision to re- lieve the suffering of the patient. Flexion and extension of a joint often aid in the removal of these bodies. Prognosis.—The danger to life or limb is trivial when the opera- tion is performed antiseptically. Relief from the suffering is certain if all the offending agents be removed. Ganglion is a name applied to a limited though abnormal collec- tion of fluid found in connection with the sheaths of tendons, and situated most commonly at the back of the wrist, although found not infrequently at the anterior surface and in the palm. It is also de- pendent on the protrusion of the synovial lining of the carpal articular surfaces, through a rupture of the fibrous sheath by which they are connected with each other. Two methods of treatment are commonly employed : 1. The simple or palliative method. 2. The radical or curative method. The palliative method comprises simple measures, such as rest to the part, pressure, counter-irritation, tapping, etc. These measures are sometimes followed by permanent recovery. 512 OPERATIVE SURGERY. The radical method has two distinct plans of procedure : 1. The rupture of the ganglion by pressure with the thumbs or by a sharp, quick blow with the back of a book, while the hand is placed on the knee. After this the simple measures may be employed. 2. The sac may be divided subcutaneously, under antiseptic precautions, or a free incision may be made through the soft parts down to the sac. It is then opened, the contents evacuated, and the borders trimmed sufficiently to permit their union, which is accomplished by sewing them with a continuous suture of fine catgut. Antiseptic precautions should be rigidly enforced during and subsequent to this plan of operation. It sometimes becomes necessary to scoop or dissect out the diseased membrane, especially when the disease is in the course of the tendi- nous sheaths of the digits, before a cure can be effected. The injection of irritating fluids, such as tincture of iodine, etc., is recommended with much reserve. Prognosis.—The radical method of treatment is the only one that offers a fair prospect of cure, and this is not usually successful unless the diseased membrane be treated by means of direct incision. If it become necessary to dissect or scrape away the synovial sheaths, the prognosis of usefulness of these digits is somewhat dubious. How- ever, so far as the preservation of life and limb is concerned, neither is exposed to unusual danger if the surgical principles of antisepsis be strictly observed. Wiring of Bones for Compound Fractures.—This operation is con- sidered now to be an entirely proper one, when it can be done with strict antiseptic precautions. It is indicated especially if the tendency to displacement of the fragments be great, due to either involuntaryor voluntary muscular movements. Operation.—Administer an anaesthetic, and employ all antiseptic precautions. Enlarge the wound of the soft parts in the direction best intended to expose to view the injuries of the deeper tissues and to avoid injury of the blood-vessels and nerves. Trim off the bruised portions of the soft parts, both deep and superficial, with scissors. The periosteum should be carefully preserved, and be replaced in the normal position, when possible, even if it have been detached from the bone. The disconnected fragments of bone, and other loose portions of bone that can not be preserved, should be taken away. Remove the blood-clots, check the haemorrhage, and make counter-openings for drainage. The fracture is now reduced, and the remaining fragments are drilled and united together firmly with fine silver wire or silk-worm gut. The drainage-tubes are then introduced, the openings of the soft parts are closed by catgut sutures, the limb dressed antiseptically, and immovably fixed by being incased in a plaster-of-Paris splint, or with strips of tin or iron placed longitudinally. The general princi- ples relating to antiseptic dressings should be observed in the further MISCELLANEOUS OPERATIONS. 5^3 treatment of the case. The wire sutures need not be removed unless they cause trouble. Prognosis.— The prognosis is excellent. Many useful limbs have been gamed by this method, combined with strict antisepsis, perfect immobility, and suspension, that would otherwise have been amputated or have recovered with great loss of function. 33 INDEX. Abdominal aorta, ligature of. 60. linear guide to, 60. Abdominal section, 362. explorative, 362. Abdominal tourniquet, Brandis', 287. Esmarch's, 287. Lister's, 287. Lloyd's, 289. Pancoast's, 287. Abscess in the right iliac fossa, 373. perityphlitic, 373. Actual cautery, 35. Acupressure, 31. pins, 32. Adams' operation for subcutaneous division of the neck of the femur, 216. Adductor magnus, tenotomy of, 158. Agents for controlling hemorrhage, 23. Agnew's operation for radical cure of in- guinal hernia, 383. Air in the veins, 55. symptoms, 55. treatment of, 55. preventive treatment of, 55. Allis' ether-inhaler, 8. Amputating knife, manner of grasping the, 230. knives, 230. knives, the catlin, 231. saw, proper method of using an, 233. saws, 232. Amputation, agents required for, 230. circular method, 224. circular method, modified, 226. classification of flaps, 224. comparative merits of different forms of flaps, 230. double-flap method, 227. equilateral flaps, 229. hood flap, 229. how to operate, 235. Langenbeck's method, 228. mixed double-flap method, 228. oval method, 227. periosteal flap, 229. rectangular-flap method, 228. single-flap method, 227. Teale's method, 228. the retractor in, 236. Amputation at the ankle-joint, Pirogoff, 270. Bruns' modification of Pirogoff's, 272. Esmarch's modification of Le Fort's, 273. Fergusson's modification of Pirogoff's, 271. Le Fort's modification of Pirogoff's, 272. Roux's, 269. Syme's, 267. modification of Syme's, 268. Amputation of the arm, 248. circular-flap method, 248. large anterior and small posterior flaps, 250. musculo-cutaneous flaps, Langenbeck, 249. unequal double-flap method, 249. Amputation at the elbow-joint, 247. circular method, 247. single-flap method, 248. Amputation of the forearm, 246. circular method, 246. equilateral skin-flaps, 246. musculo-cutaneous flaps, 247. Amputation at the hip-joint, 287. anterior oval method, Verneuil, 296. circular method, Dieffenbach, 292. lateral-flap method, 296. long anterior and short posterior flap, Maenec, 290. single-flap method, Malgaigne, 293. Amputation at the knee-joint, 278. bilateral method, 279. circular method, 280. long anterior, with a short posterior flap, 281. through the condyles, 281. through the condyles, Carden, 282. through the condyles, Gritti, 283. Stokes' modification of Gritti's, 283. Amputation of the leg, lower third, 274. lower third, bilateral method, 276. lower third, circular, with periosteal re- flection, 274. lower third, hood or oval flap, 277. middle third, 277. middle third, unilateral-flap method, 278. supra-malleolar, 274. upper third, 278. Amputation, lower extremity, 255. through medio-tarsal joint, Chopart, 262. 516 INDEX. Amputation through medio-tarsal joint, Forbes' modification of Chopart's, 264. of the last four metacarpal bones, 243. through the metacarpal bones, 242. Amputation at the metacarpo-phalangeal ar- ticulation, 239. through all the metatarsal bones, 258. Amputation, osteoplastic, of heel and ankle, Mikulicz, 273. Amputation of the penis, old plan, 462. Hilton's modification, 462. Humphrey's modification, 463. Amputation at phalangeal articulations of the hand, 237. Amputation above the shoulder-joint, 255. Amputation at the shoulder-joint, 250. by circular incision, 252. by internal and external flaps, Dupuytren, 250. by oval method, Larrey, 252. Spence's method, 253. Amputation, subastragaloid, De Lignerolles, 264. subastragaloid, Hancock, 266. subastragaloid, Tripier's method, 266. Amputation, tarsal, irregular, Moliere, 266. Amputation at the tarso-metatarsal joint, Li^franc, 260. Bauden's modification of Lisfranc's, 262. Hey's modification of Lisfranc's, 262. Skey's modification of Lisfranc's, 262. Amputation of the thigh, 283. antero-posterior musculo - integumentary flaps, 285. bilateral method, 284. circular integumentary flap, 285. long.anterior-flap method, Sedillot, 286. single circular incision method, Celsus, 285. Amputation of the thumb, at the carpo-meta- carpal articulation, lateral-flap method, 241. at the carpo-metacarpal articulation, oval method, 240. Amputation of the toe, fifth, with its meta- tarsal bone, lateral-flap method, 259. fifth, with its metatarsal bone, 259. great, by large square internal flap, 257. great, with its metatarsal bone, 259. Amputation of the toes, all, at the metatarso- phalangeal joint, 258. of toes, in their continuity, 255. of toes, two adjoining, 257. of single toes, 256. of single toes, by lateral flap, 256. Amputation of upper extremities, 236. Amputation at the wrist-joint, 244. circular method, 244. double-flap method, Ruysch, 244. radial flap, Dubrueil, 245. single palmar-flap method, 245. Amputations, 223. Amussat's operation of left lumbar coloto- my, 368. I Anaesthesia, how to prepare a patient for, 12. ] Anaesthesia, local, 16. Anaesthetic, purity of, 11. Anaesthetics, 5. inhalers for, 7. Anchylosis, 297. bony, of knee-joint, supra-condyloid, oste- otomy for, 217. of inferior maxilla, 178. of inferior maxilla, removal of a wedge- shaped piece, Esmarch, 179. Aneurism-needle, 59. Fletcher's, 60. Mott's, 59. students', 60. Syme's, 59. Anger's operation for hypospadias, 464. Ankle and heel, osteoplastic amputation at, Mikulicz, 273. Ankle-joint, amputation at, Bruns, 272. Fergusson's modification of Pirogoff's, 271. Le Fort's modification of Pirogoff's, 272. Le Fort's modification of Esmarch's, 273. Pirogoff's, 270. Roux's, 269. Syme's, 267. Syme's, modification of, 268. Ankle-joint, excision of, 199. excision of, subperiosteal, Langenbeck, 199. disarticulation at the, 267. Annandale's operation for webbed fingers, 301. Antiseptic fluid, Thiersch's, 61. protective, 48. receptacle for instruments, 21. solutions, 22. spray apparatus, 48. Antrum, perforation of the, 484. Anus, absence of, 403. artificial, 373. examination of, 401. imperforate, 402. Aorta, abdominal, ligature of, 60. Aorta, abdominal, linear guide to, 60. Apparatus, antiseptic spray, 48. douching, 49. for enterectomy, Treves', 365. Arch, palmar, superficial, ligature of, 106. Arch, palmar, superficial, linear guide to, 106. Arm, amputation of the, 248. by large anterior and small posterior flaps, 250. by musculo-cutaneous flaps, Langenbeck, 249. circular-flap method, 248. unequal double-flap method, 249. Arteries, ligature of, 56. general considerations, 56. guides to, 56. iliac, 62. instruments required for, 59. I operations on special, 60. j Artery, abdominal aorta, ligature of, 60. INDEX. 517 Artery, abdominal aorta, linear guide to, 60. axillary, first portion, ligature of, 95. axillary, first portion, linear guide to, 95. axillary, ligature of, 95. axillary, third portion, ligature of, 97. axillary, third portion, linear guide to, 97. brachial, ligature of, 98. brachial, linear guide to, 99. Artery, carotid, common, ligature of, 106. common, linear guide to, 107. common, ligature of both, 110. external, ligature of, 110. external, linear guide to, 110. internal, ligature of, 111. Artery, dorsalis pedis, ligature of, 82. dorsalis pedis, linear guide to, 82. dorsalis penis, ligature of, 69. epigastric, ligature of, 71. epigastric, linear guide to, 71. facial, ligature of, 115. femoral, deep, ligature of, 77. femoral, ligature of, 72. femoral, linear guide to, 72. gluteal, ligature of, 66. gluteal, linear guide to, 66. Artery, iliac, circumflex, deep, ligature of, 71. iliac, common, ligature of, 62. iliac, external, ligature of, 69. iliac, internal, ligature of, 65. Artery, innominate, ligature of, 86. lingual, ligature of, 113. lingual, linear guide to, 113. mammary, internal, ligature of, 94. mammary, internal, linear guide to, 95. occipital, ligature of, 116. peroneal, ligature of, 85. peroneal, linear guide to, 85. popliteal, ligature of, 77. popliteal, linear guide to, 77. profunda femoris, ligature of, 77. pudic, internal, ligature of, 68. pudic, internal, linear guide to, 68. radial, ligature of, 101. radial, linear guide to, 101. sciatic, ligature of, 67. sciatic, linear guide to, 67. subclavian, ligature of first portion, left side, 87. subclavian, ligature of first portion, right side, 89. subclavian, ligature of second portion, 92. subclavian, ligature of third portion, 90. subclavian, second portion, linear guide to, 89. subclavian, third portion, linear guide to, 89. temporal, ligature of, 116. thyroid, inferior, ligature of, 95. thyroid, inferior, linear guide to, 95. thyroid, superior, ligature of, 113. tibial, anterior, ligature of, 79. tibial, anterior, linear guide to, 79. tibial, posterior, ligature of, 82. tibial, posterior, linear guide to, b«J. ulnar, ligature of, 104. Artery, ulnar, linear guide to, 104. vertebral, ligature of, 92. vertebral, linear guide to, 93. Arthrectomy, 508. Artificial anus, 373. Artificial hemostatics, 24. Artificial respiration, 14, 54. Aspiration of the bladder, 421. Assistants at operations, 40. Astragaloid osteotomy, Stokes', 303. Astragalus, excision of, 199. Auricularis magnus nerve, operations on, 146. Axillary artery, first portion, ligature of, 95. Axillary artery, first portion, linear guide to, 95. Axillary artery, ligature of, 95. Axillary artery, third portion, ligature of, 97. Axillary artery, third portion, linear guide to, 97. Axillary glands, extirpation of the, 481. Bandages, 24. elastic, 24, 54. Battery, electric, 53. Bauden's amputation at tarso-metatarsal joint, 262. Bichloride-of-mercury dressing, 51. Bilateral lithotomy, 450. Nelaton's modification of, 451. Billroth's operation for excision of the tongue, 342. Birth-mark, 132. Bladder, aspiration of the, 421. digital exploration of the, 422. extroversion of the, 423. extroversion of the, F. F. Maury's opera- tion, 423. extroversion of the, Pancoast's operation, 424. extroversion of the, Wood's operation, 424. stone in the, 427. operations on the, 410. puncturing the, 425. puncturing the, through the rectum, 426. puncturing the, under the pubes, 426. rupture of the, 421. Bloodless stretching of sciatic nerve, great, 148. Bone-forceps, 136, 163. Bones, operations on, 162. excision, 165. gouging, 162. osteotomy, 212 sequestrotomy, 163. sequestrotomy, direct method, 164. sequestrotomy, indirect method, 165. wiring of, in compound fractures, 512. Bourgary's excision of bones of forearm, lower extremities of, 192. Bow-legs, 221. Brachial artery, ligature of, 98. 518 INDEX. Brachial artery, linear gu ide to, 99. Brachial plexus, operations on, 146. Brandis' tourniquet, abdominal, 287. Breast, extirpation of the, 480. Brisement force, 297. Bronchi, foreign bodies in the, 505. Bronchotomy, 492. Bruns' amputation at ankle-joint, 272. Buchanan's medio-lateral operation of lithot- omy, 451. Buck's operation of cheiloplasty, for lower lip, 322. interno - lateral flap method of cheilo- plasty of upper lip, 325. semicircular flap method of cheiloplasty of uppper lip, 325. Bull's (W. T.) transfusion of saline solu- tions. 130. Bunion, 302. Calcaneum, excision of, 198. Canalization, Neubcr, 47. Cancer of the rectum, 412. Capillaries, operations on, 131. division and ligaturing, 134. subcutaneous ligaturing, 132. Garden's amputation at the knee-joint, 282. Carotid artery, common, ligature of, 106. common, linear guide to, 107. external, ligature of, 110. external, linear guide to, 110. internal, ligature of, 111. Carotid arteries, common, ligature of both, 110. Carpo-metacarpal articulation, amputation of the thumb at, by lateral-flap method, 241. by oval method, 240. Castration, 458. Catgut ligatures, 39. how prepared, 40. Catheter, introduction of a, into the blad- der, 417. Catheterization, 417. Cautery, actual, 35. galvano-, 37. thermo-, 36. Celsus' circular amputation of thigh, 285. method of cheiloplasty for lower lip, 321. Cheever's operation for removal of naso- pharyngeal polypi, 4S9. Chiene's osteo-arthrotomy, 220. Cheiloplasty, 320. Buck's method of, for lower lip, 322. Buck's interno-lateral flap method of, for upper lip, 325. Buck's semicircular flap method of, for upper lip, 325. Celsus' method of, for lower lip, 321. deformity of lower lip, V-shaped incision, 320. Dieffenbach's operation of, for upper lip, 326. horizontal incision for lower lip, 321. Cheiloplasty, Malgaigne's operation of, for lower lip, 324. Sedillot's operation of, for lower lip, 324. Sedillot's vertical-flap method of, for up- per lip, 326. Syme's operation of, for lower lip, 322. Chloroform, 6. inhaler, Esmarch's, 6. poisoning by, or overdose of, treatment for, 14. Cholecystectomy, 361. Cholecystotomy, 360. Chopart's amputation through medio-tarsal joint, 262. Circumclusion, 32. Circumcision, 458. Cirsoid growths, 134. Clavicle, excision of, 180. Clean towels and old linen, 22. Clover's ether inhaler, 9. Cocaine, 17. Cock's operatian of tapping the urethra, 478. Colotomy, left inguinal, linear guide to, 372. left inguinal, Littre, 372. left lumbar, Amussat, 368. left lumbar, linear guide to, 368. right lumbar, 372. Compresses, 26. Compress, graduated, 26. Cone, ether, simplest form of, 7. Continuous suture, 44, 349. Contraction of palmar fascia, 160. Cotton-batting dressing, 49. Cripp's operation of excision of the rectum, 413. Crural nerve, anterior, operations on, 149. Curvature of the spine, 298. Czerny's operation for radical cure of in- guinal hernia, 387. Czerny-Lambert intestinal suture, 351. Davy's lever, 29, 288. Decalcified drainage-tubes of Neuber, 47. Deep circumflex iliac artery, ligature of, 71. Deformities, 297. of upper lip, 325. Deformity of lower lip, V-shaped incision, 320. De Lignerolle's amputation, subastragaloid, 264. Delpech's operation of urethroplasty, 470. De Morgan's incision for spinal accessory nerve, 146. Dental nerve, inferior, operations on, 144. Deviation of the septum nasi, 491. Dieffenbach's amputation at the hip-joint, 292. operation of cheiloplasty for the upper lip, 326. operation of rhinoplasty, 310. operation of urethroplasty, 470. Digital pressure, 27. Disarticulation at the ankle-joint, 267. INDEX. 519 Disarticulation, at the elbow-joint, 247 at the hip-joint, 287. at the knee-joint, 278. at medio-tarsal joint, 264. at the metacarpo-phalangeal articulation, at the metatarso-phalangeal joint, 258 at the phalangeal articulations of the foot, at the phalangeal articulations of the hand 237. ' at the shoulder-joint, 250. at the tarso-metatarsal joints, 260. at the wrist-joint, 244. of the fingers, 237. of the last four metacarpal bones, 243. of the toes, 256. sub-astragaloid, 264. Dorsalis-pedis artery, ligature of, 69. linear guide to, 82. Dorsalis-penis artery, ligature of, 82. Douching apparatus, 49. Dowcll's operation for radical cure of in- guinal hernia, 388. Dubrueil's amputation at the wrist-joint, 245. Duodenostomy, 356. Duplay's operation for hypospadias, 465. Dupuytren's amputation at shoulder-ioint 250. J ' contraction, 160. contraction, operation for, 160. Drainage of wounds, 46. Drainage, spiral, Ellis', 46. Drainage-tube, decalcified, of Neuber, 47. rubber, 46. Dressing, open, 53. Dressings, bichloride of mercury, 51. combined, 49. cotton batting, 49. iodoform, 49. peat, 50. protective, 48. Elastic bandages, 24, 54. Elbow-joint, amputation at, 247. amputation at, circular method, 247. amputation at, single-flap method, 248. disarticulation at the, 247. excision of, Hiiter, 189. Electric battery, 53. Ellis' drainage spiral, 46. Elongated uvula, 335. Emergencies, special, 54. Empty vessels, 21. Engine, surgical, 169. Enterectomy, 364. Treves' apparatus for, 365. Enterotomy, 363. right inguinal, Nelaton's operation of, 363. Epigastric artery, ligature of, 71. linear guide to, 71. Epispadias, 467. Nelaton's operation for, 467. Thiersch's operation for, 468. Erector spina?, tenotomy of, 159. Esmarch's chloroform inhaler, 6. Esmarch's modification of Le Fort's ampu- tation at ankle-joint, 273. Esmarch's operation for anchylosis of infe- rior maxilla, 179. Esmarch's tourniquet, abdominal, 2S7. Ether, 5. amount required to produce anaesthesia, 10. cone or inhaler, simplest form, 7. dangers from use of, 11. method of administering, 13. treatment for poisoning by, or overdose of, 14. Ether inhaler, Allis', 8. Clover's, 9. Lente's modified, 9. Noyes', 10. simplest form of cone, 7. Squibbs', 10. Etherization, intestinal, 15. Excision of the ankle-joint, 199. of ankle-joint, subperiosteal, Langenbeck 199. ' Excision of the astragalus, 199. Excision of bones of forearm, lower ex- tremities of, Bourgary, 192. Excision of the bones of the leg, 202. Excision of the calcaneum, 198?' Excision of clavicle, 180. Excision of elbow-joint, Hiiter, 189. of the elbow-joint, Liston, 190. of elbow-joint, subperiosteal, Langenbeck, 190. Excision of the fibula, 202. Excision of great trochanter of femur, 207. Excision of hip-joint, 208. subperiosteal, Langenbeck, 209. Sayre, 211. White, 208. Excision of humerus, 185. head of, subperiosteal, Langenbeck, 186. lower extremity of, 188. shaft of, 187. upper end of, Langenbeck, 185. Excision of the knee-joint, 202. by transverse incision, 207. non-subperiosteal, Mackenzie. 204. subperiosteal, Langenbeck, 205. subperiosteal, Oilier, 206. Excision of joints of lower extremities, 197. Excision of maxilla?, both, 174. Excision of maxilla, inferior, 175. alveolar process, 178. central portion, 176. half of, 177. lateral portion of body, 176. whole of, 178. Excision of maxilla, superior, 170. below floor of orbit, 173. by median incision, with removal of the whole bone, 172. subperiosteal, 173. Excision of metacarpo-phalangeal ioiuts, 197. Excision of nerves, 141. 520 INDEX. Excision of the patella, 207. Excision of phalangeal joints of hand, 197. Excision of the radius, 192. Excision of the rectum, 412. Cripp's operation, 413. Maisonneuve's operation, 414. Volkmann's operations, 413. Excision of rib, portion of, 180. Excision of scapula, 182. body of, 183. for malignant growths, 184. glenoid angle of, 187. subperiosteal, Oilier, 184. Excision of scrotum, 122. Excision of the sternum, 179. Excision of the tibia, 202. Excision of the tongue, 339. Billroth's operation, 342. Heart's operation, 342. Knox's operation, 342. Kocher's operation, 343. Regnoli's operation, 342. Sedillot's operation, 342. Excision of the tonsils, 337. Excision of the ulna, 192. Excision of wrist-joint, 193. of the wrist-joint, complete, Langenbeck, 194. Exploration, digital, of the bladder, 422. Extensor communis digitorum, tenotomy of, 153. longus digitorum, tenotomy of, 156. ossis metacarpi pollicis, tenotomy of, 153. primi internodii pollicis, tenotomy of, 153. proprius pollicis, tenotomy of, 156. secundi internodii pollicis, tenotomy of, 153. quadriceps cruris, tenotomy of, 157. Extirpation of the axillary glands, 480. of the breast, 480. of the parotid gland, 481. of the penis, Gouley, 463. Extroversion of the bladder, F. F. Maury's operation, 423. Pancoast's operation, 424. Wood's operation, 424. Extremities, lower, excision of joints of, 197. Facial artery, ligature of, 115. Facial nerve, operations on, 145. Fasciotomy, 151. Fascia, palmar, 159. Dupuytren's contraction of, 160. Dupuytren's operation for contraction of, 160. Fascia, plantar, 159. Fecal fistula, 37o. Femoral artery, ligature of, 72. linear guide to, 72. deep, ligature of, 77. Femur, great trochanter of, excision of, 207. neck of, subcutaneous division of, Adams, 216. Fergusson's amputation at the ankle-joint, 271. Ferguson's operation of uranoplasty, 834. Fibula, excision of the, 202. Fingers, disarticulation of the, 237. Fingers, webbed, 300. Annandale's operation, 301. Nelaton's operation, 301. Fistula in ano, 404. incision with closure, 407. operation by direct incision, 406. treatment by ligaturing, 407. Fistula, fecal, 373. Fistula, salivary, 335. Horner's operation, 336. operation by a seton, 336. Flat foot, Ogsten's operation, 302. Fletcher's aneurism needle, 60. Flexor, biceps cruris, tenotomy of, 157. biceps cubiti, tenotomy of, 154. carpi radialis, tenotomy of, 153. carpi ulnaris, tenotomy of, 154. longus digitorum, tenotomy of, 154. longus pollicis, tenotomy of, 155. profundus digitorum, tenotomy of, 153. sublimis digitorum, tenotomy of, 153. Fluid, antiseptic, Thiersch's, 51. Foot, flat, Ogsten's operation, 302. Forceps, artery, 33. bone, 136, 163. bone-holding, 167, 235. needle, 42, 332. throat, 348. thumb, 18.. wire-twisting, 329. Fore-arm, amputation of, 246. circular method, 246. equilateral skin-flaps, 246. musculo-cutaneous flaps, 247. Foreign bodies in the bronchi, 505. Forbes' amputation through the medio- tarsal joint, 264. Fractures, compound, wiring of bones in, 512. French operation of rhinoplasty, 307. Gall-bladder, operations on the, 360. Galvano-cautery, 37. Ganglion, 511. Gastro-enterostomy, 355. Gastrostomy, 353. Gauze, iodoform, 50. Gely's intestinal suture, 350. General considerations of operative sur- gery, 1. nursing, 3. place for operation, 3. season of year, 2. temperature of room, 3. time of day, 3. Genu valgum, 218. osteotomy for, 218. Genu varum, osteotomy for, 220. Giraldes' operation for hare-lip, 318. Gland, parotid, extirpation of the, 482. Glands, axillary, extirpation of the, 480. Glover's suture, 44. INDEX. 521 Gluteal artery, ligature of, 66. Goitre, removal of a, Watson, 508. Gouley's operation for extirpation of tl penis, 463. Gouley's operation for hypospadias, 464. Gracilis, tenotomy of, 157. Graduated compress, 26. Grafting, skin, 307. Gritti's amputation at the knee-joint, 283. Grooved director, 18. Guide, linear, to abdominal aorta, 60. to axillary artery, first portion, 95. to axillary artery, third portion, 97. to brachial artery, 99. to carotid artery, common, 107. to carotid artery, external, 110. to dorsalis pedis artery, 82. to epigastric artery, 71. to femoral artery, 72. to gluteal artery, 66. to iliac arteries, common, 62. to iliac artery, external, 69. to left inguinal colotomy, 372. to left lumbar colotomy, 368. to lingual artery, 113. to mammary artery, internal, 95. to palmar arch, superficial, 106. to peroneal artery, 85. to popliteal artery, 77. to pudic, internal, artery, 68. to radial artery, 101. to sciatic artery, 67. to subclavian artery, second portion, 89. to subclavian artery, third portion, 89. to thyroid artery, inferior, 95. to tibial artery, anterior, 79. to tibial artery, posterior, 83. to ulnar artery, 104. to vertebral artery, 93. Guides, whalebone, introduction of, 420. Gussenbauer's intestinal suture, 351. Hallux valgus, 222. Hancock's subastragaloid disarticulation, 266. Hare-lip, 315. complicated, 319. double (simple), 319. simple, 317. simple double-flap operation, 318. Giraldes' operation, 318. simple single-flap operation, 317. sutures, 45. Heart's operation for excision of the tongue, 342. Heaton's operation for radical cure of in- guinal hernia, 381. Hemorrhage, agents for controlling, 23. Hemorrhoids, 119. Hemorrhoids, internal, operations for, 119. crushing, 120. excision, 119. injection, 121. ligaturing, 120. ligaturing with incision, 120. Hemostatics, artificial, 24. Hernia, 380. s femoral, radical cure for, Wood's opera- tion, 388. femoral, strangulated, 397. Hernia, inguinal, radical cure for, Agnew's operation, 383. Czerny's operation, 387. Dowell's operation, 388. Heaton's operation, 3S1. Wood's operation, 384. Wood's operation with pins, 386. Wiitzer's operation, 382. Hernia, inguinal, strangulated, 395. Hernia, obturator, strangulated, 4ol. Hernia, strangulated, 390. Hernia, umbilical, 389. Hernia, umbilical, strangulated, 400. Hey's amputation at tarso-metatarsal ioint 262. J ' Hilton's amputation of the penis, 462. Hip-joint, amputation at, 287. anterior oval method, Verneuil, 296. circular method, Dieffenbach, 292. lateral-flap method, 296. long anterior and short posterior flap, Maenec, 290. single-flap method, Malgaigne, 293. Hip-joint, excision of, 208. Sayre, 211. subperiosteal, Langenbeck, 209. White, 208. Hip-joint, disarticulation at the, 287. Holder, needle, 42. Horner's operation for salivary fistula, 336. Horse-hair sutures, 43. Humerus, excision of, ] 85. of lower extremity of, 188. of shaft of, 187. subperiosteal of head of, Langenbeck, 185. of upper end of, Langenbeck, 186. Humphrey's amputation of the penis, 463. Hiitcr's excision of elbow-joint, 189. Hydrocele, 455. incision of sac of, 456. incision with excision of part of sac, 456. injection of sac, 457. injection of sac, accidents after, 457. tapping of sac of, 455. Hydrocephalus, 134. Hydro-rachis, 135. Hypertrophy of the tongue, 340. Hypospadias, 463. Anger's operation, 464. Duplay's operation, 465. Gouley's operation, 464. Szymanowski's operation, 466. Iliac artery, circumflex, deep, ligature of, 71. Iliac arteries, common, ligature of, 62. linear guide to, 62. Iliac artery, external, ligature of, 69. linear guide to, 69. Iliac artery, internal, ligature of, 65. linear guide to, 66. 522 Imperforate anus, 402. Imperforate rectum, 414. Incisions, 20. Indian method of rhinoplasty, 311. Infra-orbital nerve, operations on, 142. Ingrowing toe-nail, 302. Inhaler, chloroform, Esmarch's, 6. Inhaler, ether, Allis', 8. Clover's, 9. Lente's modified, 9. Noyes', 10. simplest form of cone, 7. Squibb's, 10. Inhalers for anaesthetics, 7. Innominate artery, ligature of, 86. Inorganic or metallic sutures, 43. Instrumental pressure for controlling hemor- rhage, 28. Instruments necessary for the performance of an operation, 18. Instruments, receptacle for, 21. Instruments should be plain, 21. Internal cesophagotomy for stricture, 346. Interrupted suture, 44. Intestinal etherization, 15. Intestinal suture, Czerny-Lambert, 351. Gely's, 350. Gussenbauer's, 351. Jobert's, 350. Lembert's, 350. Intubation of the larynx, O'Dwyer, 503. Iodoform dressing, 49. Iodoform gauze, 50. Italian method of rhinoplasty, 312. Jaw, lower, anchylosis of, 178. Esmarch's operation for, 179. Jaw, lower, excision of, 175. of alveolar process of, 178. of central portion of, 176. of half of, 177. of lateral portion of body of, 176. of whole of, 178. Jaws, upper, excision of both, 174. Jaw, upper, excision of, 170. below floor of orbit, i 73. by median incision, with removal of whole bone, 172. subperiosteal, 173. Jejunostomy, 356. Jobert's intestinal suture, 350. Joint, ankle, amputation at, Esmarch's modi- fication of Le Fort's, 273. Pirogoff, 270. Pirogoff's, Bruns' modification of, 272. Pirogoff's, Fergusson's modification of, 271. Pirogoff's, Le Fort's modification of, 272. Joint, ankle, amputation at, removal of en- tire foot, Syme, 267. removal of entire foot, modification of Syme's, 268. removal of entire foot, Roux's modifica- tion of Syme's, 269. Joint, ankle, disarticulation at the, 267. Joint, ankle, excision of, 199. INDEX. Joint, ankle, subperiosteal, Langenbeck, 199. Joint, carpo-metacarpal, amputation at, 240. Joint, elbow, amputation at, 247. circular, 247. single flap, 248. Joint, elbow, disarticulation at the, 247. Joint, elbow, excision of, Hiiter, 189. Liston, 190. subperiosteal, Langenbeck, 190. Joint, hip, amputation at, 287. anterior oval method, Verneuil, 296. circular method, Dieffenbach, 292. lateral-flap method, 296. long anterior and short posterior flap, Maenec, 290. single-flap method, Malgaigne, 293. Joint, hip, disarticulation at the, 287. Joint hip, excision of, 208., Sayre, 211. subperiosteal, Langenbeck, 209. White, 208. Joint, knee, amputation at, 278. bilateral method, 279. circular method, 280. long anterior, with a short posterior flap, 281. through the condyles, Garden, 282. through the condyles, Gritti, 283. through the condyles, Stokes' modifica- tion of Gritti's, 283. Joint, knee, disarticulation at the, 278. Joint, knee, excision of, 202. by transverse incision, 2i>7. non-subperiosteal, Mackenzie, 204. subperiosteal, Langenbeck, 205. subperiosteal, Oilier, 206. Joint, knee, osteotomy for bony anchylosis of, 217. Joint, medio-tarsal, amputation through, Chopart, 262. Forbes' modification of Chopart's, 264. Joint, metacarpo-phalangeal, amputation at, 239. disarticulation at, 239. excision of, 197. Joint, metatarso-phalangeal, amputation of all the toes at, 258. disarticulation at the, 258. Joint, shoulder, amputation above the, 255. Joint, shoulder, amputation at the, 250. by circular incision, 252. by internal and external flaps, Dupuytren, 250. oval method, Larrey, 252. Spence's method, 253. Joint, shoulder, disarticulation at the, 250. Joint, subastragaloid, amputation at, De Lignerolle's, 264. subastragaloid, Hancock's, 266. subastragaloid, Tripier's, 266. Joint, tarso-metatarsal, amputation, Lis- franc, 260. Bauden's modification of, 262. Hey's modification of, 262. Skey's modification of, 262. INDEX. 523 Joint, wrist, amputation at, 244. circular method, 244 double-flap method, Ruysch, 244. radial flap, Dubrueil, 245. single palmar flap, 245. Joint, wrist, disarticulation at the, 244. Joint, wrist, excision of, 193. complete, Langenbeck, 194. Joints, movable bodies in, 510. Joints of lower extremities, excision of, 197. Joints, phalangeal, of foot, amputation at, 256. disarticulation of the, 256. excision of the, 197. Joints, phalangeal, of hand, amputation at, 237. disarticulation of the, 237. excision of the, 197. Joints, tarso-metatarsal, disarticulation at the, 260. Kclotomy, 392. Keyes' operation for varicocele, 124. Knee-joint, amputation at, 278. bilateral method, 279. circular method, 280. long anterior, with a short posterior flap, 281. through the condyles, Carden, 282. through the condyles, Gritti, 283. Stokes' modification of Gritti's, 283. Knee-joint, disarticulation at the, 278. Knee-joint, excision of, 202. by transverse incision, 207. non-subperiosteal, Mackenzie, 204. subperiosteal, Langenbeck, 205. subperiosteal, Oilier, 206. Knee-joint, osteotomy for bony anchylosis of, 217. Knife, amputating, manner of grasping the, 230. Knife, amputating, the catlin, 231. Knives, amputating, 230. Knot, reef or square, 38. Knots, 38. Knox's operation for excision of the tongue, 342. Kocher's operation for excision of the tongue, 343. Langenbeck's amputation of the arm, 249. Langenbeck's excision of the ankle-joint, subperiosteal, 199. of the elbow-joint, subperiosteal, 190. of the hip-joint, subperiosteal, 209. of the humerus, head of, subperiosteal, 186. of humerus, upper end of, 185.^ of knee-joint, subperiosteal, 203. of wrist-joint, complete, 194. Langenbeck's method of amputation, 228. Langenbeck's operation for removal of nasal polypi, 487. Langenbeck's operation for removal of naso- pharyngeal polypi, 488. of rhinoplasty, 308. Lanuelongue's operation of uranoplasty, 334. Laparotomy or abdominal section, 362. explorative, 362. Larrev's amputation at the shoulder-joint, 252. Laryngectomy, 506. Laryngotomy, 497. sub-hyoid, 506. Laryngo-tracheotomy, 501. rapid, St. Germain, 501. Larynx, intubation of the, O'Dwyer, 503. Larynx, surgical anatomy of the, 493. Lateral lithotomy, 441. Latissimus dorsi, tenotomy of, 158. Le Fort's amputation at the ankle-joint, 272. Left lumbar colotomy, Amussat, 368. Leg, amputation of the, at the lower third, 274. at the lower third, bilateral method, 276. at the lower third, circular, with periosteal reflection, 274. at the lower third, hood or oval flap, 277. supra-malleolar, 274. through the middle third, 277. through middle third, unilateral-flap meth- od, 278. at the upper third, 279. Leg, excision of the bones of the, 202. Lembert's suture, intestinal, 350. Lente's ether inhaler, modified, 9. Lever, Davy's, 29, 228. Ligature of abdominal aorta, 60. Ligature of arteries, 56. general considerations of, 56. guides to, 56. instruments required to, 59. Ligature of axillary artery, 95. first portion, 95. third portion, 97. Ligature of brachial artery, 98. Ligature of carotid arteries, common, both, 110. Ligature of carotid artery, common, 106. external, 110. internal, 111. Ligature of dorsalis pedis artery, 82. of dorsalis penis artery, 69. of epigastric artery, 7L of facial artery, lis. of femoral artery, 72. of femoral artery, deep, 77. of gluteal artery, 66. Ligature of iliac artery, common, 62. circumflex, deep, 71. external, 69. interna], 65. Ligature of innominate artery, 86. of lingual artery, 113. of mammary artery, internal, 94. of occipital artery, 116. of palmar arch, superficial, 106. 524 INDEX. Ligature of peroneal artery, 85. of popliteal artery, 77. of pudic artery, internal, 68. of radial artery, 101. of sciatic artery, 67. Ligature of subclavian artery, first portion, left side, 87. of first portion, right side, 89. of second portion, 92. of third portion, 90. Ligature of temporal artery, 116. of thyroid artery, inferior, 95. superior, 113. Ligature of tibial artery, anterior, 79. posterior, 82. Ligature of ulnar artery, 104. of veins, 117. of vertebral artery, 92. Ligatures, 37. catgut, how prepared antiseptically, 40. hemp and silk, how prepared antisepti- cally, 39. Linear guide to abdominal aorta, 60. to axillary artery, first portion, 95. to axillary artery, third portion, 97. to brachial artery, 99. to carotid artery, common, 107. to carotid artery, external, 110. to dorsalis pedis artery, 82. to epigastric artery, 71. to femoral artery, 72. to gluteal artery, 66. to iliac arteries, common, 62. to iliac artery, external, 69. to left inguinal colotomy, 372. to left lumbar colotomy, 368. to lingual artery, 113. to mammary artery, internal, 95. to palmar arch, superficial, 106. to peroneal artery, 85. to popliteal artery, 77. to pudic artery, internal, 68. to radial artery, 101. to sciatic artery, 67. to subclavian artery, second portion, 89. to subclavian artery, third portion, 89. to thyroid artery, inferior, 95. to tibial artery, anterior, 79. to tibial artery, posterior, 83. to ulnar artery, 104. to the vertebral artery, 93. Lingual artery, ligature of, 113. linear guide to, 113. Lingual nerve, operations on, 145. Lip, lower, Buck's operation of cheiloplasty for, 322. Celsus' method of cheiloplasty for, 321. Malgaigne's operation of cheiloplasty for, 324. Sedillot's operation of cheiloplasty for, 324. Syme's operation of cheiloplasty for, 322. Lip, upper, Buck's interno-lateral flap method of cheiloplasty, 325. Lip, Buck's semicircular-flap method of chei- loplasty, 325. deformities of the, 325. Dieffenbach's operation of cheiloplasty for, 326. entire loss of the, 325. Sedillot's vertical flap method of cheilo- plasty, 326. Lisfranc's amputation at the tarso-metatar- sal joint, 260. Lister's excision of the wrist-joint, 195. Lister's tourniquet, abdominal, 287. Litholapaxy, 432. Lithotomy, 440. bilateral operation, 450. bilateral operation, Nelaton's modifica- tion of, 451. lateral, 441. median, 447. medio-bilateral, 452. medio-lateral operation, Buchanan, 451. supra-pubic, 452. J Lithotomy in the female, 454. vesico-vaginal, 455. I urethral, 455. Lithotrite, introduction of the, 429. Lithotrity, 428. combined crushing and evacuating, 436. in the female, 440. perineal, 437. rapid, 432. Littre's operation for left inguinal coloto- my, 372. Lloyd's tourniquet, abdominal, 289. Loreta's operation for divulsion of the pylo- rus, 359. Loreta's retrograde divulsion for stricture of the oesophagus, 346. Lumbar plexus, branches of, 149. Macewen's supra-condyloid osteotomy for genu valgum, 218. Mackenzie's non-subperiosteal excision of knee-joint, 204. Maenec's amputation at hip-joint, 290. Maisonneuve's operation of excision of the rectum, 414. Malgaigne's amputation at hip-joint, 293. Malgaigne's operation of cheiloplasty for lower lip, 324. Mammary artery, internal, ligature of, 94. j linear guide to, 95. Maxillae, superior, excision of both, 174. I Maxilla, inferior, anchylosis of, 178. Esmarch's operation for, 179. Maxilla, inferior, excision of, 175. alveolar process of, 178. central portion of, 176. half of, 177. lateral portion of body of, 176. whole of, 178. Maxilla, superior, excision of, 170. below floor of orbit, 173. 1 by median incision, with removal of whole i bone, 172. INDEX. 525 Maxilla, superior, excision of, subperiosteal, 173. Maxillary nerve, superior, operations on, 142. Maury's (F. F.) operation for extroversion of the bladder, 423. Mechanical apparatus for loss of nasal sep- tum, 310. Mechanical means employed in uranoplasty, 334. Median lithotomy, 447. Median nerve, operations on, 147. Medio-bilateral lithotomy, 452. Medio-lateral lithotomy, Buchanan, 451. Medio-tarsal joint, amputation at, Chopart, 262. Forbes' modification of Chopart's, 264. Meningocele, 135. Metacarpal bones, amputation of last four, 243. amputation through the, 242. disarticulation of the last four, 243. Metacarpo-phalangeal articulation, amputa- tions at, 239. disarticulation at, 239. joints, excision of, 197. Metatarsal bones, amputation through all the, 258. Metatarso-phalangeal joint, disarticulation at the, 258. Metallic sutures, 43. Mikulicz's osteoplastic amputation at the ankle-joint, 273. Moliere's amputation at ankle, 266. Mother's mark, 132. Mott's aneurism needle, 59. Movable bodies in joints, 510. Multifidus spina?, tenotomy of, 158. Musculo-cutaneous nerve, operations on, 147. Musculo-spiral nerve, operations on, 147. Nelaton's operation for removal of nasal polypi, 488. of urethroplasty, 470. for webbed fingers, 301. Nephrectomy, 374. abdominal, 375. lumbar, 375. Nephro-lithotomy, 376. Nephrorraphy, 370. Nerve, auricularis magnus, operations on, 146. crural, anterior, operations on, 149. dental, inferior, operations on, 144. facial, operations on, 146. infra-orbital, operations on, 142. lingual, operations on, 145. maxillary, superior, operations on, 142. median, operations on, 146. musculo-cutaneous, operations on, 147. musculo-spiral, operations on, 146. occipital, great, operations on, 145. perineal, operations on, 149. plantar, operations on, 149. popliteal, external, operations on, 148. popliteal, internal, operations on, 148. radial, operations on, 147. saphenous, external or short, operations on, 150. saphenous, internal or long, operations on, 150. sciatic, great, operations on, 147. sciatic, small, operations on, 148. spinal accessory, operations on, 146. supra-orbital, operations on, 141. tibial, anterior, operations on, 148. tibial, posterior, operations on, 148. ulnar, operations on, 147. Nerves, branches of brachial plexus of, operations on, 146. Nerves, excision of, 141. Nerves of the cranium, operations on, 141. Nerves, spinal, operations on, 145. Nerves, stretching of, 141. Nerves, suturing of, i50. Nerves, transplantation of, 151. Neuber's canalization, 47. Neuber's decalcified drainage-tubes, 47. Nitrous oxide, 7. Non-subperiosteal excision of knee-joint, Mackenzie, 204. Noyes' ether inhaler, 10. Occipital artery, ligature of, 116. Occipital nerve, great, operations on, 145. O'Dwyer's intubation of the larynx, 503. CEsophagectomy, 346. CEsophagostomy, 347. (Esophagotomy, 344. internal, for stricture, 346. CEsophagus, removal of foreign bodies from, 347. stricture of the, 345. stricture of the, retrograde divulsion for, Loreta, 346. Ogsten's osteo-arthrotomy, 220. JNaevus, 132. operations for, 132. Nail, toe, ingrowing, 302. Nares, posterior, plugging the, 484. Nasal polypi, removal of, 485. Langenbeck's operation, 487. Nelaton's operation, 488. Nasal septum, mechanical apparatus for loss of, 310. Naso pharyngeal polypi, removal of, Cheev- er's operation, 489. Langenbeck's operation, 488. Needle, aneurism, 59. Fletcher's, 60. Mott's, 59. " students'," 60. Syme's, 59. Needle forceps or holders, 42. Nelaton's modification of the bilateral op- eration of lithotomy, 451. N61aton's operation of enterotomy, right inguinal, 363. for epispadias, 467. 526 INDEX. Ogsten's operation for flat-foot, 302. Ollier's operation for osteoplastic rhino- plasty, 313. Ollier's subperiosteal excision of knee-joint, 206. Ollier's subperiosteal excision of scapula, 184. Open dressing for wounds, 53. Operating table, 21. Operation, antiseptic, preparation for, 52. Operations, assistants at, 40. nursing after, 3. place for, 3. preparatory treatment for, 4. requirements, essential, 4. requirements, necessary, 4. requirements, precautionary, 53. season of year for, 2. surroundings of patient after, 3. temperature of room after, 3. time of day for, 3. Operations on bones, 162. excision, 165. gouging, 162. osteotomy, 212. sequestrotomy, 163. sequestrotomy, direct method, 164. sequestrotomy, indirect method, 165. Operations on the gall-bladder, 360. Operations on hollow viscera in contact with serous surfaces, 348. Operations on special arteries, 60. Operations on the palate, 329. Operations on the stomach, 352. Operation wounds, treatment of, 41. Operative surgery, general considerations, 1. Ostco-arthrotomy, Chiene, 220. Ogsten, 220. Reeves, 220. Osteoplastic amputation of heel and ankle, Mikulicz, 273. Osteoplastic rhinoplasty, 313. Ollier's method, 313." Pancoast's method, 314. Sabine, T. T., 314. Osteotomy, 212. for genu varum, 220. inter-trochanteric, Sayre, 217. inter-trochanteric, Volkmann, 217. supra-condyloid, for bony anchylosis of knee-joint, 2 i7. supra-condyloid, for genu valgum, Mac- ewen, 218. astragaloid, Stokes, 303. Palate, operations upon the, 329. Palmar arch, superficial, ligature of, 106. linear guide to, 106. Palmar fascia, 159. Dupuytren's contraction of, 160. Dupuytren's operation for contraction of, 160. Pancoast's operation for extroversion of the bladder, 424. operation for rhinoplastic osteoplasty, 314. Pancoast's tourniquet, abdominal, 287. Paracentesis abdominis, 377. Paracentesis thoracis, 483. Paraphymosis, 461. Parotid gland, extirpation of the, 482. Patella, excision of, 207. wiring the, 509. Peat dressing, 50. Pectineus, tenotomy of, 158. Penis, amputation of the, old plan, 462. Hilton's modification, 462. Humphrey's modification, 463. Penis, extirpation of the, Gouley's opera- tion, 463. Perforation of the antrum, 484. Pericardium, tapping the, 479. Perineal lithotrity, 437. Perineal nerve, operations on, 149. Perineal section, 471. Perineal urethrotomy, external, 471. with a guide, 472. without a guide, 473. Perityphlitic abscess, 373. Peroneal artery, ligature of, 85. linear guide to, 85. Peroneus brevis, tenotomy of, 155. Peroneus longus, tenotomy of, 155. Peroneus tertius, tenotomy of, 156. Phalangeal articulations of the hand, am- putations at the, 237. of the hand, disarticulation at, 237. of the foot, disarticulation at, 256. Phalangeal joints, excision of, 197. Pharyngotomy, 506. Phlebotomy, 125. Pins, acupressure, 32. Pirogoff's amputation at the ankle-joint, 270. Plantar fascia, operations on, 159. Plantar nerve, operations on, 149. Plaster-of-Paris jacket, Sayre's, for curva- ture of the spine, 298. Plastic surgery, 304. preparation of patient, 304. size of flap, 304. Plastic surgery, methods of transfer, 305. grafting, 307. inversion or eversion, 306. jumping, 306. skin-grafting, 307. sliding, 305. Taliacotian operation, 306. Plexus of nerves, brachial, operations on branches of, 146. lumbar, operations on branches of, 149. Plugging the posterior nares, 4S4. Polypi, nasal, removal of, 4*5. Langenbeck's operation, 487. Nelaton's operation, 488. Polypi, naso-pharyngeal, removal of, Chcev- er's operation, 489. Langenbeck's operation, 488. Popliteal artery, ligature of, 77. linear guide to, 77. INDEX. 527 Popliteal nerve, external, operations on, 148. internal, operations on, 148. Precautionary requirements for operations, 53. Preparations for an antiseptic operation, 52. assistants, 52. douching, 52. instruments, 52. operating table, 52. operator, 52. patient, 52. the wound, 52. Pressure, digital, for controlling hemor- rhage, 27. instrumental, for controlling hemorrhage, 28. Proctotomy, external, 412. Prolapsus ani, 409. Protective, antiseptic, 48. dressings, 48. Pudic artery, internal, linear guide to, 68. ligature of, 68. Puncturing the bladder, 425. through the rectum, 426. under the pubes, 426. Pylorus, divulsion of, Loreto's operation, 359. Pylorus, resection of the, 356. Quadriceps extensor cruris, tenotomy of, 157. Quilled suture, 45. Radial artery, ligature of, 101. linear guide to, 101. Radial nerve, operations on, 147. Radius, excision of, 192. Ranula\ 338. Rapid laryngo-tracheotomv, St. Germain, 501. Rapid lithotrity, 432. Receptacle, antiseptic, for instruments, 21. Rectal examination, introduction of whole hand, 409. Rectotomy, 412. Rectum, cancer of the, 412. Rectum, excision of the, 412. Cripp's operation, 413. Maisonneuve's operation, 414. Volkmann's operations, 413. Rectum, imperforate, 414. stricture of the, 414. surgical anatomy of, 408. Reef or square knot, 38. Reeves' osteo-arthrotomy, 220. Regnoli's excision of the tongue, 342. Removal of a goitre, Watson, 508. Removal of nasal polypi, 485. Langenbeck's operation, 487. Nelaton's operation, 488. _ Removal of naso-pharyngeal polypi, Cheev- er's operation, 489. Langenbeck's operation, 488. Requirements, precautionary, for opera- tions, 53. Resection of the pylorus, 356. Respiration, artificial, 14, 54. Retractors, 59. Retroclusion, 32. Rhinoplasty, 307. Dieffenbach's operation, 310. French operation, 307. Indian operation, 311. Italian operation, 312. Langenbeck's operation, 308. loss of the bony or cartilaginous septum, with or without loss of nasal bones, 309. Rhinoplasty, osteoplastic, 313. Ollier's operation, 313. Pancoast's operation, 314. Sabine, T. T., 314. Rib, excision of a portion of a, 180. Ricord's operation for varicocele, 125. Rigaud's operation of urethroplasty, 470. Rod, Trendelenburg's, 31, 288. Roux's amputation at ankle-joint, 269. Rubber drainage-tube, 46. Rupture of the bladder, 421. Ruysch's amputation at the wrist-joint, 244. Sabine, T. T., osteoplastic rhinoplasty, 314. Saline solutions for transfusion, 129, 130. Salivary fistula, 335. Horner's operation, 336. operation by a seton, 336. Saphenous nerve, external or short, opera- tions on, 150. internal or long, operations on, 150. Sartorius, tenotomy of, 157, 158. Sayre's excision of hip-joint, 211. intertrochanteric osteotomy, 217. plaster-of-Paris jacket for curvature of the spine, 298. Saw, amputating, proper method of using an, 233. Saws, amputating, 232. Scalpel, method of holding, 18. Scapula, excision of, 182. body of, 183. for malignant growths, 184. glenoid angle of, 187. subperiosteal, Oilier, 184. Schwartz's saline solution for transfusion, 130. Sciatic artery, ligature of, 67. linear guide to, 67. Sciatic nerve, great, operations on, 146. small, operations on, 147. Scissors, 20. Scrotum, excision of, 122. Section, abdominal, 362. explorative, 362. Sedillot's amputation of thigh, 236. operation for removal of the tongue, 342. operation of cheiloplasty, for lower lip, 324. vertical-flap method of cheiloplasty of upper lip, 326. Semi-membranosus, tenotomy of, 157. 528 INDEX. Semi-tendinosus, tenotomy of, 157. Septum nasi, deviation of the, 491. Sequestrotomy, 163. direct method, 164. indirect method, 165. Serrefines, 33. Shock, 55. treatment of, 55. Shoulder-joint, amputation above, 255. Shoulder-joint, amputation at, 250. by circular incision, 252. by internal and external flaps, Dupuytren, 250. oval method, Larrey, 252. Spence's method, 253. Shoulder-joint disarticulation at the, 250. Silk ligatures, how prepared antiseptically, 39. Skey's amputation at tarso-metatarsal joint, 262. Skin-grafting, 307. Solutions, antiseptic, 22. saline, for transfusion, 129, 130. Sound, introduction of a, into the bladder, 417. Special emergencies, 54. Spence's amputation at the shoulder-joint, 253. Spinal accessory nerve, operations on, 14G. Spine, curvature of, 298. Sayre's plaster-of-Paris jacket for, 298. Spiral drainage, Ellis', 46. Splenectomy, 377. Spray apparatus, antiseptic, 48. Square or reef knot, 38. Squibb's ether inhaler, 10. Staphyloplasty, 335. Staphylorrhaphy, operation of, 330. Sterno-cleido-mastoid, tenotomy of, 159. Sternum, excision of, 179. St. Germain's operation of rapid laryngo- tracheotomy, 501. Stimulants, 53. Stokes' amputation at knee-joint, 283. astragaloid osteotomy, 303. Stomach, operations on the, 352. Stomatoplasty, 327. Stone in the bladder, 427. Strangulated hernia, 390. femoral, 397. inguinal, 395. obturator, 401. umbilical, 400. Stretching of nerves, 141. bloodless, of the sciatic nerve, 148. Stricture of the oesophagus, 345. of the urethra, operations for, 471. of the rectum, 414. " Students' " aneurism needle, 60. Styptics, 24. Subastragaloid disarticulation, De Ligne- rolles, 264. Hancock, 266. Tripier, 266. Subclavian artery, ligature of first portion, left side, 87. of first portion, right side, 89. of second portion, 92. of third portion, 90. Subclavian artery, second portion, linear guide to, 89. third portion, linear guide to, 89. Sub-hyoid laryngotomy, 506. Subperiosteal excision of ankle-joint, Lan- genbeck, 199. of elbow-joint, Langenbeck, 190. of hip-joint, Langenbeck, 209. of hip-joint, Sayre, 211. of humerus, head of, Langenbeck, 186. of jaw, upper, 173. of knee-joint, Langenbeck, 205. of knee-joint, Oilier, 206. of maxilla, superior, 173. of scapula, Oilier, 184. Supra-malleolar amputation of the leg, 274. Supra-orbital nerve, operations on, 141. Supra-pubic lithotomy, 452. Surgical engine, 169. Suture, continuous, 44, 349. different forms of, 41. glover's, 44. hare-lip, 45. horse-hair, 43. inorganic, 43. interrupted, 44. intestinal, Czerny-Lembert, 351. Gely's, 350. Gussenbauer's, 351. Jobert's, 350. Lembert's, 350. metallic, 43. quilled, 45. twisted, 45. Sutures, 42. Suturing of nerves, 150. of tendons, 161. Syme's amputation at ankle-joint, 267. Syme's aneurism needle, 60. Syme's operation of cheiloplasty for lower lip, 322. Szumann's saline solution for transfusion, 130. Szymanowski's operation for hypospadias, 466. Szymanowski's operation of urethroplasty, 471. Table, operating, 21. Tapping hydrocele, 455. the pericardium, 479. the urethra, Cock, 478. Tarsal amputations, irregular, Moliere, 266. Tarsectomy, 303. Tarso-metatarsal joint, amputation at, Lis- franc, 260. Bauden's modification of, 262. Hey's modification of, 262. Skey's modification of, 262. INDEX. 529 Tarso-metatarsal joints, disarticulation at the, 260. Taxis, 391. Teale's method of amputation, 228. Temporal artery, ligature of, 116. Tenacula, 33, 34, 53. Tendo Achillis, tenotomy of, 155. Tendon suturing, 161. Tenotomy, 151. in lower extremities, 154. in upper extremities, 153. of adductor longus, 158. of biceps flexor cruris, 157. of biceps flexor cubiti, 154. of erector spina?, 159. of extensor communis digitorum, 153. of extensor longus digitorum, 156. of extensor ossis metacarpi polKcis, 153. of extensor primi internodii pollicis, 153. of extensor proprius pollicis, 156. of extensor secundi internodii pollicis 153. of flexor carpi radialis, 153. of flexor carpi ulnaris, If 4. of flexor longus digitorum, 154. of flexor longus pollicis, 155. of flexor profundus digitorum, 153. of flexor sublimis digitorum, 153. of gracilis, 157. of latissimus dorsi, 158. of multifidus spina?, 158. of pectineus, 158. of peroneus brevis, 155. of peroneus longas, 155. of peroneus tertius, 156. of quadriceps extensor cruris, 158. of sartorius, 157, 158. of semi-membranosus, 157. of semi-tendinosus, 157. of sterno-cleido-mastoid, 159. of tendo Achillis, 155. of tensor vaginae femoris, 158. of tibialis anticus, 156. of tibialis posticus, 154. of trapezius, 159. Tensor vagina? femoris, tenotomy of, 158. Thermo-cautery, 36. Thiersch's fluid, antiseptic, 51. operation for epispadias, 468. Thigh, amputation of, 283 antero-posterior musculo-integumentary flaps, 285. bilateral method, 284. circular integumentary flap, 285. long anterior flap method, Sedillot, 286. single circular incision method, Celsus, 285. Thumb, amputation of, at the carpo-meta- carpal articulation, lateral-flap method, 241. oval method, 240. Thumb forceps, 18. Thyroid artery, inferior, ligature of, 95. linear guide to, 95. Thyroid artery, superior, ligature of, 113. 3i ; Thyrotomy, 505. Tibia, excision of, 202. ' Tibial artery, anterior, ligature of, 79. | linear guide to, 79. Tibial artery, posterior, ligature of, 82. linear guide to, 83. Tibialis anticus, tenotomy of, 155. Tibialis posticus, tenotomy of, 154. Tibial nerve, anterior, operations on, 148. posterior, operations on, 148. Toe, amputation of the fifth, with its meta- tarsal bones, 259. lateral-flap method, 259. of great, by large square internal flap, 257. of great, with its metatarsal bone, 259. Toe-nail, ingrowing, 302. Toes, amputation of all, at the metatarso- phalangeal joint, 258. in their continuity, 255. of single, 256. of single, lateral flap, 256. of two adjoining, 257. Toes, disarticulation of the, 256. Tongue, excision of the, 339. below or through the jaw, Regnoli's operation, 342. Billroth's operation, 342. entire, 341. Heart's operation, 342. Knox's operation, 34:>. Kocher's operation, 343. Regnoli's operation, 342. Sedillot's operation, 342. Tongue, hypertrophy of the, 340. Tongue-tie, 338. Torsion, 32. Torsoclusion, 32. Tourniquet, abdominal, Biandis', 287.' Esmarch's, 287. Lister's, 287. Lloyd's, 289. Pancoast's, 287. Towels, clean, 22. Trachea, surgical anatomy of, 493. Tracheotomy, 499. above the isthmus, 500. below the isthmus, 500. instruments, 495. through the isthmus, 501. Transfusion, 54, 126. arterial, 131. direct from arm to arm, 127. injection of milk, 131. injection of saline solution, Bull, W. T 130. injection of saline solution, Schwartz, 130. injection of saline solution, Szumann, 130. Trapezius, tenotomy of, 159. Trendelenburg's rod, 31, 228. Trephining the cranium, 136. Treves' apparatus for enterectomy, 365. Tripier's subastragaloid disarticulation, 266. 530 INDEX. Tube, drainage, rubber, 46. tracheotomy, 53. Twisted suture, 45. Ulna, excision of, 192. Ulnar artery, ligature of, 104. linear guide to, 104. Ulnar nerve, operations on, 147. Uranoplasty, Ferguson's operation of, 334. Lannelongue's operation of, 334. mechanical means employed in, 334. Urethra, tapping the, Cock, 478. Urethroplasty, Delpech's operation of, 470. Dieffenbach's operation of, 470. Nelaton's operation of, 470. Rigaud's operation of, 470. Szymanowski's operation of, 471. Urethrotomy, internal, 475. Urethrotomy, external perineal, 471. with a guide, 472. without a guide, 473. Uvula, elongated, 335. Varicocele, 121. compression, 123. compression by double loop of Ricord, 125. compression by wires, 123. Keyes' operation for, 124. radical treatment for, 123. subcutaneous ligaturing, 124. Videl's operation for, 123. Varicose veins, 118. Veins, air in the, 55. symptoms, 55. treatment of, 55. treatment of, preventive, 55. Veins, ligature of, 117. Veins, varicose, operations for, 118. acupressure, 118. injection, 118. subcutaneous ligaturing, 118. Venesection, 125. Vertebral artery, ligature of, 92. linear guide to, 93. Verneuil's amputation at hip-joint, 296. operation of rhinoplasty, 311. Vesico-vaginal lithotomy in the female, 455. Vessels, empty, 21. Videl's operation for varicocele, 123. Volkmann's intertrochanteric osteotomy, 217. Volkmann's operations of excision of the rectum, 413. Watson's operation for removal of a goitre, 508. Webbed fingers, 300 Annandale's operation, 301. Nelaton's operation, 301. Whalebone guides, introduction of, 420. White's excision of hip-joint, 208. Wiring of bones in compound fractures, 512. the patella, 509. Wood's operation for extroversion of the bladder, 424. for radical cure of femoral hernia, 388. for radical cure of inguinal hernia, 384. for radical cure of inguinal hernia with pins, 386. Wounds, operation, treatment of, 41. Wrist-joint, amputation at, 244. circular method, 244. double-flap method, Ruysch, 244. radial flap, Dubrueil, 245. single palmar flap, 245. Wrist-joint, disarticulation at the, 244. excision of, 193. excision of, complete, Langenbeck, 194. Wiitzer's operation for radical cure of in- guinal hernia, 382. TEXT-BOOK OF OPHTHALMOSCOPY. By EDWARD G. LORING, M. D. PART I. The Normal Eye, Determination of Refraction, Diseases of the Media, Physiological Optics, and Theory of the Ophthalmoscope. 8vo, 267 pages, with 131 Illustrations, ano Four Chromo-Lithograph Plates, CONTAINING FOURTEEN FIGURES. 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