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                MANUAL

                    OF

 STJR3XCAL OPERATIONS;

                CONTAINING

      THE NEW METHODS OF OPERATING

        DEVISED BY LISFRdNC;

               FOLLOWED BY

Two Synoptic Tables of Natural  and Instrumental
                 Labours.
BY J. jggSTER, M. D. & P.
 OF THE UNIVERSITY OF TURIH-^i'
    THE TRANSLATION AND NOTES
 BY JOHN D. GODMAN, M. D.

LECTTJRER ON ANATOMY AND PHYSIOLOGY

  PHILADELPHIA:
H. O. OAREY & I. LEA.
1825. 
                       wo











EASTERN DISTRICT OF PENNSYLVANIA to wit:
  BE IT Remembered, that on the twenty-first day of No-
vember in  the  forty-ninth year  of the independence of the
United  States of America, A. D.  1825, H. C. Carey and  I.
Lea of  the said district, have deposited in this office  the title
of a book, the  right whereof they claim as Proprietors, in the
words following, to wit:
  "A Manual of Surgical Operations; containing the new methods of
operating devised by Lisfranc; followed by two Synoptic Tables of Natural
and Instrumental Labours.—By J. Coster, M. O. Ik P. of the University
of Turin. The translation and notes by John D. Godman, M. D. Lecturer
on Anatomy and Physiology.
  In conformity to the act of the congress of the United States,
intituled "  An  act for the encouragement  of learning, by
securing the copies of maps, charts, and books, to the authors
and proprietors  of such copies, during the times therein  men-
tioned."—And  also to the  act,  entitled, "  An act supple-
mentary to an  act entitled,  " An act for the encouragement
of learning, by securing the copies of maps, charts and books,
to the authors and proprietors of  such copies during the times
therein  mentioned,"  and extending the benefits  thereof  to
the arts of designing, engraving, and etching historical and
other prints."                       D. CALDWELL,
               Clerk of the Eastern District of Pennsylvania. 
   TO WILLIAM GIBSON, M.D





I'ROFESSOR OF SURGERY IN THE UNIVERSITY OF PENNSYLVANIA,





        THIS MANUAL OF OPERATIONS





           IS RESPECTFULLY DEDICATED





                 BY HIS FRIEND,





                         THE TRANSLATOR. 
*
   ***, 
                   INTRODUCTION.                Vli
                                 . %
  It is not our intention, in^publishing-this-Manual, to
enter  jpto  the details of afftttions which demand the
           -orator nor th  :~-    '■      .•■•-l ---»

           INTRODUCTION.
  If surgery be the most  efficacious resource of the
healing art, it is only, as Professor Richerand observes,
in the hands of such as cultivate it with the diligence it
merits, and the information  it demands.  It is not by the
sight, nor by familiarity with rules  alone, that an ope-
rator  who  wishes to acquire this knowledge should be
guided; it is necessary to add thereto, long continued
and active practice. It is not sufficient to have  an exact
acquaintance  with  the form, structure, situation, and
functions of the different organs constituting the living
body; it is not sufficient to have surmounted the disgust,
difficulties, and  fatigue which must necessarily be en-
dured by such as interrogate  the  cold remains of mor-
tality, in order to learn how to relieve those who suffer.
Doubtless the surgeon  should  be long  accustomed  to
perform operations on the dead before he attempts them
on the living body, because success depends  in great
measure on his address; and an error committed in this
respect is no less disagreeable  to him, than dangerous
to his patient: but, still this is not the whole of Surgery.
How dare one who calls himself a professional  man, lay
rash hands on the organs of an unfortunate who implores
his aid, without having learned to calculate the results
of an operation; if he undertake it without considering
the constitution of the patient, or  the condition of the
viscera—in a word, if he has not a profound acquaint-
ance with the principles of Medicine?—The healing art,
too long retarded by the ridiculous and dangerous sepa-
                        a2 
   7'    ...  ____, ......  „„„               v. been st
parated.
   If the surgeon be ignorant of every thing but the me-
chanical part of the science, he cannot appreciate the
influence of the great viscera on external parts, neither
can  he estimate the action of the latter upon the viscera;
he cannot, for example, perceive that a great operation
may be  followed by  most  disastrous  consequences,  if
performed during the existence of an internal inflam-
mation;  he cannot  be aware  that the  irritation caused
by the use of instruments may  re-act on important vis-
cera, and  the irritation  of these re-acting  equally on
the external wound, will more easily inflame it, and the
cure, should it ever happen, will be  certainly delayed
for a very long time.*

   *  The  difference between a surgeon and a mere operator,
may be more thoroughly appreciated by contrasting them:—
the surgeon inquires into the  causes and removes the conse-
quences of constitutional or  local disease—the operator in-
quires into the willingness of his patient to submit, and resorts
to the knife.   The surgeon relies on the restoration of the
healthy actions by regimen and medicine—the operator relies
on himself, and cuts off the diseased part.  The surgeon, re-
flecting on the comfort and feelings of his patient, uniformly
endeavours to save him from pain and deformity—the operator
considers his own immediate advantage and the notoriety he
may  acquire, regardless of all other considerations.  The sur-
geon reluctantly decides on the employment of instruments__
the operator delays no longer  than to give his knife a  keen
edge.  The surgeon is governed by the principles of medicine
—the operator most generally  by the principle of interest: one
is distinguished by the numbers he  has  saved from mutilation
and restored to usefulness—the other by the number of  crip-
ples he has successfully made.  The surgeon is  an honour to
his profession and a benefactor  to his  fellow  creatures—the 
                   INTRODUCTION.                 VU

  It is not our intention, in publishing-this-Manual, to
enter  into  the details of affections which demand the
aid of the operator, nor the circumstances which autho-
rise or forbid his interference; these are circumstances
which we suppose  to be  known.  In adhering constant-
ly to the title of  our work,  we shall only give  in  the
most succinct manner, the operations which  the practi-
tioner ought to know how to perform appropriately.
  Convinced of our own insufficiency, we  have  often
drawn from the works of the great masters which have
done honour to France.  The labours of her Boyer, Du-
puytren, Percy, Richerand, Roux,  &c,  are  the guides
under whose auspices we  have attempted the present
task; nor have we ever neglected to profit by the  intel-
ligence of  the surgeons  of other countries, who, though
fewer in number than those of France, where surgery
appears  to have become acclimated, nevertheless show.
themselves from time to time, like those brilliant stars
which speedily disappear, and astonish, for  an instant,
by the spectacle of their novelty. The names of Scarpa,
of Vacca, and of Astley Cooper, are sufficient alone to
render a nation illustrious.
  The operations contained in this volume are general-
ly described according to the modifications  introduced
by Mr. Lisfranc.  The name of this skilful surgeon is
already  sufficiently known  in Europe, either through
the students  who come  from all  quarters  to perfect
themselves under his eye, or by his unwearied efforts
to simplify the operations, or to discover more sure  and
expeditious methods than those already known;  efforts
which have already placed Lisfranc in the first rank
among French surgeons.  Mr. Averill, a young English

mere operator renders the profession odious, and  is one of the
greatest curses to which mankind, among their manifold mise-
ries, are exposed.—J. D.  G. 
VM                INTRODUCTION.

surgeon, one of nis former pupils, has published a trea-
tise which contains some ^F his operations, as practised
on the dead body, and  from which we have derived all
possible advantage.
  If we have not introduced in this work all the clear-
ness and order that it may be desirable  to find, we do
not pretend to cast the blame on the authors of the me-
thods we describe.  After having done our best to treat
with due brevity and  exactness a  subject naturally so
arid, it only remains for us to ask a little indulgence if
we have not attained our end. 
MANUAL OF SURGICAL OPERATIONS.
               Of Incisions in General.
   It may possibly be considered as useless to give rules
for the performance of the simplest of all  surgical ope-
rations, yet it is proved  that there is little hope of ad-
vancing in any science, if principles be not studied with
the most serious attention.  But, it is not sufficient to
know how  to perform  the first operations  according to
certain fixed rules, if we do not, at the same time, ac-.   #
quire that ease and dexterity which eminently distin-   •;*'•
guish the expert from the  awkward surgeon.  Hence    *%
flows the necessity of being well acquainted with the
different methods of holding the scalpel or bistoury, in
making the incisions we are about to describe. It is only
this practice which can give  the  hand  the necessary
suppleness and dexterity: moreover, the rules prescribed
for holding the  bistoury  are of the greatest utility for
the attainment of this object; and to show that it is not
useless to insist on this point, we quote the expressions
of a distinguished professor:—" When we are well ac-
quainted with all that is simple, we  more easily learn
and perfectly execute that which is compound: and, we
often find that success in great undertakings very much
depends on the perfect performance of small things."

           Rules for holding the Bistoury.
  We may divide  the different modes of holding the
bistoury into five principal positions, which are here de- 
                         10
 scribed, in order to avoid repetition, when  we treat of
 operations requiring the use of this instrument.
   First position.—The bistoury is held like a pen. The
 edge is turned towards the palm, and the point towards
 its ulnar edge; the thumb and  fore finger are placed
 on the junction of the blade and handle, and the middle
 finger on the flat part of the blade, at a greater or less
 distance from the point, to  limit the depth of the inci-
 sion: the ring and little fingers serve for a point ot sup-
 port, as in writing.
   Second position.—This is entirely similar to the first,
 except the edge is turned from the palm of the hand.
    Third position.—The edge of the bistoury is turned
 from the palm of the hand: the thumb and middle finger
 are placed on the junction of the blade and handle,  and
 the fore finger on the  flat of the blade; the ring  and
^.middle finger remain  closed on the handle, in order to
 confine it upon the ulnar edge of the palm.
    Fourth position.—Entirely similar  to the third, ex-
 cept that the edge is turned towards the palm.
    Fifth position.—-The bistoury is held like a  violin
 bow; the thumb and middle finger  are fixed on the junc-
 tion of the blade and handle; the  fore finger on the flat
 of the blade; the ring finger on the side of the handle,
 and the little finger remains  free,  and is raised up.

         Simple puncture for opening an abscess.
    When  a  purulent collection is quite  superficially
 seated, a  simple aperture made with a lancet generally
 suffices for the  evacuation of the matter; but, if  it be
 deep seated, it  is necessary  to employ a straight bis-
  toury, which is used in  the following manner:—
    Holding the bistoury in the first position, it is plung-
  ed slowly and  perpendicularly into the abscess, until
  the want of resistance warns us that  the point lias en-
  tered the purulent cavity.  The middle finger placed on 
11
the flat of the blade serves to determine the depth to
which it may be introduced.  This  simple  puncture is
often alone sufficient, and should be  principally employ-
ed in parts exposed to view, in order to avoid the defor-
mity of too large a cicatrix.  But, should the pus be too
thick, it will  not escape through such an opening;—in
this case we perform the following operation:—

            Puncture and straight incision.
   With the thumb and finger of the left hand draw the
skin tight; (this is a general rule;  the skin should al-
ways be tightened  from the side opposite to the course
of  the incision.)   Holding the bistoury in the third po-
sition, plunge the blade  perpendicularly through the in-
ternments; and when it has been introduced to a suffi-
 cient  depth, lower the instrument, until it forms with
 the plane of the incision an angle of  45°; and continue
 to cut in this manner from left to right.   Having ex-
 tended  the  incision to the point desired, raise the in-
 strument and terminate the incision by bringing it again
 to the perpendicular, in order that it may be of an equal
 depth from  one extremity to the other, and avoid mak-
 ing in the skin the glancing incision known by the name
 of queued                    ....
    It is  necessary in making this incision  not to thrust
 the blade too deeply, for fear of injuring important parts
 in the vicinity.  It is well to know, also, that if the in-
 teguments be not  properly stretched, they roll before
 the instrument, and cause the patient unnecessary pain.

    • We have no English technical for this cut; it is a partial
 division of the integuments, unnecessarily prolonged beyond
 the limits of the proper incision, either by beginning with the
 knife held too  horizontally, or withdrawing it in  the  same
 manner; thus, bringing the edge into contact with the surface,
 beyond the point where the skin is to  be entirely cut through. 
12
   These  precautions are equally applicable to all  inci-
 sions made over the course of arteries, to the operation
 for hernia, the removal of subcutaneous tumours, &c.

                   Crucial incision.
   This is formed by two straight incisions, the  first of
 which goes from left to right, as has been above describ-
 ed; the second is divided into two parts, each of which
 cuts the first at right angles.  To perform this  second
 incision in two opposite directions, holding the bistoury
 in the  third position, and  stretching the  integuments
 opposite the side from the operator, makes a first cut
 which terminates perpendicularly  in  that which was
 first  made: then, changing the  position  of  the  bis-
 toury, and stretching the  integuments  towards him-
 self with  the  ulnar edge of the left hand, he makes a
 strong movement of pronation and rotation,  with his
 right hand, to commence the  other section, which  he
 completes at the same point where the  first ended, by
 bringing the instrument, (which forms an angle of from
 45 to 50°,) to the  perpendicular.
  The crucial incision may also be made in the  follow-
 ing manner:—
  After having made  the first incision, as usual, from
 left to right, holding the bistoury in the fourth position,
 the blade is  introduced  flat, about the middle  of the
 first incision;  and, when the point reaches the  spot
 where it is wished to stop, the edge is turned upwards,
 and the point  is made  to project through the skin; this
 part of  the incision is finished by giving the handle  a
 swinging movement, and drawing it towards one.  The
 other section is performed in the same manner, only the
operator is obliged to effect with  his hand a movement
 of rotation from above  downward, in order to introduce
the bistoury beneath the skin, that he may bring it out
 on the side next to him. This last method is more pain- 
13
ful  than the other; and, if the first be performed with
proper precautions, it deserves always to be preferred.
  After making  the incision, to dissect up the flap, we
seize its point, with  the thumb and fore finger of  the
left hand, and then carry the bistoury from one angle to
the other, changing the position  alternately from  the
first to the second; thus successively dissecting up all
the flaps. This manner of varying the position of the bis-
toury, in all dissections of this kind, saves much time,
and gives gracefulness to the operator.

                   The T Incision.
  This incision is performed  exactly as the crucial is
done, except that we only make a single incision on that
which has been made, from left to right.   The flaps are
dissected up in the same manner.

                   Ihe V  Incision.
  The bistoury is held  in the third position;  the second
incision ought to fall in with the first, at a more or less
acute angle.  The flaps are dissected up, by carrying
the blade of the bistoury from  one edge of the divided
skin to the other, which is held between the thumb  and
forefinger of the left hand, as mentioned  in  the crucial
incision.

                  Elliptic Incision.
  This  is often used in  surgical operations, to extirpate
schirrus breasts,  tumours of considerable  size,  aud on
all  occasions where a small portion of integument is to
be removed along with the diseased part.
  The  operator  stretches  the  integuments on the  side
next him  with the ulnar edge,  or the fingers of, his left
hand, while an assistant stretches them on the other side.
Holding the bistoury  in the tuird  position, the operator
makes the first incision on the  bide next him, beginning
                         B 
14
 always toward the lower part of the tumour, and finished
 it from left to right.  The second is made in the same
 manner, taking care to connect  the  two extremities
 with those of the preceding incision.  To facilitate the
 flow of pus, the  axis of the semilunar incision ought
 to make an angle of 45° with the axis of the body.  The
 cyst of the tumour is next to be dissected out, proceed-
 ing always from below, upwards; for otherwise the blood
 will conceal the parts that remain to be dissected.  This
 is a general rule  for all such dissections, which ought
 also to be made parallel to the course of  the muscular
 fibres.

 Incision to  correct deformities resulting from cicatri-
                ces on the Face or JVeck.
   When cicatrices  have been left on the skin of the
 neck by scrofulous tumours which  have suppurated, we
 circumscribe them by two incisions; dissect up, and re-
 move the skin  comprised between  the  cuts;  then  the
 wound  is healed by the first  intention,  bringing the
 parts together by adhesive straps.  But, if the edges of
the incision cannot be approximated on account of their
too great distance, or adhesions, we detach the skin by
 catting the  subjacent texture, as  in operating on the
lips, and then the union takes place very easily. When
 the wound is  healed, if any traces of the incision re-
main, they resemble the folds of the neck, especially if
they have been  made, as they should be, in a transverse
direction.   The same  operation may be employed for
 large cicatrices, which disfigure the  countenance; we
may, if it be necessary, even secure the edges of the
 wound with  pins.

 Incision to  avoid penetrating a cyst, or any important
                      cavity.
   In making a perpendicular incision  with  a straight 
15
bistoury, we may penetrate a cyst which we intend to
remove, and empty it entirely, which will  render the
dissection very difficult, if it does not make it altogether
impossible.  We may penetrate  an important cavity,
such as the chest, the abdomen, a hernial sac, &c.  To
avoid this, we adopt the following method:—
  We use a bistoury with a convex blade, which should
be held very horizontally in the fifth  position. The inte-
guments are divided little by little, avoiding  to raise the
handle of the instrument  for  fear  of introducing its
point into the cyst: the same  movement and the same
precautions are  repeated until the part desired is ex-
posed; should it  be an abscess, it must be dissected down
to its base, and removed.

Opening of abscesses situated among parts supplied
       with numerous nerves and blood vessels.
  When an abscess is deeply seated, and we must pene-
trate beyond, a  nervous plexus or numerous blood ves-
sels  as may happen in the neck, for instance, it will be
dangerous to open it with a cutting instrument. In this
case, Lisfranc adviges the following method:
  First make  a  longitudinal incision through the skin.
Then penetrate beyond this first incision with a director,
moving it from  left  to right, and from before, back-
wards, by  which we dilate the opening sufficiently to
allow the pus to  escape.  By this  mode, it is impossible
to wound either  the nerves or arteries.

                 Counter opening.
  After  making a longitudinal  incision, we  take  a
grooved director, curved near its point; we then take
the handle between the thumb, index, and middle fingers
of the  right hand,  to introduce it to  the point, where
the  counter opening is to be made.  The hand is then
changed, in order to ascertain with the end of the right 
1G
 lore finger whether there be not an artery or nerve be-
 tween the point of the director and the integument it
 elevates.   Then, holding the bistoury in the fifth posi-
 tion, we cut horizontally for half a line beyond the point
 of the director.  We  then  change the fifth position of
 the bistoury, for the first, to introduce the blade into the
 groove for the space of half an inch  or  an inch, turning
 the edge upwards:  we bring it to the perpendicular, to
 cut the parts situated in front of the edge.

   Dilatation of an opening, on the grooved director.
  The handle of the director  being  held as in the pre-
 ceding case, the point is introduced by  the open extre-
 mity of the fistula.  We  then take a straight bistoury
 in the right hand, after having seized the handle  of the
 director with the left, then holding it in the fourth po-
 sition,  the edge  upwards, the blade is  introduced into
 the groove in the length of the director, and we  cut by
 raising the handle of the bistoury until its point arrives
 at the blunt end of the director: then we force upwards
 the point of the instrument to pass it through the skin;
and by depressing the handle  we finish the incision as
 directed for the crucial incision.  The director is to be
withdrawn when the incision is finished.
   LIGATURE OF ARTERIES IN GENERAL.
  The art of applying ligatures to arteries with the pro-
per degree of constriction,  is of the highest importance
in the performance of surgical operations: the following
precautions  are to be observed  in all cases  where liga°-
turesare used.
  The fingers of the left hand should be applied on the
skin, in a direction parallel to that of the incision; not
only to trace its course and determine its extent, but
also to tighten the integuments.  The ligatures ought
to be round and compact; such as are  made with a sftn- 
17
pie waxed thread, are commonly sufficiently strong to
cause the necessary constriction.
  The artery should  be denuded as little as possible;
yet it should be dissected  clean towards the  point
where the ligature is to be placed. This, applied trans-
versely to the axis of the artery, must be drawn with
sufficient force to rupture the internal and middle mem-
branes, taking care not to include the nerves and veins
which accompany the  artery in the ligature.   As the li-
gature is a foreign  body, it should be made as small as
possible; therefore,  we  cut off one of the ends, unless
Lawrence's method is preferred, which consists in cut-
ting off both ends of the ligature near the knot.* Should
the patient faint during the operation, it is not necessary
to unite the parts before he recovers his senses, in order
to ascertain by the hemorrhage whether any  more ves-
sels still remain to be  tied. Such is the English method,
advocated  by Jones.  In France a flat ligature is com-
monly used, formed of several strands of thread placed
together, and united by being waxed.   To pass this li-
gature under the  artery,  a  grooved director is used,
slightly curved towards its  point, the  curved  needle
carrying the ligature, or the needle fixed  in  a handle.!

  * This may be very advantageously done when the ligature
is composed of animal matter, especially if of buckskin dressed
for  the purpose.   This  material does not prevent the wound
from healing by the first intention, and is gradually  and cer-
tainly removed by the absorbents of the part.   We have seen
ligatures of this kind used in several capital operations, and
always with great apparent advantage.  The introduction of
them  into practice is attributed to Dr. Physick, who is justly
considered, in all respects, a " Sukgeon " of the highest value
to his  country—J. D. G.
  f One of the earliest descriptions and figures of this instru-
ment, is given in the works of Ambrose Pare".   A very admi-
rable  instrument for taking up deep-seated arteries was devised
                           B 2 
                         18

The last is preferable, because it is not liable to pierce
the nerves or veins accompanying the artery.   The li-
gatures commonly fall off about the fifteenth or twentieth
day, after having produced a division of the artery.
 .  Scarpv  properly objects to this ligature,  on  the
ground that the obliteration of the artery being produced
solely  by the cellular tunic, the serious accident  of a
consecutive hemorrhage often results; he  therefore re-
commends what he calls the  temporary ligature, as of
very great importance.
   It should be made of two waxed threads placed par-
allel to each other,  so as to form a small flat tape.   Be-
tween  this and the vessel  a little roll or cylinder of
linen spread with cerate is placed.   The length of this
cylinder should  be  such as not to exceed the breadth of
the ligature  more  than  a line, or a very little more
above  and below: the breadth of the ligature should be
about aline for a large artery of the limbs.   The  con-
striction produced should  not be excessive;  it should be
sufficient only  to bring the internal walls of the artery
into contact.  The ligature should  never be placed  near
the origin of  a large lateral  branch.
   Numerous  experiments having demonstrated that ad-
hesive inflammation was  sufficient at the end of three
days, to maintain the internal coats of the artery in con-
tact, and produce a solid  and durable obliteration of its
caliber; and,  as after that time, the ligature serves no
purpose  but  that of causing  ulceration of the  part to
which  it is applied, Scarpa advises that it should be re-
moved: in order that the removal may be effected with-

some time since by our distinguished countryman Dr. Physick,
with the use and excellence of whoseybrccps for securing deep-
seated arteries, nearly all our practitioners are acquainted; nor
need any other instrument for this purpose be recommended In
the surgeon.—J.  D. G. 
19
out pulling, or too considerable a dilatation of the wound,
he has invented the following simple method of doing it.*
   He takes a common grooved  director, slit at its inferior
extremity, for the length of half an  inch: to one of the
edges of this director are fixed two small flattened rings,
the greatest diameter  of which is proportioned  to  the
breadth of the tape, used for the ligature.   One of these
rings is situated half a line above the inferior extremity
of the director; the other a little below its handle:  the
director has a very narrow furrow at the bottom  of the
groove throughout its whole length.  A small knife with
a convex  cutting edge is employed, whose blade should
not be more than five lines long, and sufficiently slender
to  glide easily in the groove of the director; its blunt
point  should  penetrate  with  facility the furrow at the
bottom of this groove.   At the  base of the little knife
there is a button, which prevents the blade from advanc-
ing farther beyond the slit  in the director  than the
length of its edge.
   The end of the ligature dependant from  the wound is
passed first through the inferior, and then through the
 superior  ring of the director.   By the aid of this  very
 sure guide,  the director  is  gently  introduced to  the
 bottom of the wound, until the lower ring rests solidly
 on the knot  of the ligature.  Then,  the tape passed
 through the rings is tightened, by drawing it lightly and
 fixin^ it around  one of the wings of the director, so that
 the lower ring cannot move  in any manner.  We  take
 care to place the sound in such a manner as to have the
 groove exactly in the  same direction as the tied artery:
 to secure this, it is sufficient that the wings of the direc-
 tor be transverse to the course of the vessel.  Thus pre-

   ' A translation of Scarpa's very interesting observations and
 experiments on the application  of ligatures, will be found in
 the 2d vol. new series, of the Philadelphia Medical and Physical
 Journal.—J. D. G. 
                         20                            1

pared, the operator holds the director in one hand, while
with the other he conducts the little knife as vertically
as possible into the groove.   When the blade arrives at
the commencement of the slit, it descends vertically and
without varying between the two edges, comes upon the
ligature near the knot, and transverse to its direction.
It is then sufficient to support the blade  lightly, and
give it a slight sawing motion/ to cut the ligature im-
mediately upon the cylinder which secures  the artery
from all injury. We begin then by removing the cylinder
with very small forceps,*  and carefully withdraw the
director which brings the ligature away with  it.

LIGATURE OF ARTERIES IN THE SUPERIOR EXTREMITIES.
     Ligature of the radial artery near the wrist.
   Make an incision about two inches long in the direc-
tion of a line, which running from the styloid process of
the radius,  would  pass between the  condyles of the
humerus:  we find  the artery superficially seated along
the internal edge  of the supinator radii longus;  raise
it with the grooved director and  tie it.t

     Ligature of the ulnar artery near the wrist.

   Make an incision two inches long in the length of the
external edge of the flexor carpi ulnaris; beginning half
an inch below  the pisiform  bone.  Divide the fascia;
the assistant then draws the inner edge of the wound

   • To avoid using such forceps, it is only necessary to pass a
small thread through the cylinder, as recommended by Giun-
tini previous to using it. By means of this thread, the cylinder
is easily removed after cutting the ligature.
   f The curved needle is generally all that  is  necessary  for
passing ligatures under superficially seated arteries; the same
needle passed under the vessel by means of Physick's, forceps,
is quite sufficient for taking up deep  seated vessels.—J. D. G- 
21
towards the radius:  the operator dissects  cautiously
along the tendon, and discovers the artery situated on
the outside of the ulnar nerve; then raises and ties the
vessel.

Ligature of the radial artery at the upper part of the
                      fore-arm.
                [lisfranc's method.]
  Supinate the fore-arm, and draw a line, which starting
from the  middle of the space between the condyles of
the humerus, shall finish on the external side of the ra-
dius, about three inches and a half from where it begun.
Draw a second line, which  departing from the inferior
extremity of the first, by remounting on its outside to-
wards  the external condyle  of the humerus, will  form
with it an angle, whose base situated  near the articula-
tion of the fore-arm and humerus, will be little more than
half an  inch in width.  On this second line, half an inch
below the articulation the incision is  to be made.  We
divide  the fascia, and by tightening  the  skin towards
the outside of the radius, we arrive  at  the first inter-
muscular space, which we  find directing towards the
ulna, precisely in the line pointed out.   We penetrate
this interspace carefully, and find the artery situated  on
the inside of the nerve.  We insulate it, and then pass
the ligature.

Ligature of the ulnar artery at the upper part of the
                     fore-arm.
  The  limb  being  supinated,  begin  at  three fingers
breadth below the internal condyle of the humerus an
incision, to be continued for the length of three inches on
the anterior and  a little on the internal face of the ulna.
After dividing the skin and fascia, we tighten them to-
wards the inside of the arm, with the  thumb and fingers
of the left hand, and  search for the first intermuscular 
22
space, which we find by looking from this, towards the
opposite side.   We carefully penetrate this  interspace
formed by the flexor ulnaris, palmaris longus and flexor
sublimis, and find the artery situated external to the
nerve.  When the muscular system is much developed,
or the subject is thin, it is useless to take all  the pre-
cautions indicated in commencing the incision, because
in cases where the intermuscular spaces are well marked
we cut directly on them, provided we have learned how
to distinguish them.
  When we take up these small arteries after any other
wound than that caused by amputation of the limb, as
they have numerous communications with other arterial
branches, it is necessary to secure both extremities of
the divided vessel.  In this case we commonly enlarge
the incision; but when the artery is completely divided,
its ends  retract, the blood flows, and it becomes very
difficult to find the vessel whence it escapes.  On this
account we first enlarge  the  incision, on the side next
the heart, to tie the extremity on that side: then we find
the other much more readily, which supplies all the blood
that can continue to flow.

Ligature of the brachial artery near the articulation of
               the arm and fore-arm.
  This artery may be injured in opening the basilic vein
and cause an aneurism, which may require an operation.
Dominic Jlnel, a French military surgeon, is thought to
have been the first who used the ligature in such a case,
without opening the  aneurismal tumour.*  This opera-
tion may be performed in the following  manner:__
   Two inches below the external condyle >f the hume-
rus, we commence an incision,  two inches  in length

   * See a very interesting case  described by Dr. Physick, in
 Coxe's Medical Museum and in Dorsey's Elements of Surgery. 
23
along the inside of the biceps muscle. We cut the skin,
cellular  substance and fascia, and come upon the me-
dian nerve, immediately behind which the brachial artery
is  found. The nerve is to be separated from  the artery
and the  ligature passed.

Ligature of the Brachial artery, near the middle of the
                         arm.
   The limb is to be  supinated; the operator searches
with the point of his fore finger for the median nerve
along the internal edge of the biceps muscle, to assure
himself  of the direction of the artery which follows that
of the nerve; then he  makes an incision extending two
inches along the  inner  edge of the biceps towards the
middle of the arm.   The median nerve is exposed by
this first incision, and the brachial artery is found situa-
ted at its inner side.
   It may happen, though very rarely,* that the brachial
artery bifurcates before arriving at the  articulation;
when this is the case the division commonly occurs in
the axilla, and  the  two branches run  parallel on each
side of the biceps until they arrive at the fold  of the
elbow, whence they continue as usual.

           Ligature of the axillary artery.
                [lisfranc's method.]
   A wound, or aneurism of the artery may exist near
 the upper  part of  the  arm; in this case, we apply the
lio-ature on  the artery  in the hollow of the arm-pit, in
 the following manner:—
   Supposing the  axillary space to be divided into three
   * This division of the brachial artery occurs  much  more
 frequently  than is generally imagined;  uumerous instances
 have presented themselves during the dissections of a single
 season.  I have published a statement of these cases in vol. i,
 new series, of the Philadelphia Medical Journal.—J. D. G. 
                           24                           ^

  equal parts, comprised between the edges of the latis-    '
  simas dor>i, and  pectoralis major and minor, we make
  an incision about three inches long at the junction of the
  two anterior thirds with the  middle one,  beginning di-
  rectly over the head of the humerus, in the direction
  of a  line which would continue the division already in-
  dicated. ^Ve  then encounter  the axillary plexus, and
  the median  nerve, under  which the  artery is situated.
   After  the integuments are divided, the blade of the
  knife must  be as  little used  as possible, for fear of in-
 juring the nervous, arterial and venous branches exist-
 ing in this situation.

 Ligature of the subclavian artery below the clavicle.

                [lisfranc's method.J

   This operation is performed in cases of axillary aneu-
 rism.
   Extending the arm and carrying it backwards to put
 the pectoral muscle on the stretch, observe  the depres-
 sion  formed  by the union of the clavicular and sternal
 portion of this  muscle; the incision should be made in
 this direction,  by  commencing  half an inch from the     I
 sternal extremity of the clavicle, below this bone, and
 continuing for  about three inches along its outer edge.
 The two portions  of the  muscle are to  be separated
 from one extremity of the incision to the other, follow-
 ing the direction of the  muscular fibres.   If the inter-
 stice does not exist, the muscle must be divided by the
 edge of the knife, in the corresponding direction.   We
 now bring the arm towards the body, in order to relax the   *
 muscles, and at the same  time  to enlarge the opening
of the wound; about one-third  of the  length of the cla-
 vicle from its sternal extremity, we find the vein situa-
 ted immediately before the artery, which is often con- 
£5
cealed under a great quantity of fat and cellular tissue.
A great deal of caution is necessary to avoid injuring
the vein; to effect this we are advised to employ the handle
of the scalpel, or the finger nails.  After dividing the
muscle and cellular tissue, the artery is to be raised and
tied.*

Ligature of the subclavian artery above the clavicle.
                r_LISFRANC's METHOD.]
  Make  an incision  three inches long, immediately
above the superior edge of the clavicle, by commencing
half an inch from its sternal extremity, or towards the
outside of the sterno-cleido-mastoid muscle, and continue
it in the direction of  a line that would terminate at the
other extremity of the clavicle.  We  cut the skin, pla-
tysma myoides,  and cellular texture, avoid the  vein
which crosses the artery almost at a right angle, and in-
troduce the fore finger of the right hand into the wound,
to search for the bony tubercle which  exists on the su-
perior and  anterior border of the first rib; the artery is
constantly situated on the outside of this tuberoM^Ihe
nerves  composing  the axillary plexus are founirWme-
what below, on  its  outside.  The depth at which the
artery is situated sometimes causes many difficulties in
passing the ligature around it.

        Ligature of the common carotid artery.
   Hardor relates a case of ligature of this artery which
was performed at the hospital of Charity, accoiding to
the ancient method, which consisted in opening the sac,
and placing a ligature above and below the tumour; but
  * See Dr.  Parrish's papr-r on the ligature of this artery,
accompanied by  an excellent plate in the 3rd volume of the
Eclectic Repertory.—J. D. G.
                         o 
                          26                         rif|

the hemorrhage was so profuse that the patient died uii-  w
der  the hands of the operator. Astley Cooper was the
first who  practised the ligature of the common carotid
in a  case  of  aneurism without opening the  sac; since
that  time it has been performed frequently wi th success.*   j
The  following method is to be employed:—
  Make  an incision two inches and a half long, by be-
ginning from the external and inferior side  of the thyroid
cartilage,  and continue  it upwards along the inside of   i
the sterno-cleido mastoideus,  so  as to form an angle   4
with the thyroid cartilage.  Dissect carefully  along the
muscle, which is to be pressed a  little outwards.   We
avoid the  internal  jugular  vein  placed  somewhat in
front and  on the outside of the  artery;  the pneumo-
gastric nerve is below, towards its outside;  the  whole
enveloped  by a membrane of cellular tissue, forming a
species of sheath. We tie the artery at the point where
it  comes  from, under the sterno-mastoideus and omo-
hyoideus muscles.

J.IG^URES OF THE ARTERIES  IN THE  INFERIOR EXTRE-
   ^^                 MITIES.
        Ligature of the arteria dorsalis jiedis.
  The leg being flexed on the  thigh, and the  sole of the
foot placed  on a solid plane,  we  make an incision two
inches long over the instep,  in the direction  of the se-
cond toe.  After  having divided the  integuments  and
  *This artery has been very frequently taken up in the Uni-
ted States with success, both in cases of aneurism, and pre-
vious to the removal of large  fungous tumours  of the antrum.
  The young surgeon should be very  careful in deciding as to
the necessity of taking up  this vessel, and not be induced to
undertake it from  the  facility  and success with which it has
been done.  Certainly in some of  the cases in  which this ope-
ration has been resorted to, it might have been  dispensed with,
as well as much suffering and risk, hare been avoided.—J. D. G. 
27
dorsal aponeurosis  of the foot, we come on the tendon
of the long extensor of the great toe, situated at the in-
side of the foot,  and the first tendon of the extensor
brevis digitorum pedis.  We there find and secure the
artery.

Ligature of the  posterior tibiale artery behind the in-
                      ner ancle.

   Make an  incision about half an inch long below, an
inch  and a half long above the  inner ancle,  and two
lines behind  it.   We meet there with a thick aponeuro-
tic layer, and when this is divided, the artery presents
itself.
   It  is important, as Lisfranc  teaches, to keep two
lines behind  the malleolus; lest we divide the sheaths of
the tendons.

Ligature of the  posterior-tibial artery near the middle
                    third of the leg.

                 [LISFRANc's METHOD.]

   After making an incision about three inches  long, de-
parting from some point of the  tendo  achilles,  below
the malleolus internus, ascend almost obliquely to near
the  tibia,  cutting the skin and cellular substance.
 The vena saphena interna is to be avoided. We cut the
 aponeurosis, and glide the fore  finger into the inferior
 an"le of the wound, its palmar  surface turned against
• the  anterior surface of the tendon,  distinguishes  its
smootliness.  The finger is then  moved  from the iiyier
 towards the outside, and from below upwards, to sepa-
 rate the muscles; if we encounter aponeurotic bridles,
 they are to be divided by the bistoury; then the posterior
 tibial artery is found, having outside of it the posterior
 tibial venous trunk, and the nerve on the inside. 
C8
     Ligature of the posterior tibial artery near the  tipper
                      third of the leg.
                    [marjolin's method.]
      Flexing the leg on the  thigh, we  make  an incision,
    dividing  the skin and aponeurosis along the internal
    edge of the tibia, from the  posterior and internal part of
    its tuberosity to near the middle of the leg.   We then
    cut the adherences of the solseus muscle, by shaving
    along the edge of the tibia; an assistant turns the solseus
    and gastrocnemius internus from behind forwards;  the
    operator cuts the aponeurosis, passing behind the artery
    and  the three deep seated muscles of the leg, and ex-
    poses the artery.

    Ligature of the anterior tibial artery near the middle
                         of the leg.
                   [lisfranc's method.]
      Extending the leg, and resting it on its posterior sur-
    face, we commence an incision  on the outside  of the
    spine of the tibia, which should ascend  obliquely from
    within outwards, so that its upper part shall be an inch or
    an inch and a half from the spine of the bone, according to
    the development of the muscular system. Dividing thus
    the skin and cellular texture, we cut transversely through
    the aponeurosis of the  leg with the bistoury.  This in-
    cision gives us the advantage of being constantly parallel
    to the muscular fibres: we next enter  the  first inter-
    muscular  space from the spine of the tibia, where we
    find the artery between the tibialis anticus  and the  ex--
H   teWor longus pollicis pedis, immediately on  the inter-
    osseous ligament, having the  anterior tibial branch of
    the sciatic nerve on its outside, and  its accompanying
    vein on the inside. When this artery  is cut, it is neces-
    sary to  apply a ligature on both ends of the vessel,  as
    must also  be done when small arteries in the superior
    extremities are divided. 
29
Ligature of the peroneal or fibular artery, someivhat
            below the middle of the  leg.
                [lisfranc's method.]
  An incision is made, which departing from some point
on the outside of the tendo achilles, ascends obliquely
outwards, and terminates on the external and posterior
surface of the fibula.  We must be careful to avoid cut-
ting the saphena externa, which is exposed by this inci-
sion: the aponeurosis is next divided:  the fore finger is
introduced under the tendo achilles, as in the ligature
of the posterior tibial artery; the finger ascends before
the superficial muscles to separate them from the deeper
seated. We cut the aponeurosis, which is passed behinjl
the deep seated muscles; we raise  and turn outwards the
inner edge of the flexor longus pollicis  pedis, and we
find the artery sometimes situated between the fibres of
this muscle, and at others between this muscle, the fibula,
interosseous ligament and tibialis anticus.  The peroneal
artery is not to be sought towards the lower third of the leg,
because we should find nothing but its  posterior branch.
  If there be  any doubt as to the vessel from which
blood flows, and we cannot determine whether the pero-
neal or the posterior tibial is wounded, we may cut down,
as if for the ligature of  the peroneal artery, since the
same incision will serve to discover the posterior tibial.

Ligature of the popliteal  artery towards its inferior
                      portion.
               {^LISFRANC's METHOD.]
  If we are not sure what artery is wounded, and wish
to stop the circulation at the same time in the anterior
and posterior tibial and peroneal branches, we may place
a ligature immediately above the division of these arte-
ries, in the following manner: 
   Extending the leg, and resting it on its anterior face,
we make an incision for three or four inches along the
median line of its  posterior part, commencing several     ?
lines above the articulation of the knee.  The skin, cel-
lular tissue and aponeurosis being divided in the median
line, nevertheless,  more on the outside than the inside,
because the size of the gastrocnemius internus is some-
what more  considerable than  that  of* the  externus,
we find  the  intermuscular space; separate cautiously,
all the parts before us,  until we arrive  at  the inferior
portion of the popliteal artery.
   By prolonging this incision somewhat,  we may tie the
posterior tibial and  peroneal arteries at their upper part.
•"he same incision may serve for  the  posterior tibial
trunk.  In addition, this method enables  us  to expose
all the arteries of the leg at the same point, and estab-
lish a certain diagnostic  of the seat of hemorrhage in a
doubtful case.

          Ligature of the popliteal artery.
                [USFRANC'S METHOD.]
   The extended thigh and leg rest  on their anterior
surfaces.  We make an  incision, which  departing from
the inside of the base of the triangle composing the pop-
liteal space, terminates at the apex of the same triangle.
   The cellular tissue and  crural aponeurosis are to  be
divided, and should the saphena vein be  in the way it is
to be avoided.   Next comes the great sciatic nerve,
which is also to be  pushed out of the way, towards the
outside of the wound. We divide the fatty matter in front
of the nerve with the extremity of the  director or the
handle of the scalpel.  We then find the popliteal  vein
which is to be separated  from the artery, and  the latter
secured by the ligature.  It is well to observe  that after
making the incision we  may slightly flex the leg on the
•high, to relax the muscles of the artery. 
                         31

Ligature of the crural artery near themiddle of the thigh-

                f_LISFRAN0's METHOD.]
  The limb being in a state of semiflexion, and lying on
its  outside, we  make an  incision three inches  long,
which departing from the superior  extremity of the infe-
rior third of  the thigh,  courses along the lower edge of
the sartorius muscle, in the space midway between the
latter and the gracilis. We divide the skin,  cellular
tissue and aponeurosis;  exposing  the inner edge of the
sartorius, we easily  recognize this muscle by the course
of its fibres.  Next, raising this edge, we find the crural
arterv covered by an aponeurotic layer, which is divided
in order to arrive at the artery.

Ligature of the crural artery near the fold of the groin.

   The patient is placed on his back, and the limb to be
operated  on  is semiflexed;  we begin an incision half an
inch  below the  ligament of Paupart, over the middle of
the crural arch: it is tofre continued three inches down-
 wards, following  the direction of a  line which would
 rather approach the  internal than the external edge of the
 thigh, parallel to the course of the artery. The internal
 saphen vein, exposed by this incision, is to be avoided;
 then we divide the fascia, fatty texture, and arrive at
 the sheath of the vessels;  we cut this cautiously,  and
 the artery presents itself, bounded on the outside,  and
 in front by the anterior crural nerve, and also by the
 crural vein.   We raise the artery with the director and
 apply the ligature.

         Ligature of the external iliac artery.
    After  shaving the pubis on the  side to be operated on,
 we commence the incision, an inch within and a line or
 two  below the  anterior superior spine of the ilium; it  is
 
 to be continued in a semilunar form, in the direction of
 Paupart's  ligament, until it terminates precisely over
 the external abdominal ring, which will make the whole
 cut a little more than three  inches long.  We divide the
 external oblique exposed by this incision; raise it, and
 successively encounter the  internal  oblique and trans-
 versalis.  The edges of these  muscles are to be raised
 with the finger or the handle  of the scalpel,  and the
 spermatic cord is exposed; we  pass the finger behind it
 to push away the peritoneum, and we find the  tartery
 bounded by the vein on its  inner side, and exactly en-
 closed  by a cellular membrane, which must be  cauti-
 ously divided.  Care is to  be  taken after cutting the
 tendon  of the  external oblique, to use the edge  of the
 knife as little as possible, in order to avoid injuring the
 epigastric artery, which is commonly situated towards
the internal extremity of the incision, crossing the direc-
 tion of the spermatic cord.   This accident happened in
 1821, to Mr. Dupuytren, at  the Hotel Dieu of Paris: the
hemorrhage was so profuse that he was obliged to apply
two ligatures to the vessel to arrest it.


            Ligature of the internal iliac.

  The patient  lying on his back,  we make an incision
five inches long over the inferior and lateral part of the
abdomen, in a direction parallel to that of the epigastric
artery, about an inch and a half from the outside of this
vessel. The skin, fascia and muscles,  are successively
divided; after having destroyed the connexions of the
peritoneum with the psoas and iliac muscles,  we
it by pressing it inwards in the direction of the
superior spine  of  the ilium and the first division of the
iliacs.  We pass the fore finger of the right hand into the
wound,  to  seek for  the artery, and while we hold it
with that finger, pass the ligature with the other hand.
an 
33
                Ligature of the aorta*
  In a case of aneurism of the primitive iliac artery,
where there was no other chance of saving the patient,
Astley Cooper attempted this  operation, after having
assured himself, by experiments tried on dogs, that the
circulation could be carried on by the collateral branches,
when the aorta was obliterated.  This case was published
in the first volume of the Surgical  Essays, whence we
have extracted the following description:—
  " The patient's shoulders were slightly elevated by
pillows, in  order to relax, as much as possible, the ab-
dominal muscles; for I expected that a protrusion of the
intestines, would produce embarrassment in the opera-
tion, and was greatly gratified to find that this was pre-
vented by their empty state, in consequence of the in-
voluntary evacuation of faeces;  and here let me remark,
that I should, in a similar operation, consider it abso-
lutely necessary, previously to empty the bowels by
active aperient medicines.
   " I then made an incision, three inches long, into the
linea alba, giving it a slight curve to avoid the umbilicus;
one inch and a half was above, and the remainder below
the navel; and the inclination of the incision was to the
left of the umbilicus in this form ["">].  Having divided
 the linea alba, I made a small aperture into the perito-
 neum, and introduced my finger into the abdomen; and
 then, with a probe-pointed  bistoury, enlarged the open-
ing into  the  peritoneum to nearly the  same extent as
 that of the external wound. Neither the omentum nor
 the intestines protruded; and during the progress of the
 operation, only one small convolution projected beyond
 the wound.
    " Having made a sufficient  opening  to admit my lin-
 ger into the abdomen,  1 then passed it between the in-
 testines to the spine, and felt the aorta greatly enlarged,
 and beating with excessive force.   By means of my fin- 
                         34

 ger nail I scratched through the peritoneum on the left
 side of the aorta, and then gently moving my finger from
 side to side, gradually passed it between the aorta and
 spine, and again penetrated the  peritoneum  on the right
 side of the aorta.  I had now my finger under the artery,
 and  by its side I conveyed the blunt aneurismal needle,
 armed with a single ligature behind it;  and my appren-
 tice, Mr.  Hey, drew the ligature from the eye of the
 needle to the  external wound;  after which the needle
 was  immediately withdrawn.
   " The next circumstance, which required considerable
 care, was the exclusion of the intestine from  the ligature,
 the ends of which were brought together at the wound,
 and  the finger was carried down between them, so as to
 remove every portion of the intestine from between the
 threads:  the ligature  was then  tied,  and the ends left
 hanging from the wound. The omentum was drawn be-
 hind the  opening as far as the ligature  would admit, so
 as to facilitate  adhesion; and the  edges of the wound
 were brought together by means of a quilled suture and
 adhesive  plaster,
   " During the time of the operation, the faeces passed
offinvolutarily,and the patient's pulse, both immediately,
and  for an hour  after  the operation,  was 144 in the
minute.   He was ordered thirty drops of  tincture of
opium and camphorated  mixture, and  the  involuntary
discharge  of faeces  soon after ceased.   I  applied my
hand to his right thigh immediately after the operation,
and he said that I touched his foot; so that the sensibility
of that leg was very imperfect.
   [" For the following particulars  I am indebted to Mr.
Cox, one of my apprentices.
  " At midnight his pulse was 132.
  26th.  " At one o'clock  in the morning,  the  patient
complained of heat in  the abdomen, but he  felt no pain
 upon pressure:  he  said that his  head  felt hot, and that 
35
he had pain in the shoulders; his lower extremities, which
were cold soon after the operation, were now regaining
their heat;  his  body was  in other parts covered with a
cold sweat.  The sensibility of the lower extremities has
been very indistinct since the operation.
   " At two o'clock, he felt so comfortable from his medi-
cine that he wished to have more of it, and ten drops of
tincture of opium were given him; his legs were wrapped
in flannel, bottles of hot water were applied to the feet,
and he then said that the heat of his belly was lessened.
   " At  six o'clock the  sensibility of his limbs was still
imperfect.
   " At  eight o'clock,  A. M.  he expressed  himself  as
feeling  quite comfortable;  he  however passed no urine,
and had no evacuation; his right limb was warmer than
the left, and the sensibility was returning.
   " At noon the temperature  of the right jimb was 94,
that of the left or aneurismal  limb 87£.
   " At one o'clock, P. M. Mr. Cooper visited him; and
as he walked  up the ward, he appeared much gratified
at seeing his patient, who was at the point of death the
evening before, and was now adjusting his bed-clothes,
and smiled as  Mr. C. approached the bed.
   " At three  o'clock,  after a fit of coughing,  the man
 was much alarmed with the idea  of the thread having
 slipped into the wound:  it was a false alarm; but, to
 prevent the idea of its recurrence, it was fastened to a
 quill: soon after this he complained of pain in the abdo-
 men; it was not very severe, nor did  it  last long; readily
 yielding to fomentations.   As he had no evacuation, he
 was ordered an enema.
   « At six o'clock, P. M. he vomited, soon after the
 trlyster had been administered; the heat of the right leg
 was 9G, that of the left or diseased limb 87£.
   « At nine in the evening he took half a glass of port
 wine in warm water, which he immediately rejected; he 
                                                  v •*

                         36

 complained of pain in the loins; his pulse was 104, and
 feeble; he was very restless; and had an involuntary dis-
 charge of faeces.
   " Eleven at  night, his  pulse was 100 and weak; he
 still vomited.
   27th. " At seven, A. M. the report  was that he had
 passed a restless night;  the vomiting had  returned at
 intervals;  his pulse was  104, weak and fluttering; he
 complained of pain all over his body, more  particularly
 in  his head; and  the carotids beat with  considerable
 force; he  had great anxiety expressed  in the counte-
 nance, was very restless, and the urine dribbled from
 him with some degree of pain at the end of the penis.
   " At eight o'clock, A. M. the aneurismal limb appeared
 livid, and  fit cold, more particularly around the aneu-
 rism; but the right leg remained warm.
   " At eleven o'clock his  pulse was 120, and weak; he
 appeared to be sinking.   To  the questions  which were
 put to him he did not return any answer; he  appeared to
 have an uneasiness about the heart, as he kept his hand
 upon  the left breast. He died at eighteen minutes after
 one, P. M. having survived the operation forty hours.
  " After being informed of his death, I requested Mr.
 Brookes, of Blenheim Street, to attend with me at the
inspection of the body.   Mr.  Travers,  surgeon of St.
Thomas's  Hospital, Mr. Stocker,  apothecary of Guy's,
and a large concourse of medical students, attended the
examination.
  " When the abdomen was opened, we found not the
 least appearance of peritoneal inflammation, excepting
at the edges of the wound.  The omentum and intestines
 were  free from any unnatural colour; the ed»es of the
 wound were glued together by adhesive inflammation,
 excepting at the part at which the ligature projected.
 We were  much gratified  to find that  the ligature had
 not included any part of the omentum  or intestine: the 
97
thread had been passed around the  aorta, about three
quarters of an inch above its bifurcation, and about an
inch, or rather more, below the part where the duodenum
crossed the artery.  Upon carefully  cutting open the
aorta, a clot of more than an inch in  extent was found
to have sealed the vessel above the ligature;  below the
bifurcation, another, an inch in extent, occupied the right
iliac artery, and the left was sealed  by a third, which
extended  as far as the aneurism; all were gratified to
observe the artery so  completely shut  in forty hours.
The aneurismal sac, which was  of a most enormous size,
reached from the common iliac artery to below Poupart's
ligament, and extended to  the  outer side of the thigh.
The artery was  deficient from  the upper to the lower
part of the sac, which was occupied by an immense
quantity of coaguluin.
  " The neck of the thigh bone  had been broken within
the capsular ligament, and had not been united." p, 124.]
 OF AMPUTATIONS  IN GENERAL,  THROUGH
 THE BONES, AND AT THE ARTICULATIONS.

  Operations of this kind being generally regarded as
very easy to be performed,  are rarely found described
by the hand of a master.  It is nevertheless certain, that
rules  laid  down  with precision, render  the practice
simpler,  more prompt and surer.  As the course of the
blood may be easily arrested by the application of the
tourniquet, this operation is not attended by any imme-
diate danger, nor  does it require a great knowledge of
anatomy.  Any one may perform it; but if he practices
the operation for  some  time on the dead body, he may
acquire an incredible dexterity in performing it on the
                         D 
38
  living. These observations arc only applicable to ampu-
  tations of the thigh, leg, arm and forearm.  Those which
  are performed at the articulations of the foot, hand and
  different parts of the  body,  pne-suppose an exact ac-
  quaintance with the structure of these parts.
    To perform these operations well, the surgeon ought
  to be aided by active and intelligent assistants. In fact,
  whatever may be his own  address, he will  appear awk-
  ward in the eyes of the spectators,  if he has none but
 inexperienced assistants; because in these circumstances,
 as much intelligence is required on the part of the assis-
 tants as on that  of the operator. The assistants should
 be at least two in number;  one to sustain the limb ope-
 rated on, the other to  withdraw the skin and muscles
 which may present themselves before the knife and saw,
 and to superintend the  application of the tourniquet:  a
 third assistant will be necessary, if the arteries are to be
 compressed with the hands.
   When we amputate at the joints, there are some authors
 who  think, that  the whole  surface of the cartilage  ex-
 posed should be  removed, to prevent the secretion of
 the synovia, which may  oppose the adhesion of the parts.
 If this destruction of the cartilages does not accelerate
 the cure, it is at least free from danger.
   After performing the amputation,  it is necessary to
 attend to taking up the  arteries.  They are  to  be laid
 hold  of in  succession by means of the forceps, taking
 care to secure the vessel exactly between the blades of
 the forceps, lest we should tie one side of  the  artery
 leaving the other gaping, did we introduce one point of
 the forceps into the caliber of the artery, as some practi-
tioners advise. An  assistant passes  a  waxed ligature
 around the artery, which is tied, taking care not to dis-
 engage it from the forceps by  too sudden a  movement.
 Holding the two ends of the ligature in the pi I msof < ach
hand, he directs the loop over the artery with his fore 
                         39

fingers. He then makes a first knot, which he tightens by
supporting the backs of the two first phalanges of the
thumbs against each other; a second knot is then made
and drawn tight in the same manner. When all the liga-
tures  are applied,  we cut off one  of the loose ends of
each to diminish the bulk of these foreign bodies within
the wound.  The remaining ends are made into a single
bundle which we always place in the most depending an-
gle of the wound, in  order to serve as a drain to the pus.
  In general we unite  the edges of the wound imme-
diately after the operation; Mr. Dupuytrkn, on the con-
trary, allows an hour to elapse before placing the flaps
in contact.  This appears to be  advantageous, as it of-
ten happens that the  operator believes that he has no
other  vessel to tie, because he perceives no more he-
morrhage; but as soon as the spasmodic  contractions of
the open arteries cease, hemorrhage comes on, and we are
obliged to remove the dressings to  tie the vessels which
were  at first  not to be discovered.  Mr. Dupuytren's
practice secures us against this accident, because we
can always tie the vessels, which may still pour out
blood.
   It sometimes happens that the blood  oozes  from the
surface without its being possible to perceive the orifice
of the artery which furnishes it.  In  this case we in-
clude a portion of the soft parts by means  of a curved
needle conveying a ligature,  which may embrace with-
out inconvenience a part of the tissues which the needle
surrounds, along with the artery.
  We shall now describe each amputation in particular,
by commencing with those, which, although they appear
to be of slight importance to the patient, should not be'
thus regarded  by the surgeon.
  The  following articles are required  for the perfor-
mance of amputations:—1st. a cushion  or a tourniquet 
                          40

 to compress the arteries;  2d. a  straight  knife more or
 less  fong  and narrow;  3d.  a  common bistoury; 4th. a
 retractor for the  purpose of withdrawing the flesh when
 about to use the saw; 5th. a saw; 6th. artery forceps;
 7th.  waxed  ligatures;  8th.  adhesive  straps  and  lint,
 compresses and a rolled  bandage:  When we amputate
 at the joints the  saw is not necessary; when we operate
 on the toes or fingers, it  is not  necessary  to compress
 the arteries.


     AMPUTATIONS OF THE SUPERIOR EXTREMITIES.

 .imputation of the first and second phalanges of the
                      fingers.

   In  England a  circular incision is first made around
 the finger about three lines below the articulation; next,
 a longitudinal incision is made on  each side of the finger,
 extending  from the circular cut  to the joint, so as to
 form  two flaps, one anterior, and  the other posterior;
 these  being dissected up, the  operation is terminated by
 dividing the tendons and articular ligaments.
   This operation is  long and painful; Lisfrano's me-
 thod is to be preferred.
  First period.—The  hand  is pronated, an assistant
keeps the sound fingers extended at the same time that he
bends the one on which the operation is to be performed.
The  surgeon seizes  the diseased  phalanx by its palmar
and dorsal face, between the thumb and fore finger of
the left hand. Then taking a straight bistoury in his right
hand, which  he holds in the third position, he applies its
 heel perpendicularly within the sixth of an inch below the
upper part of the projection, caused by the flexion of the
phalanx,  carries  it directly from right to left, and di-
vides  successively the skin,cellular texture, tendon, and 
41
its sheath,  and part of the articular capsule. Should the
tumour be  considerable, the incision performed accord-
ing to these principles, may be made below the articu-
lation.  In such a case, to avoid mistake, we cut on the
level of the fold which  exists on the palmar surface of
the finger, when the second joint is to be operated on,
and the sixth of an inch below it when the third joint is
to be removed.
   Second period.—The bistoury  moving always from
left to right, is applied on the  side of the  articulation
on whose whole  extent it rests: its edge is directed to-
wards the operator,  its handle is nearer the surgeon
than  its blade, that  is the  instrument  forms in front
with  the  axis  of the  finger an  angle  of  about 00°.
Thus the  lateral ligament  and the tissues covering it
are cut.
   Third period.—The bistoury carried  in a retrograde
direction, occupies the opposite lateral face of the joint;
there its edge  is again turned towards the operator, but
the blade is  nearer to him than  the handle, and forms
behind an angle of sixty degrees with the axis of the
finger.  The lateral  ligament and superincumbent tex-
tures are divided.  The phalanx  to be removed is then
taken by  both its sides,  the bistoury  is carried around
its head,  glides beneath  it parallel to the length of the
bone for the space of three  lines, and cuts  a semicircu-
lar flap, large  enough to cover the whole wound.
   If the operator be very experienced, the periods des-
cribed may  be reduced to a single one.  The parts be-
ing arranged as stated, the  bistoury passes from left to
 ri«dit  from the point where two-thirds  of  the circle is
 finished around the joint, and the instrument in passing
 over the  three articular  surfaces, will successively and
 uninterruptedly assume  the three positions described.
 The incision then must still have an inferior concavity;
 we subsequently proceed as before  directed.  If  the
                           d 2 
42
ringer cannot be flexed, a semicircular incision made ii
a direction from left to right, and proceeding from the
pal mar surface of one side to finish near the palmar sur-
face of the other, would have the relative distance from.
the folds near the joint, heretofore indicated.
  Lisfranc has also thought of amputating these joints
from  their palmar surfaces: the following is  the des-
cription of his method:—The hand  is  strongly supina-
ted, ail the fingers are flexed, abstracting the one to be
operated on: the surgeon applies the  thumb of his left
hand on the extremity of the palmar surface of the dis-
eased finger, the second phalanx of his middle finger is
placed on the dorsal face of the joint he is about to open,
with whose axis, this phalanx forms nearly a right angle;
thus his  middle finger  extends beyond the transverse
diameter of the articulation.   The operator armed with
a bistoury held  in the third position, supinates  his hand,
applies  the flat of the instrument on the pulp of  his
middle finger placed below the articulation, which serves
him for a  point of support.  The point of the bistoury
is then  plunged in below the fold, if  it be the second
phalanx, and  the  sixth  of  an inch lower if the third
phalanx is to  be operated  on; but it is necessary that
the instrument should  shave the lateral and anterior
faces of the articulation.  When we begin to  introduce
the bistoury, the handle is a little less elevated than the
point; and in proportion as the textures are penetrated,
the instrument assumes the horizontal  position, which it
soon  quits, because at the moment when the point ap-
pears on  the diametrically opposite side, the handle in
its turn becomes more  elevated than the  blade: then
the surgeon traces along the  phalanx  from above down-
wards, for the  space of half an inch, and terminates  the
anterior flap.   Finally, the surgeon moves his bistoury
at  the base of the flap, on one of the lateral faces of the
joint, the point of the instrument being perpendicular to 
43 ✓
the horizon, and the edge to the axis of the articulation:
the bistoury is then moved from  one lateral  face to the
other, shaving the flaps, thus encircling the articulation,
which  being largely opened, is  easily traversed.  The
phalanx is removed without making a posterior  flap.
Ordinarily, no ligatures are used, and the wound is healed
by the first intention; dressed with adhesive straps,
spread with cerate, a compress, and bandages.

Amputation of the fingers at the metacarpophalangeal
                    articulation.

                [lisfuanc's method.]

   The hand is pronated;  the left thumb of the operator
placed on the dorsal face of the diseased finger, and his
fore finger on its palmar surface; the patient is directed
to move the finger, that the operator may assure himself
that he touches the  articulation, with the fore-finger of
his left hand.  The  phalanx to be amputated  is slightly
flexed on the carpus.  With a straight bistoury held in
 the  third  position,  we commence an incision with  its
 whole edge nearly over the middle  of the head of the
 metacarpus or  articulation; we cut nearly parallel to the
 finger bone, by lowering  the handle  of the instrument,
 which is  brought back to the perpendicular,  to cut the
 extremity of the flap transversely, in order that it may
 not form a point; then the handle is  lowered, by carry-
 ing it towards the patient's wrist, to make on the pal-
 mar face of the finger an incision down to the articula-
 tion, exactly corresponding with the first cut. To in-
 troduce the bistoury into this articulation,  the operator
 draws the edge of his bistoury in the length of the bone
 he has laid bare, until he encounters an obstacle; this is
 the superior head of the first phalanx: he then attempts
 to pass it in without effort, holding his bistoury perpen- 
44
 dicularly with the edge transverse to the joint; if unsuc-
 cessful, he attempts to introduce it a little farther back,
 until he plunges it into the articulation.  He traverses the
 joint, then seizing  the  skin of the side  opposite that
 where the joint was entered, with  the thumb and
 index of the left hand to remove it from before the bis-
 toury, he passes the whole blade between the base of the
 phalanx and these integuments, cuts out  a flap of the
 same form as the first, by cutting from  behind forwards,
 in the length of the bone, and  returns  the finger  which
 had been displaced to its natural  position, in order to
 allow the instrument to glide between  the  bone and
 soft parts.
   When this operation is performed on the fore or little
 finger, the internal flaps of the little finger and the ex-
 ternal one of the index finger  ought to be longer than
 for the others.
  We do not generally tie the arteries when we amputate
 a finger, in consequence  of an accident,  but if it be  in
 consequence of chronic inflammation, the ligature should
 be used, because the arteries are much more voluminous
 in the latter case.  The wound is healed by the first in-
 tention, apd to keep the  flaps  in contact, "we  bring the
fingers together, and secure them by a bandage,  when
the operation has been performed on the middle or ring
finger.  This method should be preferred for these two
fingers, to that performed on the second phalanx, because
 the stump left is not only useless but deformed; whereas,
 after this operation, the deformity is scarcely preceptible!
  Nevertheless, if it be  desired to remove the second
phalanx, Lisfranc advises that one or  tv\o deep longi-
tudinal incisions should be made on the palmar face of
 the first phalanx, to produce an  adhesion  of the flexor
tendon to the periosteum, by means of the inflammation
resulting from  these cuts. After the cicatrix has formed,
we amputate the second phalanx, and the first is capable 
45
 of  performing the necessary movements of flexion and
 txtension.

 Amputation of the thumb at its carpo-metacarpal arti-
                      culation.

   When the right thumb is to be operated on, the hand
 is supinated; and if the left thumb is to be removed, the
 hand is placed  in  a state of pronation.  An assis-
 tant sustains the  wrist; the operator takes hold of the
 diseased thumb with the thumb and fore finger of his
 left hand;  then  armed with a straight bistoury, held  in
 the third position, he enters the edge at the middle of
 the space comprised between the thumb and  index fin-
 ger. He cuts boldly down to the os trapezium, where  he
 arrives  at the carpo-metacarpal articulation, by hold-
 ing the  bistoury perpendicularly, with the point turned
 upwards.  Having reached  that part, he places the edge
 of the bistoury in the direction of the joint, and opens  it,
by cutting the capsular ligaments. Then seizing the soft
 parts of the outside of the metacarpus, he removes them
from before the edge of his knife, which  he passes be-
tween the bone and  the soft parts.   He  courses along
the edge of the bone and cuts a flap proportioned to that
of the opposite side.   In cutting this flap, he places the
thumb in its  natural position,  which he had displaced,
in order to pass the instrument across the articulation,
as above stated.   The arteries are taken up, if there  be
hemorrhage, and the wound is  healed by the first inten-
tion. 
                                                1
                         46                           ^

 Amputation of the little finger at its carpo-metacarpal
                    articulation.

               [lisfranc's method.]

   The hand is supinated and supported by an assistant;
the surgeon first seeks for the articulation of the metacar-
pus with the os unciforme.  To do this, he traces with the
forefinger of the right or left hand, according to whichever
side he operates on, the internal edge of the fifth meta-
carpal bone, till he arrives at an eminence; there is the
articulation: he moves  the bone several  times, in order
to render himself more certain.  He places his left thumb
near this point, on the dorsal surface, his fore-finger on
its palmar surface, seizing as much of the soft parts as
he can, in order to  draw them  towards the ulnar edge
of the hand.   Then holding a  straight  bistoury in the
first  position, he thrusts it perpendicularly  from above
downwards, across  the skin and muscles towards the
inside of the articulation.   He shaves the metacarpal
bone, with the edge of  the bistoury to cut a flap, which
he completes by coming out a little  beyond the articu-
lation of the head  of this bone with the first phalanx.
  An assistant raises the flap, the surgeon dissects the
integuments from the dorsal face of the bone, without
cutting the tendons; this  done he plunges the instru-
ment from above  downwards and somewhat obliquely
from without inwards, between the fourth and fifth meta-
carpal, so that it will come out on the inner and ante-
rior side of the latter, without interfering with the  skin
of the palmar  face.  To effect this,  he takes it between
the thumb  and the  first fingers of the left hand,  and
draws it towards the outside, while he cuts from behind
forward,  with  the full  edge of the knife, between the
two bones, to come  out at their phalangeal  extremity.
He then carries the edge of the bistoury, transversely 
47
over the internal edge of the articulation,  immediately
at the base of the flap; he enters this joint by following
the direction of a line, which, beginning at  its inside,
terminates at the middle part of the second metacarpal
bone.  He cuts the dorsal ligaments with the point of
the knife,  without  seeking to  penetrate them, and to
divide the  ligament'which unites the superior heads of
the fifth and fourth metacarpal  bones, he thrusts the
point of the bistoury in front of their joinings; then mov-
ing it  on  its point, by raising the handle, he cuts the
interarticular ligament, and opens the joint entirely. The
operation is then finished, by  applying the edge of the
bistoury, near its point behind  the articulation to finish
the section of the palmar muscles and  ligaments.  The
vessels are secured, and the wound healed by the first
intention.

Amputation of all the fingers at their metacarpo-pha-
                 langeal articulation.

                [lisfranc's method.]

   Supposing the left hand is to be operated on; it is kept
in a state of pronation by an assistant; the  thumb of the
surgeon's  left  hand is applied on the  external  surface
of the metacarpophalangeal  articulation of the fore
finger; his  fore finger  is ou the internal surface of the
metacarpophalangeal joint of  the little finger.  Hold-
ing  a  narrow knife in his right hand, he makes a semi-
circular incision, convex anteriorly; this  incision be-
gins at the outside and anterior part of the second meta-
carpal bone, goes along the points where the fingers se-
parate from  the metacarpus, to come  out  at the inside
of the fifth  metacarpal.  A  little  dorsal  flap is thus
cut  as far as the metacarpophalangeal joint;  the assis- 
48
  tant pulls the integuments backwards: the operator then
  still proceeding from within outwards, carries the point
  of the instrument over the superior surface of the arti-
  culations, in their anatomical direction; opens and tra-
  verses them.  If we  are  not much accustomed to ope-
  rating, we should first open all the joints without enter-
  ing them deeply, and carry the instrument successively,
  not between the articular surfaces,  but  rather on the
  lateral ligaments.
    The operator then glides the  instrument first  under
  the palmar face  of  the  metacarpal extremities of the
  index and  little fingers; he next encounters all the su-
 perior and palmar extremities of the first phalanges; the
 wrist  is  placed in  a semisupine position; the operator
 holds  the diseased  fingers raised  with the ends of his
 own, and fixes his eyes on the palmar face of the  hand.
 The heel of the knife remains nearly motionless, while
 the point cuts from the radial to  the ulnar edge, by fol-
 lowing the groove which  terminates  the palmar face of
 the hand internally; the assistant, moreover, sustains the
 fingers in proportion as they are detached, and the sur-
 geon moves his hand towards the inner side of their ar-
 ticulation.
   If we wish  to operate  with the right hand on the
 hand of the  same side,  the operation  should  be  com-
 menced from the inner side, and  continued io  a direc-
 tion opposite to that which has been indicated.
   In young subjects, (about until the age of puberty)
 as  the  articular extremities of the metacarpus, are not
 yet  ossified,  the cartilages may  be divided with the
 knife; Lisfranc thinks that the operation may be made
 at least two  or three lines above  the carpo-metacarpal
 articulation, and that we  may thus gain two or three
 lines of anterior, as well as posterior flap.
  This method is  applicable  to the removal of two or
three fingers.  Suppose, for instance,  that we  wish to 
49
amputate the middle finger and little finger of the right
hand.  The surgeon, after having assured himself of the
depth of the joints, seizes with the thumb, fore and middle
fingersof the lefthand, the fingers to be removed, straight-
ens them,  and  his assistant withdraws the other fingers
from them. The operator conducts the bistoury with his
right hand, applies its point on the palmar and external
surface of the middle finger, arrives at the commissure of
the little finger, and passes on its outside; arrived at the
dorsal  surface  of the  two  fingers  to be  removed,  he
makes a semilunar incision, anteriorly convex, accord-
ing to  the principles before laid down.  It is needless to
repeat how the joints are to be opened.
  The arteries are to be tied, and the wound healed by
the first intention, taking  care to  place a tent in the
angle of the  wound, to  allow the pus to flow, in case
union by the first intention does  not succeed: the arm is
placed in a sling.

Amputation of the wrist at its articulation with the ra-
                   dius and ulna.

                [lisfranc's method.]

  First process.—Applying a tourniquet on the bra-
chial artery, or having it compressed by the hand of an
assistant; another assistant keeps the diseased hand in
a state of pronation. The operator places his two fore
fingers above the  articulation, the one on the radius,
and the other on the ulna.  He then  flexes and extends
the diseased hand alternately, and traces with his fin-
gers along the cotyloid  apophysis of the radius, on the
extremity of which he places the end Of the fore finger
of his  left hand, and the corresponding thumb over the
extremity  of the styloid apophysis  of the ulna, if he 
50
 operate on the right, and vice versa, if he is to take off
 the left hand.  With a straight knife he makes a semi-
 circular incision with  its convexity downwards on the
 dorsal part  of the wrist, commencing near the thumb,
 and ending near the fore finger, which is not withdrawn
 except to avoid the edge of the knife.
  The assistant draws the integuments upwards; then
 the operator directing the edge  obliquely, enters the
joint by returning the point where he ended the first in-
 cision, to  that where he began; but describing a semi-
 circle in the  opposite  direction, and in the anatomical
 direction of the superior articular  surfaces of the me-
 tacarpal bones.  If he does not succeed in opening the
joint by this movement from right to left, he seeks to do
 it by returning over the articulation from  left to right.
 The joint being opened, he glides the edge of the knife
 between the soft parts  of the palmar face  of the carpus,
 and  shapes  a flap proportioned  to the extent  of the
 wound, by shaving the bone and cutting  so as to come
 out near the palm of the hand.  Care must be taken to
 avoid the pisiform bone, by raising the hand.
  Second process.—After finding the inferior apophyses
 of the  radius  and ulna, and placed  the hand between
 pronation  and supination, the operator, armed  with  a
 narrow knife, plunges  the point flatwise through the
 soft parts, by  commencing towards  the anterior and in-
 ternal edge of the styloid apophysis of the ulna to come
 out  before the  styloid  process of  the radius near the
 joint, if we  operate on the rightarm: if on the left arm,
 he  enters  from the radial side.  Then he  shapes a flap,
 by  cutting towards  the palm, and observing the same
 cautions as in the preceding case;  then  applying the
 knife to the dorsal surface, he makes a semicircular in-
 cision  with the convexity downwards, similar  to that
 performed in  the first  operation.   Then crryingthe
 edge in front of the styloid process of the radius,  he 
51
enters boldly into the  articulation,  which he may tra-
verse with a  single stroke if he directs the edge obli-
quely to make it describe the semicircle, formed by the
superior articular surface of the metacarpal bones.
  The wound is healed by the first intention, after hav-
ing secured the radial,  ulnar, and interosseous arteries;
a tent of lint is left in the ulnar angle of the incision,
to facilitate the flow of pus, if union by the first inten-
tion fails. We then place the arm in a sling, so as to form
a very open angle to prevent the infiltration of pus into
the cellular sheaths, should the extremity  of the  arm be.
not sufficiently dependent, which troublesome accident
never occurs when the principles above indicated are fol-
lowed.

Amputation of the fore-arm  towards its lower third,
                   with two flaps.

  The hand is placed in a state of semi-pronation—the
tourniquet is applied, over the brachial artery, or rather
it is compressed by an assistant, while another holds the
fore-arm in the position indicated. The operator stand-
ing on the  inside of the limb as in every case of ampu-
tation of the fore-arm,  seizes with his left hand the part
he is  to remove; he thrusts  the  point of  a catlin from
above downwards, through the soft parts, by commencing
at the inner and  anterior side of the ulna, to come out
at the corresponding point on the external and anterior
side of  the radius,  shaving the bone; he then shapes a
flap, an inch or two long, by cutting towards the palm
of the hand.   He  then  penetrates in the same manner
across the  soft parts of the dorsal surface, to come out
on  the  posterior side of the cubitus;  he then cuts a flap
of the same size as the first.  The assistant raises these
flaps, the operator carries the knife perpendicularly over
the posterior surface of the ulna, to cut the tendons and 
.'2
 other soft parts not previously divided: he introduce>
 the point of the instrument between the two bones, by
 their dorsal surface, to divide the muscles and inter-
 osseous ligament;  he withdraws the knife, passes  over
 the radius, cutting the remaining soft parts, and  again in-
 troduces the knife between the two bones from their
 palmar face:  laying them bare, he  withdraws the knife,
 and arrives on the internal and anterior side of  the ulna,
 to cut the remaining soft parts.  By means of this inci-
 sion in the shape of an  8, he entirely divides the bones,
 by cutting the muscular fibres,  the tendons, interosseous
 ligament and periosteum. Taking then a retractor, hav-
 ing three slits at one end, he introduces the middle
 portion between the two bones from the anterior surface.
 The end not  split  will  serve to raise the anterior flap,
 the hands of the assistant may indeed serve for a com-
 press.  We then  take  the  saw in  the right hand, and
 marking with the thumb of the left hand the place where
 the bone should be sawed,  the limb being pronated, we
 saw at first with short and  then with long strokes, both
 bones at the same time, nevertheless, in such a manner
 that the division of the  radius  may be accomplished be-
fore that of the ulna, the articulation of the  latter with
the humerus  being more solid than that  of the radius
 with* the same bone.  In using the  saw, we must never
 bear upon it,  as its own weight is  sufficient  to produce
the necessary pressure.
  We commonly secure four arteries; the radial, ulnar,
and two interosseous. The two flaps are placed in con-
 tact to effect the union, by the  first intention, leaving a
 dossil of lint in the ulnar angle of the wound.
  If we operate on the  right limb,  and wish to emplov
the right hand, the point of the knife must  be moved
from above downwards, by  beginning from the  external
and anterior edge of  the radius and coming out in front
-jf the ulna, and vice versa  for  the  opposite side.   ThrS
 method is almost altogether rejected. 
52
   Circular amputation at the middle of the fore-arm.

   Having  compressed  the  brachial artery  as  before
stated, and having the fore-arm held in a state between
pronation and supination by two assistants, one of whom
supports the limb near the wrist,  and  the other at the
elbow, the operator places his right knee, the foot resting
on the  ground,  under the arm, and provided with a
ratlin knife, which he holds with his whole hand, makes a
circular incision at a single stroke around the limb down
to the surface of the muscles.  To do this, he passes his
wrist under the limb, and pronates it strongly, to carry
the edge of the knife as much as possible below the an-
terior face of the fore-arm,  by passing over the radius:
he then  applies the edge, and brings  it circularly to-
wards the point of departure.  The assistant draws the
integuments towards the superior part, for about the
height of two inches.  The operator dissects the bands,
which still attach the skin to the aponeurosis: then  he
makes another circular incision  through  the muscles,
similar to the former one, applying the knife immediately
at. the base of the retracted integument?,  and cutting
boldly down to the bone.
   The assistant raises the flesh, and the operator makes
a  third  circular incision through the species of cone
which the deep  muscular layers form on  the bones,
while the  parts  already  cut  are  drawn  towards  the
clttow. He denudes the bone, cuts the interosseous liga-
ment as stated in the  preceding  article; then securing
the muscles and integuments from the action of the saw,
by means of the split cloth, he pronates the limb, and
saws the bone, according  to the principles indicated in
the foregoing article.
   We may also perform the amputation with two flaps
at the same place.  We tie the  vessels and  unite the
wound  by the first intention, so that the angles of the
                       e 2 
                         34

wound correspond, one to the radius, and the other to the
ulna; leaving a dossil of lint in the angle of the wound.
  If necessary, the same operation may be  performed
near the cubito humeral articulation.

    Amputation of the fore-arm at the elbow joint.

  Although  the  cure  is  commonly delayed for a  long
tiiae after this operation, and it is perhaps more conve-
nient to amputate the humerus, in cases where we might
cut it off at  the elbow joint,  we shall nevertheless de-
scribe the manner of doing it.

             " [dupuytren's method.]

   The brachial artery is compressed by the hands of an
assistant,  or by the tourniquet: two assistants  support
the limb in a state of supination, the one  holding above,
and the other below the elbow.   The  operator standing
on the  inside, and provided with a common amputating
knife, penetrates the soft parts  by the internal and an-
terior side of the condyle of  the humerus, to come out
at the anterior edge of the external condyle; he shapes
a flap about  three inches long, shaving along the radius
and ulna, and directing the incision towards the hand.
One of the assistants raises the flap; the operator cuts the
skin and muscles of the posterior side, as if for  the pur-
pose of making a circular incision, by entering directly
into the radial articulation, on which he first carried the
blade of the knife.   If he be not  much  accustomed to
operations, he need not enter the articulation until after
he has exposed it by the anterior and posterior incision,
and by turning his knife a little obliquely towards the
bones of the fore-arm, in the direction of the joint. The
olecranon is then denuded towards its base and sawed, 
55
to preserve the adhesion of the tendons of the triceps to
this process.
   If we wish to disjoint the  olecranon, we cut the cap-
sular ligament, by carrying the handle of the knife ob-
liquely towards the posterior face of the humerus, and
by tracing with the edge along the inside of the olecra-
non  to divide the tendons and ligament; then we bring
the edge obliquely upon the  outside; divide the tendon
of the triceps and the ligament; the ulna is then luxated
backwards; pass the knife between the superior extre-
mity of the process and the articular surface of the  tu-
brosity of the humerus, and  finish the section.
  The arteries are then tied, and the wound healed by the
first intention: a pledget of lint is to be left in the inter-
nal angle of the wound, to allow the escape of pus to
take place.*

Amputation of the arm at  some point below the shoulder
                       joint.

   The patient is  to  be seated;  the brachial artery is
compressed by the  hands of an assistant or by a tourni-
quet; two assistants sustain  the arm in a state of semi-
extension, one by its lower, and  the other by its upper
part.  The operator is placed on the outside, with his
right knee on the ground,  and the other flexed in front.

   . Where several ligatures are to be left pendent from the in-
terior angle of the wound, it may be permitted us to doubt the
propriety of keeping auy other foreign substance in it, to allow
of the flow of pus.  Under all circumstances,  as much of the
surface as possible should be  permitted to heal by the first in-
tention, which will be most certainly effected by bringing the
flaps accurately together, supporting them by adhesive straps,
and  having as few foreign bodies as possible  in the wound.
                                             J. D. G. 
In this position he passes the hand  holding the  knile
ander the diseased arm,  making a strong movement of
pronation, to begin a circular incision  on  the outside,
which he terminates  at the point whence he departed,
by raising himself gradually  as his incision advances.
The assistant placed at the upper part draws the inte-
guments towards himself, for about two  inches, accord-
ing to the thickness of the muscles; if the skin is retain-
ed by little bridles, the surgeon cuts them; then regain-
inf his first position and makes a circular incision near
the base of the retracted skin, cutting  boldly through
the muscles down to  the  bone.  The assistant  again
raises them, and the surgeon re-applies his knife on  the
deep layer of muscles, which forms on the bone, a cone
with the point downwards: directing the  edge obliquely
upwards, he makes a  third circular incision down to  the
bone which he denudes of its periosteum.
  He applies the  thumb  of his left hand on the  point
which is to be sawed, to  direct the first strokes of  the
saw; takes  this instrument in his right  hand and saws
the bone without employing pressure.
  The arteries are tied; the wound is healed by the first
intention, by bringing the  edges of the wound together so
as to form an anterior and a posterior angle; a dossil of
lint is left in the posterior angle, to allow the flow of pus
in case the union by first  intention does not  take place.
  The amputation of the arm, with two flaps may also
be performed, so  as  to have one of their angles on  the
anterior and the other on the posterior side of the bone.


Circular Amputation of  the Arm at the  shoulder joint.

  There is an endless variety of  methods for the remo-
val of the arm at  the shoulder joint, which it would be 
57
superfluous to describe:  we shall therefore content our-
selves with describing such as are generally followed.

        [beclard and dupuytren's method.]

  The subclavian artery is compressed by an assistant
against  the first rib, above the clavicle; another assist-
ant holds  the arm up nearly at a right angle with the
trunk; the surgeon applies the heel of his knife on the
middle of the free extremity of the acromion;  he directs
it downwards and backwards, and after having traversed
the space of about two inches, he directs it towards the
hollow of the axilla, whose posterior border he divides at
a point which would intersect a line departing from the
centre of  the joint and forming an angle of about forty
degrees with the centre of the shoulder, to form a pos-
terior flap, when the posterior and external side of the
articulation will be laid bare. The surgeon changes the
knife at  once, makes a second incision, which starting
from the same point of the acromion, and performed  in
the same manner, divides the anterior border of the ax-
illa to form the anterior flap. The two flaps are raised:
then, after having cut the capsule and tendons inserted
on  the head  of  the humerus, the  operator passes the
knife between  the bone  and  the  glenoid cavity, and
separates the arm from the trunk, by cutting  a small
inferior flap, which contains  the  artery  and  brachial
plexus.

                 [larrey's method.]

   The patient being seated in a chair, the artery com-
pressed by one  assistant, while the other lightly with-
draws the arm from the body, the surgeon introduces
the point  of a long amputating knife under the skin and
deltoid muscle immediately below the acromion towards 
                        58

 ts posterior edge; shaves the head of the  humerus, and
comes  out  at the'anterior border of the  axilla, on the
side opposite that at which it entered.  Then he cuts
downwards and outwards, and separates the deltoid and
latissimus dorsi from the humerus to form the posterior
flap.  He introduces the point of the knife in  the  same
manner, but between the inner part of the humerus and
the soft parts which are fixed to it, and cuts an anterior
flap corresponding to the posterior.

               [lisfranc's method.]

  This method excels all the others in the promptitude
with which it  may be performed.   A practiced surgeon
may detach the arm in the lapse of four or five seconds.
The following is the description given by  its author.
  First period.—If the left arm is to be removed, the
upper part is held three or four inches, separated from
the trunk.  The surgeon places himself  behind the pa-
tient, and grasps the thick part of the shoulder with his
left hand;  his thumb  is situated on the  posterior face
of the humerus; the fore and middle fingers are, placed
on the triangular  space comprised between the scapular
extremity of the clavicle, the coracoid  process, and the
head of the humerus.  Then the operator takes a catlin
knife eight inches long, and about eight lines broad, and
plunges it parallel to the humerus on the outside of the
posterior border of the armpit, before the  tendons of the
latissimus dorsi and teres  major.  The blade forms with
the axis of the shoulder an angle of 45°; the knife trans-
fixes the posterior and external face of the humerus and
arrives under the acromio-clavicular  space: then we
give it a swinging movement, which  slightly lowers its
point,  the handle raised  and separated two or  three
inches from the arm, to the point where the instrument
forms, with the axis of the joint, an angle of 30° or 35 •. 
59
The surgeon then presses directly upon the knife which
traversing the articulation,  comes out on the external
side of the triangular space mentioned; finally,  while
the handle of the instrument remains nearly motionless,
the end of the blade cuts from within outwards,  some-
what from below upwards, and passes round the head of
the bone: as soon as  the point is discharged from be-
tween the bone and the acromion, it moves in the same
line as the  heel; the instrument follows the outside of
the arm and terminates the flap at three inches from the
articulation.   An assistant raises this flap immediately.
   Second period.—The  surgeon holding the hand low,
and cutting from the heel to the point of the knife, glides
it from behind  forwards to  the inner  side of the head
of the humerus; the instrument, whose handle  becomes
perpendicular to the horizon,  traces along the bone to
two or three inches below the  articulation, and  before
the surgeon has completely detached the arm,  by an in-
cision perpendicular to the muscular fibres, an  assistant
placed behind the patient compresses the axillary artery
between his thumbs  placed on the bleeding face of the
flap, and the four last fingers of each hand fixed on the
 integuments of the  internal  and anterior face of the
limb.
   The posterior flap contains the external extremities
 of the latissimus dorsi, the teres major and minor, the
 supra and infra spinati, the long portion of the  biceps,
 the scapular head of  the triceps, all the acromial por-
 tion of the deltoid,  and almost all that which attaches
 itself to the clavicle, outside of the coracoid apophysis.
    The anterior flap is formed By the rest of  the clavi-
 cular portion of the deltoid by the pectoralis major, the
 coracoid part of the biceps,  the coraco brachialis, part
 of the triceps, the nerves and axillary vessels.
    If we desire to remove the right  arm, cutting with
 our  right hand, instead of beginning the  operation by 
60
 the posterior part, we enter the joint by the anterior re-
 gion, reversing the movements before described.
   We  may  still  perform the  operation on this arm in
 the same manner as upon the other, by using the knife
 with the left hand.  The  surgeon is  placed behind the
 patient, and makes his posterior flap  according to the
 principles laid down above.  The internal  flap is made
 according to the same principles.  It is also easy to at-
 tack  the right shoulder  joint from its  posterior part,
 with the right hand.  After making the posterior flap,
 as when we operate on  the left arm,  the surgeon passes
 rapidly  to  the inside of  the limb,  to make the inner
 flap.
  According to the excellent observations  of Mr. Pro-
 fessor  Serres  on  the laws of Osteogeny, it results that
 the summit of the acromion remains  cartilaginous until
 the age of fourteen or   fifteen years, and often beyond
 that time; the length  of this  cartilage is  such, that it
 covers the head of  the humerus, and the ossified points
 of this process do not advance but a line or  two over the
 superior extremity of the  arm bone; the scapular  extre-
 mity of the clavicle also remains cartilaginous, but to a
 less extent.   When, therefore, we have so young a pa-
 tient, and until this age we may  dispense  with the in-
 troduction  of the  knife between the acromion and the
 head of the humerus,  and  perform  the operation,  as
 Lisfranc has also explained.
  Whatever may be the attitude of the arm, says he, I
apply the heel of the amputating knife on the outside of
the  summit  of the coracoid apophysis, direct  it down-
 wards  and backwards,  and after having carried it for
the  space of two inches, I conduct it by  ascending to-
wards the hollow  of the axilla, whose superior border
 it divides at the point which would intersect a line pass-
 ing  from the centre of  the joint, and forming an  angle
of 40° with the axis of  the shoulder.  Thus we form h 
Gl
flap, which is to be raised up, of two-thirds of the del-
toid,  of a part of the teres major and minor, the latis-
simus dorsi, and the  long  head of the triceps.  In the
second period  of the operation, whether the capsule has
been  opened  or not,  it  is  very easy  to  traverse the
joint  directly.   To do this, we boldly cut the acromion
and clavicular  cartilages,  and  enter the articulation.
We make the internal flap as when we  operate on the
adult.
   After having tied the arteries and cleansed the wound,
we place some  rolls  of lint  at the bottom  of it, and
we bring the flaps together  in such a manner  as to keep
them  in this situation with adhesive straps, and  some-
what long compresses, and sustain the whole by aid of a
large bandage  moderately tightened.  We never attempt
to produce immediate  union.*

   * If we reflect on the extent of the wouDd produced by this
operation,  and the nature of some of the parts divided, we shall
feel much inclined to piotest against keeping it open by thrust-
ing lint to the bottom of the cavity, although  it may be well to
wait until reaction has commenced over the cut surfaces, to de-
termine whether more arteries may not require the ligature.
The irritation produced b^ the mere division of the large bra-
chial  plexus of  nerves is always great, and sometimes  fatal,
when the patient has been brought very low by disease; certain-
ly this irritation will not be diminished by  the treatment above
directed,  and most certainly, after all the  arteries are secured,
nothing can be  a better dressing to the wounded surface than
the living flaps,  with which adhesion may to a very great de-
gree immediately take place.  With balls of lint in the ca-
vity of the w..und, having the flaps brought together and re-
tained over these by adhesive straps, compresses, and a mode-
rately ti^ht bandage, we  could hardly anticipate a very fa-
vourable result, though  it must be  confessed that the human
bod)  occasionally survives the most desperate injuries, appa-
rently under the most unfavourable circumstances.— J. D. G.
                            F 
62
        Partial amputation of the lower jau.

   This  operation has  been practised  with  success by
Dupiytuen,  at the  Hotel Dicu of Paris/   The cases
demanding it are those of exostosis, necrosis, caries, and
cancer of the bone.
   The  mode of operating undergoes  some variations,
according to the extent of the bone we wish to remove.
Let  us  suppose the most ordinary case, which consists
in the amputation of the chin; the following is the mode
of performing it.
   The  patient  is seated  on  a chair, and  the  head
strongly fixed backwards against the chest of an assis-
tant, who seizes one of the sides of the lower lip between
his fore finger and thumb,  while the surgeon  lays hold
of the other  in  the  same manner,  with his  left hand.
Then holding, in the third position, in his other hand, a
bistoury with a  convex edge, he makes an incision, which
departing from  the middle of the free border of the lip,
terminates  directly at the  middle of the os  hyoides. If
only a  small portion of the bone is to  be removed, this
incision will  suffice; but if the diseased portion  be of
more  considerable extent,  we  make a second incision
transversely upon the first in front of the middle of the
chin.   We then detach the adhesions of the soft parts
to the bones, by dissecting from above downwards, per-
pendicularly  to the axis of the trunk, till we arrive at
the part which is to be cut off.   We dissect in the same
manner on the opposite side,  and  denude the bone of
its periosteum  at  the  point where the saw is  to be ap-
plied."  When we have made a crucial incision, it is dis-
sected as indicated at page  12.
   If there  be any  teeth in  the way  of the  saw they
 , * Tn the United States it has been performed successfully by
Professor Mott of  New  York,  and with  partial success by
other persons elsewhere. 
63
should be drawn; then the operator taking a small saw
in his right hand, applies it  to  the  bone  at the base of
one of. the flaps, and  saws obliquely from without in-
wards, while the assistant keeps the bone firmly fixed.
He saws in the same manner on the opposite side.  To
avoid injuring the nose and upper lip, a piece of lead or
a> linen compress is placed  over  these parts.   Having
finished the section  of the bone, the surgeon glides the
edge  of the bistoury behind the posterior surface of the
amputated fragment;  then makes a division of the soft
parts, which are adherent by a single cut along the edge
of this part of the bone.  To stop the hemorrhage, the
tongue is raised and  drawn forward, in order that the
arteries may be laid hold of by the forceps.   They are
to be tied; and should the blood continue to flow with-
out our being able to perceive the arteries which fur-
nish it, we employ the actual cautery at a white heat.
   The surgeon then brings the two ends of the bone to-
wards each other, and  next places the flaps in immediate
contact,  retaining them as in the  operation for harelip,
by commencing from  the loose edge.  When the skin
participates in the disease rendering  the operation ne-
cessary, the diseased  portfan should be circumscribed
by two incisions, and  removed along with the bone. In
this case, as the union  of the edges of the wound become
more difficult, on account of their reciprocal distance,
we ought to dissect  them from the bone and gums, when
they may be brought together without difficulty.


Partial amputation of the toes at their metatarso-pha-
                langeal articulation.

   It is  better to extirpate the whole toe,  even when
amputation of a single phalanx would suffice, to remedy
the accident or the disease, because the stump left is
more inconvenient than useful. 
04
  The same principles which  govern us in removing
the fingers at their metacarpophalangeal articulation,
are to be followed  in amputations of the toes; the only
difference is, that we ought  to begin the incision with
the point of the bistoury,  instead of the full edge, and
the cut should be directed parallel to the bone, until we
arrive opposite  the articulation,  which is much deeper
seated; we then glide the point of the bistoury between
the two articular  surfaces,  partly circumscribe that ol
the phalanx  we wish to detach, and finish as has been
directed in removing the fingers.  (See page  4T.)


             Amputation of all the tors.

  This is done according to the same principles with
the amputation of  all the fingers, with  this single differ-
ence, that the great toe is comprised in this  amputation,
while in that of all the fingers,  the thumb is  not.  If we
operate on young patients, about until the age of puberty,
as the  metatarsal  extremities are still cartilaginous, in
such case9,  we  follow the principles  indicated for the
amputation of all the fingers. It is on the laws of osteo-
geny, established  by  Professor Sf.rres, that Lisfranc
has based his operation, until the  time  of life mentioned
above.


Amputation of the first and fifth metatarsals,  cutting
                  through the bones.

   This operation is principally performed,  on account
 of caries of the bone.   When we can be certain of the
 extent  of the disease.  The following is  Lisfhanc's
 method; supposing the first metatarsal of  the left foot
 is  1o be removed. 
65
  First method.—Placing the foot on a table, and hav-
ing it secured by an assistant, the  operator grasps the
integuments and  muscles situated on the inner side of
the bone, and presses them as far downwards as possible,
to make a flap of proper thickness.  Then he plunges
the point of the bistoury, held  in the third position, per-
pendicularly  from above  downwards, between the inner
side of the bone and the soft parts, which he holds with
his  left hand, immediately behind  the diseased point; he
cuts a flap in the length of this bone,  by directing his
incision towards the toe,  to coma out a little beyond the
articulation of the first  phalanx, with  the metatarsal
bone.   From the  base of this flap, which an  assistant
raises up, he commences another incision, which crosses
the bone, somewhat obliquely outwards,  on its superior
surface, and which ends on the inner and upper side of
the metatarso-phalangeal articulation.   We may, how-
ever,  without making this  second incision, dissect the
skin from the base of the  flap to the articulation indi-
cated, and have  it  drawn  outwards by an assistant.
After this,  the surgeon carries the edge  of the bistoury
between the two metatarsals, some lines in front of the
base of the flap, introducing the point by the upper and
outside of the first of these two bones, to come out obli-
quely on the external and  plantar side, without inter-
fering with the skin of either surface; thence he cuts di-
rectly down to the union of the  toes,  where  his knife
conies out.  He then denudes the bone circularly and
obliquely from  the internal basis of the  flap,  to some
lines in front of this flap, on the upper and inner side of
the bone, which is the most difficult part of the operation.
N -vertheless, it may be performed without difficulty, by
introducing the blade of a very narrow bistoury flatwise,
between the two metatarsals, and then turning the blade
towards the point of bone we wish to lay bare, to cut the
soft parts alternately from  above downwards, which ad-
                         r 2 
60
here thereto. The bistoury is withdrawn to denude the
bone on  its free edge; we then place a piece  of sheet
lead between the two bones. A small saw held in the right
hand, is applied to the bone at the base of the flap, and
we  saw obliquely from behind  forward,  and  from  the
internal to the external edge, in  the direction it has been
denucd.  The obliquity should be proportioned to the
thickness of the bone.
  If necessary, we tie the arteries, and unite the wound
by the  first  intention, maintaining the edges in contact
with adhesive straps.
  S.cond method.—The surgeon makes an incision over
the middle of the bone, on it* dorsal surface, immediately
behind  the  diseased  part; he  directs  it obliquely  to-
wards  the  inside,  and continues  it to the  lower  and
inner side,   somewhat in front of  the metatarsophalan-
geal articulation; a second incision, departing from the
same point, is directed obliquely  towards  the opposite
side, to join the first at the plantar surface.  These  two
incisions thus circumscribing a flap on the dorsal face of
the metatarsus.  We then dissect as in the first method;
denude the  bone obliquely from behind  forwards,  and
finish the rest of the operation exactly as has been above
stated.
   The same principles are all applicable to the ampu-
tation of the fifth metatarsal; only the  denudation  and
section of the bone should be somewhat less oblique, on
account  of the diameter being smaller.

Partial amputation of the foot at its tarso-metatarsal
                     articulation.

                [lisfrano's  method.]

   The patient lying on a bed,  or placed in a chair, we
apply a tourniquet over the femoral artery, or else have 
67
it compressed by an assistant: another assistant secures
the foot firmly in its natural position.  Suppose the ope-
ration  to  be performed on the  right foot: the surgeon
traces  with the fore finger of the left hand,  along the
outside of the metatarsal, until  he arrives at the tube-
rosity, where this bone  is articulated with  the  os cu-
boides.  He places the thumb of this hand on the tube-
rosity; he then carries the fore finger of the  right hand
along the  internal edge of the first metatarsal, and traces
the bone until he  arrives over its tarso-metatarsal arti-
culation;  if he cannot  by  this mode distinguish this arti-
culation,  he  draws an  imaginary line from the tuberosity
on which his thumb is applied,  supposing it to be  di-
rected transversely over the dorsal surface, and perpen-
dicular to the axis of the foot; it is at a half an inch  in
front of this line, that  the articulation of the  first meta-
tarsal, with the internal  cuneiform bone is found. The
surgeon places his left  fore finger over this point, keeping
 the thumb fixed on the opposite tuberosity. Then grasp-
 ing a narrow, short and keen knife in his right hand, he
 makes a  semilunar incision on the back of the foot, with
 its convexity anteriorly, by commencing near his thumb,
 and continuing it towards his  fore finger, which is only
 removed  to make way for the edge  of the  knife.  An
 assistant draws the skin towards the leg.  Then grasp-
 ing the foot with the whole hand, as if to dislocate it,
 the surgeon cuts with the point of the knife, the  liga-
 ments which connect the fifth  metatarsal with Ihe cu-
 boides: he   enters the articulation of these two bones,
 with the edge  of the knife, from the outer side of the
 foot,  giving to  the  edge the direction of a line, which
 would terminate on the outer side of this articulation, at
 the anterior extremity of the  first metatarsal.   Having
 then  cut the ligaments which unite the two succeeding
 metatarsal  bones to the cuboides, by giving the knife a
 less oblique direction, he carries the instrument perpen- 
                          68

 dicularly over the inner side: the point being directed up-
 wards, opens the tarso-metatarsal joint of the fir*t meta-
 tarsal, bv cutting in the direction of a line, which depart-
 ing; from the inside of this articulation, passes over the
 middle of the fifth metatarsal bone. Changing the direc-
 tion of the  instrument, the back of which he  turns to-
 wards his chest, he plung;es the point from above down-
 wards, between the projection of the internal cuneiform
 and  the  second metatarsal bone;  then by a  somewhat
 considerable effort,  he raises  the handle  of the knife,
 which describes an  arc of a circle,  to cut the interarti-
 cular ligaments, which unite the two bones.   With the
 point of the knife, he then cuts the ligament which unites
 superiorly the  head  of the  second  metatarsal to  the
 second cuneiform.   He then luxates the  foot forcibly to
 open the articulations, and he cuts the interarticular liga-
 ments, by carrying the point of the knife several times
 into the opening.  When the articulation is completely
 open,  he glide-, the  knife between the inferior face of
 the metatarsal  bones and adhering soft parts, directing
 its edge towards the toes, and  shapes a flap  of such a
 size as will  reach to the superior ed^e of the wound.
   If the left foot be operated on, we commence* the first
 incision on the  inside.
   If we  operate on a young subject,  before the aj;p of
 puberty,  as the projection of the internal  cuneiform is
 still cartilaginous, as  Serkks has  observed, Lisfranc
proposes to traverse thi« point with  the edge of the knife,
nearly on  the same  line  on which the articulation- of
the second, third and fourth metatarsals aie found. This
 will  be the more easily effected in  proportion to the
youth of the subject.
  Th  aiteries  are to be tied and the wound  healed by
the first intention; leaving a pledget of lint  in the exter-
 nal and inferior angle of the uound, to facilitate the
 escape of pus, should adhesion not take place. 
69
Partial amputation of the foot at the  articulation of
  the astragalus and os calcis, with the Scaphoid and
  Cuboid bones.

  This  operation is named after C hop art, who passes
for the first who  performed it.  Lisfranc,  in  his lec-
tures, directs it to be done in the following manner.
  The foot being placed  in its natural situation, on the
edge of a bed or table, and secured by an assistant, we
seek for the articulation. To do this, supposing the right
foot to be operated on, the surgeon traces with the fore
finger of  the right hand, from the malleolus  internus
until  it encounters the  projection formed by the sca-
phoides on the  inner side of the foot, and there the joint
is found.
  The  articulation of the cuboides with the os calcis
towards the outside,  is constantly found about half an
inch behind the projection formed by the posterior and
external extremity of the fifth metatarsal bone. These
two points being fixed, one  by the thumb and the other
by the index finger of the  left hand, while the sole of
the foot is strongly seized by the palm of that hand and
the other fingers, the gperator makes an anteriorly con-
vex semilunar incision with a narrow bladed knife, be-
o-inning at the point where his thumb is  held,  and end-
ing at the fore finger, which should only be  removed to
make way for the edge of the knife.  He enters the as-
tragalo-scaphoid joint, directing the edge obliquely in
the°course of a line which drawn from the inner side of
this articulation would fall upon  the cuboid  extremity
of  the  fifth metatarsal.   He  luxates the foot to open
the articulation, cuts the dorsal  ligaments with the point
of the instrument, enters transversely from without in-
wards into the calcanco cuboid articulation,  repeats the
 luxation, cuts  with  the point of the  instrument  the
 strong interarticular ligament,  and the joint being 
TO
widely open, he passes the whole blade of the knife be-
tween the inferior face of the scaphoid and cuboid bones
and adherent soft part?, and cuts from  behind forwards,
a flap capable of covering all the wmnd, by avoiding the
tuberosities of the scaphoides and cuboidcs, and of the
first  and third metatarsals, and by restoring the foot to
its fiatural position.
  The arteries are taken up, and the edges of the wound
immediately brought together by adhesive straps,  leav-
ing a pledget of lint in the inferior angle of  the wound,
&c. as heretofore indicated.
        Amputation of the leg ivith a single flap.

   This operation is never performed except towards the
 superior part of the lower third of the leg.
   The patient lying supine on the side of a bed or table,
 and the leg supported by two assistants, the femoral ar-
• tery is compressed with  a tourniquet or by the hand of
 another assistant. Thesurgeon, seated on the inside of the
 limb, seizes the leg with the left hand, placing the thumb
 on the internal edge of the tibia and the fore fin-er on
 the  fibula; then  with  a catlin  knife held  in the  ri Jit
 hand, he makes a transverse incision on the anterior face
 of the leg which parting  from  his  fore finder is  con-
 tinued until it arrives at the left thumb fixed as lias been
 described; then introducing the  point of the knife by the
 internal angle of the incision, and bringing it out at the
 opposite angle bysh^trtfg the posterior face of the tibia
 and fibula, he.c«ffa flap  proportioned to the thickness
 of theJimb", and  directs the knife towards the lower ex-
 tremity along  the bones.  An  assistant  raises the flap.
 The surgeon applies the edge of the knife over the pos-
 terior and  external face of the fibula, cuts the remaining
 soft parts until the point of the instrument reaches the 
n
interosseous  space,  which  he enters and divides the
soft parts there situated. The knife is then disengaged
from between the bones passed over the tibia,  denudes
it of its periosteum,*ce-entersthe interosseous space, and
is used as before; the instrument is then withdrawn and
finishes the denudation of the posterior part of the tibia.
When these  bones are fairly denuded, we pass the cen-
tral tail of a retractor between the bones and draw the
soft parts out of the way of the saw: this latter instru-
ment is grasped in the right hand; it is  applied on  the
fibula  and tibia on the outside of the leg as high as the
base of the flap, and the sawing is conducted  so  as to
finish  the division of the fibula before that of the tibia,
by employing the saw according to the principles here-
tofore established.   The anterior and posterior tibial,
and the peroneal  arteries are tied; the flap is brought
over the bones, and healed by the first intention; the ends
of  the ligatures depend fcom the posterior angle of the
wound, and lint is also left within it, for the  purposes
already specified.


 Circular amputation of the leg, four inches below the
                articulation of the knee.

   Every thing being arranged as in the preceding case,
 the surgeon  armed with a catlin knife, first makes a cir-
 cular incision to cut the skin, a second to cut the mus-
 cles, and a third to cut the deep layers, according to the
 principles heretofore laid down, for the  circular amputa-
 tion  of  the  fore-arm and  arm.  The remainder of the
 operation is entirely similar.   This operation should
 leave a stump of about four inches, for the application of
 an artificial leg.
   The  arteries being ^secured, the edges of the wound
 are brought together so as to form  an anterior and pos- 
                          72

 terior angle; in the latter  ve place the pledget of lint,
 and the ends of the ligatures are brought out through it.


     Amputation for the removal of the knee joint.

   Although we are  persuaded that this operation is in
 every case more dangerous than that of the amputation
 of the thigh, and that of consequence the latter should
 always be preferred, we shall nevertheless describe the
 former operation.
   The  patient lies supine on a bed or table, so that the
 thigh projects somewhat beyond the edge; the femoral ar-
 tery is comprised, and the surgeon flexes the leg on
 the thigh almost at right angles, and makes with an am-
 putating knife a deep incision, so as to enter the articu-
 lation by  cutting from one condyle of  the femur to the
 other, below the point of the  patella.  Then the crucial
 ligaments are  cut with the point of the instrument,
 avoiding the popliteal artery. A  second  section is then
 made by departing from one of  the angles, and termina-
 ting at the angle opposite the first incision, but passing
 above the  patella.  The  leg is now more strongly flexed
on the thigh, and an incision made around the  femur,
immediately above its condyles; the bone is entirely de-
nuded at  this point, carefully avoiding the artery, and
 sawing transversely.
  The lower extremity  of the  femur and patella being
thus removed, the superior extremity of the tibia ought
to be accurately denuded somewhat below its articular
surface, by making at several  strokes a circular incision
around this part.   We then saw it transversely at the
line  exposed, taking care to  avoid the popliteal artery.
 We then  straighten  the leg to  bring the sawed surface
 into  contact, and  ap )ly splints as in the case of frac-
 tures, keeping  the whole limb extended.  We  think 
73
that there is something more than temerity in underta-
king this operation, under any circumstances.*

       Amputation of the thigh with two flaps.

  The patient is commonly seated on the edge of a table,
with  his back  supported against  a mattress or bolster;
the tourniquet is applied as high up as possible over the
course of the femoral artery, or an assistant compresses
it against the pubis,  and another assistant sustains the
leg. The operator, being on  the outside of the limb, and
armed with a  large knife, first makes the internal  flap,
by  plunging its  point  from the middle  of the anterior
to  the posterior  face of the thigh, grasing the inner
side of the thigh bone.  He shapes a flap of two or three
inches by directing the incision towards  the knee joint.
He then forms the second flap on  the opposite side, by
introducing the instrument from the satne point he com-
menced  the first, and  grasing  the  outer side  of the
bone, comes out below at the same point where the first
incision ended; he then cuts  out  a flap in the same di-
rection and of equal  length as that on the inside.  The
two flaps being raised by an assistant,  a circular inci-
sion is made at their bases  to finish the division of the
muscular fibres adhering to  the bone, which he denudes
near  this point. Then taking the saw in the  right hand,
he  places the thumb nail on the bone to direct the first
movements of the instrument, he saws  the bone trans-
  • Mr. Park, in England, was the first who cut out the knee
joint with success, and to remove thjjends of the bones advan-
tageously, he devised a jointed saw^ionstructed  on the  prin-
ciple of a watch chain.   The operations he performed in this
way were difficult of execution, and the patients  were long in
recovering: the risk is so great, that few surgeons will feel
themselves  at liberty to recommend or repeat this operajjon. 
74
 versely,  while an assistant  carefully  raises  the flaps
 The arteries are  tied, and the wound healed by the first
 intention,  the  flaps  being held  together  by  adhesive
 straps and a roller bandage.  The pledget of lint in the
 inferior angle, ivc.11

           Circular amputation of the thigh.

   Every  thing is arranged  as in the former operation;
 the  surgeon is placed on the outside of the limbjkneel-
   * A mode of amputating the thigh with two flaps was pro-
 posed a few years since by Professor J. B. Davudge of Mary-
 land, which combines several important advantages.  The first
 incision is made with the large knife on the outside and inside
 of the limb through the integument, so as to surround the limb,
 with the exception of an inch or  more in  the centre, above
 and below.  The surgeon having calculated the size of the
 flaps required, which arc to be as long as the semi-diameter of
 the limb,  makes with  a scalpel a second and third incision
 through the skin, in form of the letter V, commencing in the
 centre of the space  left vacant on the superior and inferior sur-
 face, and continued till its diverging extremities reach the ends
 of tlic semicircular  cuts first mentioned.  The flaps of  integu-
 ment are then dissected  back until they equal in  length a little
more than the semi diameter of the limb, to allow for the retrac-
 tion that may occur. A  circular incision is then made with the
large knife, through the muscles down to the bone.   The bone
is then denuded for an inch or two, the retractor employed, and
the bone sawed off at the edge of the divided flesh.  The arte-
ries are  then secured; the muscles  drawn  down; the  ligatures
arranged so as to come  out of the superior and inferior angles
of the wound, and the flaps are brought together and kept in
place by adhesive stra; ^^ipported by  a cross bandage, roller,
 fcc.   By this amputation the bone is cut  off, an inch or more
 within the actual face of the stump, and the flaps of  integu-
ment, having the angle cut out abo\e and below, do not pre-
 sent  that unnecessary  and inconvenient lump  or puckering
 i^M^ at the angles after the common circular amputation  I
 h^^pcen this operation frequently performed by  my preceptor
 T;io:i vi II.  Wright, M. D. with great skill and success. 
75
ing on the right knee, and makes a circular incision
around the  thigh in the same manner as has been de-
scribed in the amputation  of  the  arm. He dissects
the skin for the space of about two or three inches, and
one of the  assistants turns it upwards.  A second cir-
cular  incision is made down to the bone, and  a third
obliquely over the remaining muscular fibres adhering to
the bone; the surgeon takes the saw in  his right hand,
applies it on the denuded bone towards the base of the
flap, and saws transversely, guiding the first strokes of
the saw with his  left thumb.
   After tying the  arteries, we  bring  the edges of the
flap together so  as to  form an  anterior and posterior
angle, keeping the edges in contact with adhesive straps
and a rolled bandage. The pledget of lint is placed in
the posterior angle, &c.

        Amputation of the thigh at the hip joint.

                [lisfranc's method.3

   Without attempting to describe the different methods
which  have  been devised  for the performance  of this
operation,  we shall only give that of Lisfranc, which
exceeds all those hitherto proposed,  by "the promptness
with which it may be performed, an  advantage so much
the more excellent, as the amputation of the thigh is not
only exposed to  considerable hemorrhage,  but  causes
dreadful suffering in proportion as it is prolonged.
   Let us suppose that the left thigh is to be operated on.
   First period. The ischiatic tuberosities of the patient
extend slightly beyond  the inclined plane upon which
he lies supine. The right hand  of the surgeon held in
pronation,  directs the instrument. An assistant keeps
the limb extended,  and in a state between abduction
and adduction, if possible. The surgeon stations himself
on the outside, and a little below the joint; he plunges a 
                         76

long, narrow-and thick bladed catlin knife, perpendicu-
larly, into the internal extremity of a line, making a right
angle with one which descends from the  anterior supe-
rior spine of the ilium; the inferior edge of the knife
ought to be  in  the direction of a line which  com-
mencing at the first puncture, could be continued to the
top of the greater trochanter.  The point of the instru-
ment penetrates to the head  of the femur, whose exter-
nal face it  goes round;  but it is indispensable that in
proportion,  as it is pushed  deeper, the handle of the
knife should  be lowered, so as to be inclined  outwards
and upwards, forming with the horizon and the axis of the
trunk an angle of from 50° to 55°; the instrument comes
out some lines below the  ischiatic tuberosity, where the
eyes of  the operator precede it.   In order that the tex-
tures of the posterior region of the thigh may be more
easily divided by the knife,  an assistant or the surgeon
grasps them, and makes them project  on  the  outside.
At the  moment when the puncture is  made, the knife
always  forming  the angle mentioned  above,  with the
horizon, its inferior edge following then the direction
of the line in which it was placed, descends, passes round
the great trochanter, rather sawing  than pressing,  runs
along the femur for the space of about  two inches, and
terminates  the external flap.
   At the moment this flap is made, it is  raised up, the
assistants apply their fingers on all the  arteries which
pour out blood; they are secured  immediately before
proceeding to the formation of the second flap.
   Second period.  The  surgeon, after having pressed
the soft parts inwards,  with his left hand, plunges the
point of the knife below the head of the femur, on the
inside of its neck, one of the edges is directed upwards,
the other downwards; but we should take great  care,
that the instrument inclined over the belly, forms with
the  horizon an  angle of about 60°.  The  knife passes 
                         77

 round the bone, and  comes out without touching the
 pelvis at the posterior and superior angle of the wound.
 The instrument then becomes perpendicular to the hori-
 zon, is carried along the femur, for the extent of about
 two inches, and avoids the lesser trochanter, by pressing
 the knife slightly inwards; finally,  the internal  flap is
 finished, by dividing the textures,  so  as to have them
 sloping inwards. This  flap equals the external in length.
 We must  not omit  to mention that an assistant should
 introduce  his fingers  deep into the wound, as  soon as
 the soft parts detached from the femur will permit, and
 that then the thumb of the same hand  being applied to
 the skin, which covers the superior and internal surface
 of the thigh; this  assistant  compresses  the crural and
 deep arteries before they are opened.
   The  arteries being  all secured,  the assistants keep
 the flaps raised up.
   Third period.  The surgeon grasps the femur with the
 left hand, if the bone be sufficiently long,* and carries the
 edge of the knife perpendicularly upon the inner side of
 the head of the  bone, which he circumscribes as much as
 possible.  To divide the capsule and  some other soft
 parts,  not cut  in the formation of  the flaps,  he should
 not seek to penetrate the joint in proportion as it is ex-
 posed, but, he should cut upon the  capsular ligament",
as if he wished to leave half the head of the femur in
the cotyloid cavity. Then the joint is sufficiently opened  *
 for him to cut the triangular ligament,  with the point of
the knife, on the head of the bone.  Finally, the instru-
 ment, whose point  is  perpendicular to the  horizon, is
moved to the inside, cuts from  within outwards, the re-
 mains  of the capsule and  some  muscular substance,

  • Supposing the lower part of the bone to have been carried
 away by a cannon shot or some other accident.
                        g 2 
                          78

which  in cases where the thigh is large,  could not pre-
viously be divided.
  If we operate on the right thigh, the left hand ought
to be used; but the knife may, even in this case, be guided
by the right hand, though then it will be indispensable
that the surgeon  should  be  placed against the trunk of
the body,  on the  side of the joint to be operated on.
  We  do not attempt to produce union by the first inten-
tion, but we should, as Professor Boyer advises, after
amputations in general, during some days  only,  phice
lint in the wound, to reunite  it, when the granulations
are well developed.* We moreover, apply adhesive straps
and  a  bandage very analogous to the spica (or spiral
roller) bandage of the groin.   In case of inflammation,
the application of ice should not be neglected.

  * We have already expressed an opinion as to the impropriety
of keeping large wounds open by the introduction of lint, &c.
without apparent reason. If the arteries be all secured, nothing
but irritation and inflammation can be produced by such treat-
ment; and we would venture once more to suggest, as a gene*
ral rule, that union by the first intention, should be attempted
after all operations, similar to those heretofore described.
  The  operation at the hip joint has been performed frequently
with success,  and  most recently  by Mr.  Sime of Edinburgh.
In cases where the thigh has been carried off by a cannon shot,
and the system has begun  to react sufficiently, the necessity of
the operation is evident; but it is by no means easy to decide
as to the propriety of performing  such an operation on natienta
having disease about the hip joint and head of the femur. Cer-
tainly, in many such cases, if the  irritation of the disease could
be  removed, the  constitutional  powers  would become more
vigorous and healthy; but unfortunately, the removal of the
disease requires an operation, which,under such circumstances'.
generally hastens  the patient's death.—J. D. G. 
79
AMPUTATION,  EXCISION, SECTION, AND EX-
         TIRPATION OF  SOFT PARTS.
              Amputation of the breast.

  We read in the history of the principal operations of
surgery, that Leonidas of Alexandria, was the first who
operated for cancer of the breast.   His method was as
follows:—the patient lying supine, he made a first inci-
sion through  the integuments over the tumor, then  im-
mediately applied the actual cautery to stop the hemorr-
hage; he made a second deeper incision, and again ap-
plied the cautery, and thus  in  succession, until he  had
entirely destroyed the whole breast.   Finally, he termi-
nated the operation, by cauterizing the whole surface of
the wound, to destroy all the remaining cancerous points.
This barbarous and cruel process deserved the rejection
it has received.
  In the eas< s which  demand extirpation of the breast,
we  must not forget that the skin  which adheres  to the
tumor, and the cellular texture which surrounds, ought
to be removed with it, for the  extent of at least half an
inch into the sound parts. We  need  not hope for a cure,
if this precaution be neglected.
  The pat'ent is seated in a chair,  the head supported
against the  breast of an assistant;*1  another assistant

  * The propriety of this position, is  extremely questionable,
not  only hecause few assistants can be found to support the
patient with sufficient steadiness, curing so tedious an operation
as this very generally proves, but  became the patient is rarely, 
80
 raises the arm of the diseased side, in order to render
 the great pectoral  muscle  tense. The surgeon places
 himself in front  of  the patient, but a little to one side,
 and disposing the fingers of the left hand, in a line  to
 stretch the skin on the outside, he makes, with a convex
 bistoury, a semilunar  incision obliquely from below  up-
 wards, on the outside of the tumor.  He then makes a
 second incision  on  the  inside, which  commences  and
 finishes at the same point as the first; the integuments
 are then stretched towards the sternum, with the radial
 edge of the left hand.  The axis of the ellipsis, resulting
 from these two  incisions,  should  form with the axis of
 the body  an angle of about 45°, the apex of which is be-
 below, and the base  upwards, to facilitate the flow of
 pus.  Lisfranc advises to dissect from below upwards,
 commencing on  the outside, and in the direction of the
 fibres of the great pectoral muscle,  so as not to detach
 its inferior edge, which would lay bare the ribs. If the
 dissection is made from above downwards, the blood will
 hide the  parts over which the edy;e of  the bistoury is  to
 pass,  an  inconvenience, which does not occur when we
 dissect as first above directed.
   The assistants  arrest the bleeding by applying their
 fingers over the orifices which  furnish the blood.
   When there is a chain of cancerous glands extending
from  the  bosom  into  the  axilla, we circumscribe  the
breast and glands by the same incision, but if there be
an interruption between the diseased glands and breast,
we extirpate thein by making an incision separate from

or never in a condition to remain in this position, while the ope-
ration is going on, without a great disposition to syncope.  We
have seen this operation performed frequently, and on a  con-
siderable variety of patients, and never yet met with one capa-
ble of sitting  thus, to  be  operated on.  The recumbent
position is preferable.—J. D. G. 
81
the first.  When the diseased gland is exposed, we lay
hold of it with a double hook, draw it upwards to dissect
under it and secure the vessels,  which are to be tied as
they are opened, lest they should retract too far, and
cannot then be tied; if they be of considerable size, we
tie them before they are divided.
  It may be, that the ribs participate in,the cancerous
disease; in this case we expose them, and apply the ac-
tual cautery to the diseased parts.*
  The arteries are  tied, and an hour or two after the
operation the edges of the wound are  brought together,
and healed  by the first intention; the ends of the liga-
tures are brought out at the inferior angle of the wound.
Long adhesive straps keep the parts in contact; pledgets
of lint, compresses  and a body bandage, sustained  by
means of a scapular, complete the dressing.
  The same operation is performed when a voluminous
tumor is to  be extirpated, or a cyst of rather considera-
ble size; but in such a case the crucial incision is to be
preferred: it is only when we  are not obliged to sacri-
fice  any part of the  skin, at least when we do  not see
beforehand  that more than enough skin will remain af-
ter the operation  to cover the wound, as  would be the
case in large tumors with small  bases, if instead of cir-
cumscribing the pedicle by an elliptic incision we made
a crucial incision which would uselessly preserve all the
skin of the tumor.

               Extirpation of the eyes.

   Cancerous degeneration of the eyeball, imperiously
 demands that operation which Bartisch, a surgeon ocu-

   * Professor Richcrand of Paris has even removed considera-
 ble portions  of the ribs themselves in one case of cancer. 
82
list of Germany, first described.   In performing it he
employed a curved  instrument with  two cutting edges
which he introduced beneath the upper lid to the bottom
of the orbit, and removed  the  eyeball,  after having cir-
cularly cut it-- adherences.
   If we wish 1o extirpate the eyeball, without removing
the lids, it is done in the following manner:
   The patient lies 9upine, with the head somewhat ele-
vated by means of a pillow; or rather he is seated on a
chair reclining his head against the breast of  an assist-
ant.  The  surgeon places himself in front, if the patient
be seated, or on the side of the diseased eye, if he be
lying down.  He draws the integuments outwards,  by
placing  the thumb  and  index finger of the  left hand
upon the external angle of the lids; with the right hand
he introduces flat and  horizontally a straight bistoury,
held in the fourth position, below this an<;le, and pushes
it  from  within  outwards to carry it along underneath
the integuments; when the instrument has thus  travers-
ed the space of about half an  inch, he turns the edge to
the front, or rather upwards, if the patient be lyin°- down,
makes the point project through the  skin, and  cuts  all
that is placed between the heel and point of the bistoury.
He then seizes the eyeball  with a simple hook, which he
fastens with his right hand into the transparent cornea;
then, taking the handle of the hook in the left hand, he
draws the  globe of the  eye gently forward.  He  then
holds the bistoury in the first position with his right hand,
and plunges it between the ball of the eye and the walls
of the orbit perpendicularly to the axis of the globe, to-
wards the  internal  angle  and  below the upper lid; he
then moves it from  within outwards  makino-  a  circular
incision around the globe of  the eye; and° constantly
holding the bistoury in the same position, he  finishes
where he began:  An assistant  alternately elevates the
superior and  depresses the inferior lid, in proportion as 
83
the instrument passes under one or the other.  In this
)vay the muscles belonging to the globe of the  eye  are
cut, and there are no other adhesions to the orbit except
the optic nerve and  the cellular texture, which  the sur-
geon cuts with the scissors curved on the flat  side, con-
tinuing to draw the globe of the eye forward.* The fore
finger of the left hand is introduced into the upper and
outer part of the orbit to seek for the lachrymal gland;
we seize it with  the hook, and draw it as  far outwards
as possible, to cut it oft' with the  curved scissors. All the
soft parts within the  orbit affected with the cancerousdis-
case are removed, otherwise  it will soon reappear and
continue its ravages.  It is scarcely necessary to  warn
the surgeon to be careful in guiding the  point of  the
bistoury within the  cavity of the orbit lest he should
thrust it through  the bones which form its  walls.
   When the  eyelids are  involved in the disease which
requires the extirpation of the eye, we remove them with
this organ at one and  the same operation. For this purpose
we pass the point of  the  hook  from above downwards
through  the free edge of the upper and lower lid, at  the
same  time including a part of the eyeball.   We raise
the whole together and plunge the bistoury above  the
upper lid between the walls of the orbit and the eyeball,
perpendicular to its  axis.   We finish the incision  as  in
the preceding case, and take the same precautions rela-
tive to the lachrymal  gland, and the fatty cellular texture
which is contained in the orbit.
   To  arrest hemorrhage we are careful not to use  the


   * For dividing the nerve a keen edged curved knife is cer-
tainly the best; scissors always pinch as well as cut, thus  giving
more  pain.   No oue should trust himself to use much force in
drawing  the eyeball forwards, when all adhesions, except the
nerve, aro cut.—J. D- G. 
84
   actual cautery, as practised by certain surgeon9;  we
   confine ourselves  to plujjgin^ with  lint, and should thi$
   be insufficient  we sprinkle it  with powder of rosin.
   Over this lint we apply a soft compress, which is retain-
   ed by a proper bandage.


                      Artificial eye.

     The globe of the  eye should at  least be diminished
   one-third to allow it to receive an eye of enamel intend-
   ed to palliate the  deformity which results from the loss
   of the natural eye.   If we  apply such  an eye,  after
   having evacuated  the  eyeball, or performed any other
   operation, it must  not be until after the complete  cica-
   trization of the  stump and neighbouring parts, the fol-
   lowing is the mode of placing it.
     We take the eye of enamel by its two edges with
   the thumb and fore finger of the right hand, having the
   cornea in front, we dip it in fresh water and pass it un-
   der the upper lid,  which is raised by the fingers of the
   left hand; this lid is abandoned and the inferior lid low-
   ered until the edge  of the artificial eye comes within.
   The lids  return  to their natural state  and retain  the
   eye in  its position. It must be carefully removed every
   evening and placed in a glass of fresh water; by so doing
   ulceration of the lids is prevented, and the enamel retains
   its polish  for a longer time.
     To remove it,  we depress the inferior lid, and we in-
   sinuate between it  and  the edge of the artificial eye, the
   head of a very well polished pin, with which we draw it
   forwards.
     If the globe of the eye has not been  completely re-
   moved, and a stump remains, the motions of the stump
•  will communicate to the artificial eye, movements  so 
8j
 much in harmony with those of the sound eye, that the
 illusion is perfect.
   Persons who use artificial eyes, would do well to have
 several at their disposal.


              Excision of a Pterygium.

 ,  Authors advise us to pass a thread through the nebu-
 lous  pelicle,  known by the name ef  pterygium,  and
 which commonly extends between the cornea and lach-
 rymal caruncle, for the  purpose of cutting it oft: by
 others the nitrate of silver  or other  caustic is recom-
 mended  for its destruction.  Scarpa advises, that  in-
 stead of traversing it by a needle and thread, for the pur-
 pose of raising and cutting  it off, we should lay hold of
 the varicose spot with forceps, and remove it  by the flat
 curved scissors.  Lisfranc, following Soarpa's method
 in part, proposes to excise the pterygium in the follow-
 ing manner:—
  The patient being seated on  a chair, in front of a
 window, and  the head supported against the breast of
 an assistant, who raises the upper eyelid  at the same
 time with the end of the index finger, the surgeon seizes
 the pterygium with very small forceps, and draws it
forward with the left hand; an assistant taking hold of
it  at  another point,  draws it  equally outwards:  in
this way it is  detached from the eye;  and if it be not
 sufficiently so, another assistant takes hold, with a third
pair of forceps, and raises it. Then the operator, haying
 a pair of very  delicate scissors, curved on their flat side,
 cuts off the varicose substance, thus raised up.  During
the operation, the eye is kept turned outwards, in order
to facilitate it.  We wash it with cool water, and  the
 operation is ended.  It is striking, simple, and slightly t
 painful. 
86
                Excision of the Lip*.

   When any more or less extensive part of the upper
or lower,  but much more  frequently the lower lip, is
affected by a cancerous degeneration, it is customary to
destroy the diseased part, by the reiterated  application
of the  actual cautery: Dupuytren performs  in  such
cases, the excision of the parts affected by cutting into
the sound parts.
  The patient is seated in a chair, the  head  being fixed
against the chest  of an assistant.  The surgeon seizes
the diseased lip with the thumb and  fore finger of the left
hand, draws it forward, while with a straight bistoury,
held in the  right hand, in the third position, he  cuts
boldly behind  the diseased part, removing all the can-
cerous and a small  portion of the sound part of the lip.
He then takes up the arteries. The edges of the wound
are shielded from  the contact of the air, by covering
them with a slight compress and some lint; the whole
being sustained by an appropriate bandage.
  Experience  proves that the texture  of the lip is re-
produced  to a sufficiently great extent, again to cover
the teeth.   Lisfranc relates  in his lectures, a case, in
which Dupuytren having removed all the lower lip, and
even a great part of the integument which  covers the
skin,  the  edges of the wound grew up above  the level
of the necks of the teeth, so that the deformity was not
very considerable.

              Excision of the Tonsils.

  During  a long time the tonsils were destroyed, by the
actual or  potential  cautery, in cases requiring extirpa-
tion; at the present day, excision is preferred. 
87
  The patient  is seated  in a chair, opposite a window,
reclining his head  against the  breast of an assistant.
The surgeon, placed in front, causes him  to open his
mouth widely; and if the patient is untractable, he places
a piece of cork within each angle of the jaws: an assis-
tant retains them with his fingers, for fear of aecident;
the tongue  is depressed with  a spatula.   When both
tonsils are to be removed, we begin with the left.  The
surgeon catches it with a double hook, somewhat behind
and in  front, and holding a probe pointed bistoury in
his right hand, like a pen, he passes it into the fauces,
and cuts from below upwards, and from right to  left, by
insensibly changing his hand from a state of supination
to semi-pronation, making the instrument thus describe
an arc of a  circle.  When the  right tonsil  is to be re-
moved, we  have the  hand pronated, and we change it
slowly, to a state between pronation and supination,
and  by cutting  from below upwards,  and from left to
right.   It is not  improper to allow it to bleed during a
short time.  We use acidulous or emollient gargles; arid
if the  hemorrage is  obstinate, we  have recourse to
astringents.*


               Excision of the Uvula.

  The  elongation of the uvula, or a schirrus or cance-
rous condition of it,  are the cases demanding its  exci-
sion.   Lisfranc observes, in a memoir upon the func-
tions of this organ, that we have too much neglected*
this operation in cases of pthisis, and that by destroying
the uvula he had frequently cured this affection, against


  * See Dr. Phystck's paper on the removal of the tonsils, by
a double canula and wire, in vol. 1, p. 17, of Chapman's Journal. 
88
 which all known remedies have proved unavailing." He
 thinks, also, that it is a good mode of relieving certain
 gastrites, because he says that the tickling of the throat
 produced by  the loose  and floating extremity of the
 uvula, often induces irritations of  the stomach and the
 windpipe.   He advises the removal of the whole uvula.
 According to this celebrated surgeon, n« inconvenience
 follows this operation  but the trifling one of allowing
 the nasal mucosiiy to  fall more easily upon the larynx:
 however, this inconvenience cannot be balanced against
 those which would result from a second  incision.
   Operation.—The patient is seated  in a chair facing a
 window, with his head leaning backwards  against the
breast of an assistant;  the  surgeon, placed in front of
him, causes him to open his mouth  widely, and if  he be
 timid or intractable, it is to be kept  «^pen by placing  a
 piece of cork within each of the angles of the jaw. An
assistant retains  them  with his fingers, lest the patient
should eject them by some sudden movement, and ex-
pose himself to a serious accident.  The tongue is also
to be held down with a spatula, if necessary.  Then the
surgeon carries a pair of perforated  polypus forceps into
the fauces with, the left hand, lays hold  of the uvula
with sufficient force to prevent its escape, draws it for-
wards, and to the right side of the  mouth: then holding
a pair  of  probe-pointed  and flat-curved  scissors  in the
 right hand, he introduces them almost transversely into
this cavity; the superior part of the uvula is passed be-


  * In this country we have generally considered Dr. Physick
as the originator, as he was, certainly, the successful introdu-
cer of this practice.  We know not the dale of Lisfranc's
memoir, but we have  read in •' Sprengel's History of Medi-
cine,"  that IhiB operation was  resorted to  by an ancient
 physician, with nearly similar intentions.—J. D.G. 
89
(ween the blades as far as to their joint, and is entirely
excised.  Lisfranc assures  us that this process has al-
ways succeeded in  his hands.
   If the inflammation  be  considerable, it is not amiss
to allow some  blood  to flow; the hemorrhage will cease
spontaneously, and  if this does not happen we prescribe
some astringent or emollient gargle, according to circum-
stances.


Excision of cancerous tumour of the Tongue, or of part
                   of  that organ.

   The  diseases which  demand this operation are can-
cerous  tumours situated upon the tongue; but it is ne-
cessary  carefully to  distinguish between  these  affec-
tions and such as are produced by venereal  disease*- for
the latter commonly yield to proper antisyphilitic treat-
ment.
   If the tumour adhere to the tongue by  means of a
pedicle, the following  method is employed for its re-
moval:
   The patient is seated facing a window, with his head
supported against the breast of an assistant.  The mouth
is opened, and if necessary kept so by means of pieces
of cork placed between the teeth at the angles of the
jaw.  The operator, placed in  front of the patient, lays
hold of the  tumour with  a double hook, draws it for-
ward, and retains it in  that position with the left hand.
Then he carries with  his right hand the  flat curved scis-
sors towards the base of the tumour, and  cuts it  off as
near as possible to the surface of the tongue.
   To arrest the hemorrhage  and destroy the disease
radically, the actual cautery at a white  heat, is applied
to the  wound.  If the tumour  occupy the point of  the
tongue, to a certain  extent, instead  of cutting  it oft'
                       h 2 
90
transversely behind the diseased part as directed  by
Louis, Mr. Boyer advises us  to  cut the point of the »
tongue in the shape of the letter V, having the opening
towards the anterior part.
  The patient is placed as in the former case.  The
tongue  is to be thrust out, and the surgeon fixes a sim-
ple hook into the diseased part.   He takes hold at the
same  time, of  the right edge of the tongue with the
thumb and fore finger of the left hand, and confides the
handle  of the hook  to an assistant.  He then takes a
pair of strong  straight  scissors in his right hand, and
cut9,  at a single stroke, from before backwards, bevond
the diseased pai t, and makes a second incision similar
to the first,  between the tumour and the sound part of
the left side of  the organ.  These two incisions unite at
a  more or less open angle according to the size of the
tumour removed.
   To  effect the  union of the edges  of the wound, we
pass  a small needle, bearing a linen or hempen thread,
first  through the left side and from within outwards
through the right, at about a line  and a half from  the
free  edge of the tongue, and about an equal distance
from  the edges of the wound.  The  two extremities of
the thread are tied and given to an assistant, who brings
them forward, drawing them very slightly.   A second
stitch is taken in the same manner towards the middle
of the  wound;  we then bring the edges exactly into
 contact; tie  them together by two  simple knots, first
 the two ends of the thread which were first passed, and
 then  those of the second stitch, if the lips of the wound
 are not sufficiently close on the lower surface, a single
 stitch  on this side will suffice, to prevent this  sort of
 gaping.
    The mere contact of  the  lips of the wound is com
 monly sufficient to check the hemorrhage. 
91
  At the end  of four  days or more,  we  remove the
threads, and the cicatrization in general is  completed.
  If it be impossible to preserve both sides of the tongue,
we remove this organ by amputating through the sound
part, with a bistoury, or with  strong straight  scissors.
In this case,  we seize  the tongue with a double  hook,
draw it strongly out of the mouth, and cut  it oft' boldly,
directing the instrument from right to left, and use the
actual cautery at a white heat,  to stop the bleeding.
When both sides of the tongue  are affected,  and  the
middle is sound, we remove each of the sides separately,
by cutting them off with scissors,  obliquely from within
outwards, so as to give  the extremity something of the
proper form.   The cautery is then used to check  the
hemorrhage.


          Division of the Framum Linguce.

  Nurses frequently bring children to the surgeon, to
have the freenum of the tongue divided,  because the
child cannot suck, or rather it cannot suck easily.
  The surgeon has the child brought facing a window,
opens its mouth, or, if he cannot do it otherwise, he holds
its nose  slightly.  While the infant  is crying, he raises
its tongue with the handle of a grooved director,  which
he  holds by its point,  with his left  hand,  bringing the
frsenum  against the hollow in the  middle of the director;
then by  a single cut with  the scissors, he divides the
freenum  to the necessary distance.
   But it  also  happens  that  children are sometimes
brought  to be  operated on, who  have  not  the defect of
conformation alledged; however,  to satisfy  the imagina-
tion of  the mother, or the nurse, we may appear to
divide the freenum, by making  a great snap with the
scissors; after which, the nurse will find that the infant
sucks admirably. 
                         92

   It rarely happens that this operation causes a dange-
 rous hemorrhage:  however,  should  it bleed freely, we
 use the actual cautery to check the hemorrhage.-

              Amputation of the Penis.

   The patient is placed on his back, while the surgeon
 being on the left side of him, takes the penis between the
 thumb and two first fingers of the  left hand,  near the
 point where  he  wishes to amputate it.   An  assistant
 holds it below the same place. The skin should neither
 be drawn backwards nor forwards: should it be drawn
 forwards it will be denuded for a more  or less consider-
 able extent.  If it be drawn backwards,  more  than
 enough to cover the stump will be left; this inconveni-
 ence however is not  so great as  the former.  Every
 thing being thus prepared, the surgeon armed with an
 amputating knife,  or a long bistoury, severs the penis,
 directly from below upwards, at a single stroke, half an
 inch below the diseased part.
  The arteries are  to  be secured,  but as  they are all
accompanied  by a nervous filament, which it is difficult
not to comprise in  the ligature,  would it  not be better
to use the actual  cautery at a white heat? A gum elas-
tic catheter is then  introduced, and left in the bladder,
and the wound is covered with soft lint,  which is se-
cured by a suitable bandage.
  When the penis is to be amputated  very near to the
pubis,  it is better to introduce the  catheter previous to
the operation, because the  flow of blood will render its
subsequent introduction difficult,   by  concealing the
urethra.  In such a case, we circumscribe the penis by
two lateral incisions,  which join by a  superior and an

  * A knitting needle, or any small  piece of metal  heated io
 the flame of a lamp or candle, will be sufficient. 
inferior angle; we dissect the skin, comprised within
these two incisions, and we remove the penis with this
skin, by pursuing the course above directed.  The same
mode of dressing is used, as in the first mentioned case.

                   Circumcision.

  The prepuce may be too long, and consequently in-
convenient; it may be so narrow that it cannot be drawn
back; in such cases we cut it oft.
  It is customary to  excise a part of  the  prepuce, by
drawing the skin of the penis forward,  and  to cut off all
that is pulled beyond the glans; but  this method  de-
prives  the penis of integument for a considerable extent,
behind the base of the glans.   To obviate this incon-
venience, Mr. Lisfranc  advises us to lay hold of the
thickness of the skin at the loose extremity of the pre-
puce,  with several forceps.  They are then drawn for-
wards, while the surgeon embraces this integument with
a pair  of dressing forceps, between the forceps held by
the assistants and the end of the glans; he severs all he
wishes to remove, by one cut of the scissors.  If there
be  much  bleeding,  he applies  lint dusted with resin
powder.

     Excision of the Prepuce in case  of phymosis.

   When the inflammation causing phymosis, endangers
the production of gangrene, this operation  must be per-
formed.  In such a case, Mr. Cullerier cuts nothing
but  the mucous membrane of the prepuce, to enlarge the
opening, commencing at its outer edge.   But this does
not always succeed:  we are then directed to introduce
flatwise,  under the prepuce, the blade of a straight bis-
 toury, whose point is guarded by a little ball  of wax, 
                         9*.
down to the base of the glans.  We then turn the ed^
of the knife upwards, force the point of  the instrument
through the skin, and then cut it freely to the edge,
from behind  forwards, by lowering the handle of the
bistoury.   Ought we to leave  the flap which is formed
by this incision? In this case it will form a sort of second
head alongside of the gland; to avoid this inconvenience,
we lay hold of this appendix with the left hand, and cut
it  entirely  oft', near its base.  The inconvenience of
having the penis deprived  of prepuce is  not so great as
that of having a tubercle alongside of the glans.


           Reduction of the Paraphymosis.

  We cannot avoid speaking here of the reduction of
the prepuce when it is drawn behind the glans, after
having treated of the opposite condition.
  VV e  strongly compress  the glans in the palm of the
hand to diminish its volume: this compression should be
continued  during  the space of five, ten, or fiften min-
utes; we then endeavour to bring the prepuce over the
glans, by compressing  it towards its base between the
index and ring fingers, while with the middle ones we
draw the  prepuce forward.   By this mode we  do not
enlarge the base  of  the glans,  as necessarily happens
when we attempt to  reduce it by compressing it with
the fingers  from the point to its base, as  many  persons
do, which often renders the reduction impossible.  Lis-
franc, who teaches thU method in his lectures, declares
that he has never been embarrassed by such a case. 
95
             Extirpation of the Testicle.

  When all doubt is removed relative to the nature of
the disease, and the operation is decided on, it is proper
before practising it to make a slight puncture into the
tunica vaginalis, through the scrotum.   This  precaution
is necessary to prevent an  extremely disagreeable acci-
dent, which has happened  to some surgeons, who, after
beginning the operation, have perceived, by  the flow of
water or blood, that they were mistaken relative to the
nature of the disease, which was hydrocele or hematocele.
The mode of operation is as follows.
   The patient reclines on  the edge of the table or bed,
with  his  back supported  by a pillow: two assistants
slightly separate the thighs. The hairs are then shaved
off.  The  surgeon holding a convex bladed bistoury in
the third position, begins  his incision  towards the ab-
dominal ring, and  directs it perpendicularly in front of
the testicle,  down  to its lower extremity; but before
 commencing the incision he raises the skin so as to form
a transverse fold  before the cord, at  the height of the
 abdominal ring, by seizing it on one side with the fingers
 of the left hand, and an assistant raising the skin on the
 opposite side. If the skin be diseased it should be circum-
 scribed by an eliptic incision. When the spermatic cord
 is exposed, we dissect away the cellular tissue which en-
 velops it, and we should separate the arteries and veins
 from the  vas deferens, near the upper part of the inci-
 sion; a ligature is passed around  them by  means of a
 curved needle, and we give its.ends to be held by an as-
 sistant, lest they should be drawn  within the abdominal
 ring by the retraction of  the cremaster after the cord is
 divided. With these precautions, we freely cut the sper-
  matic cord abouta third or half an inch below the ligature.
  Then taking hold of that part of the cord which remains
  attached to the testicle, draw it slightly forward, dissect- 
96
  ing up to the cellular texture and carefully removing all
  the diseased parts which may adhere to the scrotum.

                 [USFRANC'S METHOD.]
    After the first incision, which ought to reach the  in-
 ferior and almost the posterior part of the tumour, dis-
 sect from below upwards, to prevent the blood from
 concealing the parts on  which the  knife is to be used,
 which will necessarily be the  case, should we dissect
 from above downwards.
   To prevent the retraction of the cord within the ab-
 dominal ring, an assistant  seizes it between his thumb
 and two first fingers held a little separated, so that the
 thumb pressing on the cord in the space between the two
 fingers, the slipping up will be prevented. Then the sur-
 geon cuts  the cord  a little below the fingers of the as-
 sistant, and ties the vessels as has been pointed out.

             [VINCENT KARN'S METHOD.]

   The patient being placed as in the ordinary operation,
 an assistant takes hold of the  cord,  together with the
 integuments, between  his thumb  and two  first fingers,
 above the  point  where the incision should be begun.
   The surgeon takes  the diseased testicle in the left
 hand, insulates it as much as  possible from the sound
 one, and removes with a  single stroke of a long straight
 bistoury, both the testicle  and the scrotum which en-
 velops it, by beginning  the incision with  the edge of
 the knife a little below the fingers of the assistant on
 the upper and outside of the scrotum, to pass between
 the testicles in the direction of the raphe, at the inferior
and external extremity of which the incision  ought to
terminate.  We may also commence at the inferior ex-
tremity of the raphe and terminate the incison at where
we have described  its commencement in the first in-
stance.  In either case the wound  represents the se-:- 
9;
ment of a circle whose convexity is  towards the sound
testicle.  The arteries are to be tied.
  This method is showy and may be very promptly ex-
ecuted,  but it cannot be used if the diseased testicle  is
considerably enlarged; because in such a ca^e it will be
difficult not to cut the septum which separates the testi-
cles, formed by the layers of the dartos.
  The operation  being finished according  to whatever
method the case demands, we dress the wound bv bring-
ing the  edges lightly together by means  of adhesive
straps, without however attempting to produce immedi-
ate union. Some surgeons advise the use of two stitches
to draw the edges together; but we  reject this practice
which can only produce a useless and dangerous irrita-
tion. We place a dossil of lint in  the lower angle of the
wound, and cover the whole with a soft and light com-
press.
  Mr. Maunoir, the elder, a celebrated surgeon of Ge-
neva, wishing to  avoid the  removal of the testicle  in
cases of sarcocele has thought of wasting away the  gland
by  tying up  the  spermatic arteries,  in the  following
"manner:
  The patient is placed al if for the common operation
of extirpation; the surgeon makes with a convex bistoury
a perpendicular incision about an inch  long over the cord
immediately in front of the ring, after having formed the
transverse fold of which we have spoken; he dissects the
cord and ties each artery separately by means of a small
curved needle.
  This operation is tedious enough, and not less painful
than the extirpation of the testicle.   I have never seen
Mr. Maunoir perform it but once.  It was  not success-
ful,  for sometime after the patient  was obliged to sub-
mit to a second operation, for the definitive removal of
that organ. 
98
            Excision of the neck of the Uterus.

    This very dangerous  operation should  never be at-
  tempted except in cases entirely desperate. Neverthe-
  less several instances of success are recorded.  Can-
  cerous disease,  callous degeneration, and  cartilaginous
'  alterations of the neck  of  the  womb are  the diseases
  which call for this operation.
    The patient lies supine on the edge of a bed or tabic
  covered with a mat tress,  as in the operation for stone: the
  legs are separated, and  the feet are supported by two
  chairs placed on each -ide, unles the thighs are supported
  by assistants.   The surgeon being in the  middle sepa-
  rates the labia majora, and dilates the orifice of the va-
  gina, with  the index and  middle finger of the left hand.
  In the right hand he  holds a speculum uteri properly
  warmed in tepid water, and lubricated by fat or mucilage,
  which he  introduces into the vagina nearly up  to the
  handle.  The neck of the uterus presents  at the  end of
  the speculum, ordinarily  somewhat inclined towards the
  sacrum; in-this case the surgeon brings it into a straight
  position, by raising it with the extremity of a round
  or some other blunt instrument.  The  left  hand then
  takes  hold  of the handle of the speculum,  while with
  the right the operator passes a double hook to the neck
  of the uterus, seizes it strongly,  so that the points of the
  hooks  do not project through  its substance lest they
  should wound the vagina; he then withdraws the  specu-
  lum: The uterus is then gently brought down to the ori-
  fice of the vagina, by drawing slightly on the handle of
  the hook; he then cuts off all the diseased part with the
  bistoury held in the third position. The uterus may also be
  brought out by making it follow the speculum, in pro-
  portion as  that instrument is withdrawn.
    If we wish to operate  without the speculum, the fore
  finger of the left hand is passed into the vagina, as  far 
99
vs the neck of the uterus, which if not in a straight po-
sition, we bring into the direction of the vagina: we then
introduce the took with the right hand along the palmar
surface of this finger, taking care to glide the hook on
the finger, and not against the  walls of the vagina, to
avoid'injuring them.  The  neck of the  wound is then
laid  hold of with  the hook, the  points of which are di-
rected by the end of the finger in the vagina; and we
cut off the diseased portion at the orifice of the vagina,
as in the preceding case.  We may, also, if we  wish,
perform  this excision with strong scissors curved on the
flat side.  The hemorrhage is arrested by  some astrin-
gent injections, and we plug the vagina with lint,  which
is retained by a figure of 8 bandage, passed round the
pelvis and thighs.
Excision of venereal excrescences situated on the margin
  of the Anus, Vulva, and in the interior of the Vagina.


  The patient lies supine on the edge of  a bed or table,
as in the operation for the stone. Two assistants stand-
ing on the outside of  each  thigh keep the thighs sepa-
rated and flexed upon the pelvis.   The assistant on the
ri»ht  side passes his right hand under the  thigh of the
same  side, and  takes hold of the patient's arm above
the wrist; her other hand is fixed  on the upper part 6f
that arm; the assistant on the left side  does the same
with the left  arm. The patient is then prevented from
making movements  which may interrupt the surgeon.
The latter kneelingbetween the thighs on his right knee,
separates the buttocks with the thumb and fore finger of
the left hand, to stretch the skin surrounding the anus,
and holding in the right hand the flat curved scissors, 
100
he cuts the \cnereal excrescences as close as po-v-ible
to the surface of the skin, a part of which he remove.-;
if the excrescences are disposed  in groups, he removes
each group at a single cut, but if otherwise he removes
each of them singly.
  When a female is the subject of operation, and the
excrescences are situated on the outside and inside of the
labia' inajora,  wo first  remove the external; then sepa-
rating the  labia with the thumb and fore finger of the
left hand, we excise the excrescences at their base, taking
also a part of the  mucous  membrane.  If we  cannot
stretch the skin, we make a fold of it, by which the ex-
crescence  is   made  to project,  and   may be removed
with greater facility.   It sometimes happens, that after
removing a cauliflower excrescence, a considerable he-
morrhage  ensues.  It  would be dangerous to  apply
caustic  to so  extensive a surface; hence we arrest the
hemorrhage, by compresses of lint powdered with rosin.
I have, however, seen Mr. Cullerier stop a copious he-
morrhage by touching  with a pledget of  lint  dipped  in
diluted hydro-chloric  acid,  a large   wound,  resulting
from the excision of several cauliflower excrescences of
an enormous size, situated on the labia majora. A com-
press is placed over the  lint, and sustained with consi-
derable press ue, by means of a  suitable  bandage.


              Excision of the Clitoris.

  This organ is  occasionally so much enlarged as  to
project beyond the  labia inajora; and it  has been pro-
posed to remove it for the cure of nymphomania, as it is
the principal seat of sexual pleasure.  Cancerous tuber-
cles, or fungous growths forming on the clitoris also ren-
der it necessary that it should be removed.
   Operation. The woman lies supine; the assistants hold 
101
Her as for the removal of venereal excrescences, if there
be danger of restless movements; but this precaution is
not necessary if the patient is tractable.  The labia are
separated by the thumb and fore finger of the left hand,
the surgeon takes hold of the clitoris with a single hook
and raises it; he then takes the handle of the hook in his
left hand,  and with  the right removes the clitoris by a
single cut of the flat  curved scissors. If the hemorrhage
is abundant, the arteries are taken up; if not, we use  a
plug of lint sprinkled with  powdered rosin. A compress
and figure of 8 bandage will retain the whole properly.


              Excision of the Nymphx.

  When the disproportioned size of the nymphse is the
result of malformation, there is no other mode of correct-
ing tliis deformity than by  the excision of the parts.
  Operation.   The patient lies supine, with the thighs
separated.  The surgeon separates the labia majora with
the thumb and  fore finger of the left hand.   With the
right, armed with the flat curved scissors, he cuts oft'the
nymplne one after the other.   The hemorrhage  is ar-
rested by the  affusion of cold water or an astringent
fluid.   A compress of lint is applied and retained by
means of a  bandage.


Excision of part of the sterno-mastoid muscle/in^c use of
                     Wry-neck.

  When this deformity is the result of spasmodic con-
traction or  paralysis of one  of the sterno-cleido-mastoid
muscles, it  may sometimes be corrected by means of an
operation. In the first case we  divide some of the fibres
of the diseased muscle; in the other, on the contrary, we
                          i 2 
\()2
cut some fibres of the sound muscle to establish an equi-
librium between two antagonist musclcsv
  The history of the following case may serve as a guide
in the practice of this operation, and a proof that it may
be attempted with success.
  A girl of about ten  years old was affected with wry-
neck nearly from her third year, in consequence of a
continual spasmodic contraction of the right sterno-mas-
toid muscle; she entered the Hotel Dieu  in the month
of January, 1822.   Towards the sixteenth of the same
mouth Mr. Dupuytren performed the following opera-
tion.
  The patient was placed fronting a window,  the head
inclined to  the left against the breast of an assistant;
the point of a straight bistoury was thrust  through the
skin  exactly in front of the  sternal  extremity of the
contracted muscle.  The handleof the bistoury was then
depressed, to glide  the knife flatwise under the muscle,
until it came out at the outside of the clavicular border.
The edge of the knife was then turned forwards, and a
sufficient number of the  muscular fibres were  divided,
by sawing with the  knife, to allow the head to regain its
natural position.
   By this method  the integuments were not  divided,
and the deformity of a cicatrix was avoided; an end the
more desirable as the patient was a female.
   The  fibres were kept  separated by  depressing the
clavicle and inclining the head to the left side.  To ac-
 complish this  the right hand  was  strongly fastened to
the foot, by means of a  roller bandage; the  leg being
 flexed nearly as in the operation for stone. Another ban-
 dage was passed round the head and under the axilla.
   The patient was  put to bod.  At the end of thirteen
 days the wound was completely healed;  the motions of
 the neck were free, although  it was a little inclined to
 the left, in consequence of the length  of time it was con- 
103
fined to that position.   The bandages were re-applied
until the twenty-first of February, at which time they
were finally removed. The movements of the neck were
perfectly free in every  direction, and the head was  but
very slightly inclined to the right.
  If we operate on a man we divide the fibres from their
anterior surface, after having made a transverse incision
through the integuments.   To keep the  divided  fibres
properly separated we  fill the wound with lint, and ap-
ply a roller around the head and under the axilla of the
opposite side.
  It must not be forgotten, when the wry-neck«is pro-
duced by paralysis, that it is the sound  muscle which
should be more or less deeply divided.  In all cases we
operate on the side to  which the head inclines.


Incisions to remedy imperforation of different openings,
      such as the anus, vagina, nostrils, <§*c. dec.

  This malformation is generally caused by a membrane
of different degrees of  thickness, which closes these ori-
fices.
   If the membrane to be operated on occupy the orifice
of the anus and vagina, of the nostrils, or of the external
ear, we divide  it by a  crucial incision, and remove the
flaps to  prevent their re-union,  if their thickness be
somewhat considerable. We then introduce a tent of lint
into the wound in order to prevent the adhesion which
may take place, especially at the anus, without this pre-
caution.
   lmperforation  of the  lips.   Whether this  depend
upon a membrane or upon the adhesion of the surfaces
of  the lips,  we operate in the following  manner:   The
infant being seated  or lying supine, we destroy the ad-
hesion by cutting through it.  We use either the  bis- 
104
 toury or scissors introduced on a director.   When the
 iraperforation is not complete, we introduce the director
 well greased, through the opening: or ii no opening exist
 we make a slight puncture at one of the angles of the
 mouth to introduce the director, which  is directed ex-
 actly along the  depression  which exists at the point
 where the lips come into contact. No particular dress-
 ing is required after this oporation. The cries and suck-
 ing of the infant are sufficient to prevent the re-union.
   Imperforation of the Uterus.  The orifice of the ute-
 rus may be obliterated by the agglutination of the lips
 of the ostincse.  In such  a case the patient lies supine,
 the thighs separated and slightly flexed upon the  pelvis;
 the surgeon introduces a speculum uteri  into the vagina,
 to expose the neck of the  womb.  He then  introduces
 a  long straight bistoury to the bottom of the  vagina, and
 cuts transversely from one angle to the other of the de-
 pression in  the os tincse.   The lips  of the  wound are
 kept apart by means of a tent of lint spread with cerate.
   Imperforation of the  Urethra.  If there be nothing
 but a membrane at the orifice of the urethra, a slight in-
 cision made with a lancet, in  the natural direction of
 this canal, will be sufficient.  The flow of the urine will
prevent the re-adhesion of the parts.  When the imper-
foration  extends through  the  whole of  the  glans, we
pierce it from its apex to its base with a small trocar,
or with a lancet, if the surgeon be very expert: we then
pass a canula through  the wound, and  keep  it there for
some  days.
   Imperforation  of the Eyelids.  This malformation
called anchiloblepharon, occurs when an unnatural, com-
plete or incomplete adherence exists  between the  edges
of the lids.  It may either be congenital or produced by
the small pox, or some other inflammation.
   Operation. The patient being seated, or lying supine,
if the  imperforation be complete, we  make a  small inci- 
                       105

sion towards the outer angle of the eye: by this opening
we introduce a  small grooved director, well oiled, the
groove being directed exactly to the junction of the two
tarsi.  Should the convexity of the eye prevent us from
pushing the director entirely to  the internal angle, we
cut between the two lids upon the groove, from the point
by which the sound was introduced: after which it easily
arrives at the internal angle, and the incision is finished.
Should it not be inconvenient to introduce it at first
from one angle to the other, the operation will be much
more promptly concluded.  When the occlusion is in-
complete, the director should be introduced by the open-
ing which naturally exists.  To prevent the renewal of
the adhesion we use mucilaginous injections from time
to time, and anoint the edges  of the lids with  some ce-
rate occasionally. (For imperforation of the iris, see ar-
tificial pupil.)
OPERATIONS  FOR  THE  EXTRACTION OF
              FOREIGN  BODIES.
                    Of Polypi.

  The means most generally employed for the destruc-
tion of polypi, are extirpation, and the ligature; we shall
describe the different methods employed in the most
common case?. 
106
            Extirpation of *Yasal Polypi.

  The patient is seated in front of a window, with the
head thrown  far back, and firmly supported against the
breast of an assistant.  The surgeon stands before him,
having~a pair of polypus forceps  in  the  right hand,
whose  blades and extremities should be narrower  than
are generally used, in order that they may move freely
in the  nasal  cavities.  He causes the patient  to open
his  mouth, and introduces the fore finger  of his  left
hand, in a state of supination, as far back as behind the
velum palati, and places the end of this finger against
the posterior opening of the nostrils: he then introduces
the closed  forceps into the nostril, in the direction of the
external  opening: but he  soon  elevates the  hand, in
order to pass it  parallel to the  floor of the  nostrils,
should the  polypus be situated near their posterior  part.
In the contrary case, he directs the forceps towards the
polypus, sometimes  upwards, laterally, &c.
  Having reached the polypus, he separates their jaws,
and seizes it as closely as possible to the point by which
it arises; the  index finger placed at the back part of the
mouth, is here of great utility, in directing the jaws of
the polypus,  when seated  far back.  He then gives the
forceps a twist,  and drawing them forwards, pulls oft'
the polypus.   If this cannot be done at the first effort,
or if the polypus is only detached in fragments, still
preserving adhesions  to the pituitary membrane, or
should there  be several polypi, the surgeon uses the for-
ceps several times, if  necessary,  and endeavours to
break the  pedicle,  by continuing  the combined move-
ments of traction and twisting.  We sometimes experi-
ence great difficulties in bringingout the polypus tumours,
after having detached them: in this case, it is necessary
to  remove them by fragments,  or to extract them  by 
107
means of the disjointed  forceps of Richter, the blades
qf which are  introduced separately, and  then brought
together, just as is done with the obstetric forceps. We
may also push the polypus  backwards, and  extract it
by the mouth, if it be situated near the posterior part of
the nares.
   To ascertain whether a polypus excrescence be en-
tirely removed or not, the surgeon compresses the nostril
of the sound side, and requests the patientto blowthrough
the other nostril, keeping the mouth closed.   If the air
or injections pass freely, if we cannot perceive, by look-
ing into the nostril,  nor by the use of the forceps, any
vestige of the polypus, the operation  is crowned with
success.
   A  few injections of cold water, or a slightly astringent
 fluid, suffices to arrest the  hemorrhage.   But if it be
 very copious, and these means insufficient to arrest it,
 we must  have recourse to  plugging.  (See plugging of
 the nasal fossa.)
   There are some cases, in which, by pushing the tumour
 alternately,  from one side to the other,  it is detached,
 and  may be removed by the nearest opening.  To do
 this, the fore finger of one hand is introduced into the
 mouth, to its back part, and the little finger of the other
 hand is passed into the nostril, for the purpose of mak-
 ing  the motions indicated.  The forceps closed, will
 answer instead of the  little finger, if that cannot  be
 introduced.

               Ligature of Nasal Polypi.


    This method is especially employed in polypi situated
 at the posterior part of the nostrils, though the preced-
 ing  operation can,  and ought to be preferred, even in
  this case. 
108
                [nuAsnoR's method.]

   The instruments necessary are, 1st Bellocq's director;
 a wire, commonly of silver, from fourteen "to fifteen in-
 ches long, bent so  as to form a loop in the middle, and
 forming two hooks at its extremities, to receive a hempen
 thread, two or three inches long, the ends of which are
 tied together, so as to bring the extremities  of the wire
 into contact.  2d. A cord  formed of several  strands of
 waxed hempen thread, passed through the loop of the
 wire, and whose two ends are brought together, without
 tying. 3d. A double  cylinder, destined to receive the two
 ends of the wire.
   Every thing being prepared, the patient sits on a chair
 facing a window, with his head leaning against the breast
 of an assistant.  The surgeon introduces Bellocq's direc-
 tor into the nostrils in the  direction of its  floor until
 it arrives beyond the posterior opening behind the velum
 palati.  He then pushes the stylet, which is thrown for-
 wards through the  mouth till  it is on a level with the
 teeth in the upper jaw.  To the button of this stylet he
 attaches  the thread which unites the two extremities of
 the wire, withdraws the stylet into the canula, and brings
 the director out of the nostril, to bring forward the loop
 formed by the wire, which he follows  with his left fore
 finger in order to direct it upon the polypus,  which this
 loop  should embrace exactly, and as near as  possible to
 its pedicle.  If the  fore  finger be insufficient to direct
 the loop, on account of the height or distance at which
the polypus is seated, its  place is supplied by drawing
on the string which  was thrown around the loop of wire!
This string serves also to  draw back the  loop when it
has taken an improper direction.  When the polypus is
perfectly secured, which we know  by drawing on the
 two extremities of the wire, we remove the string from
the loop,  by pulling one of its ends.   The extremities 
i09
of the silver wire are then detached  to introduce each
of them  through the double canula; they are fixed  to
the rings at the  top of the canula to twist them and
strangulate the polypus, which is accomplished by turn-
ing the instrument round  and round.  The ligature is
tightened daily by means  of the double  canula, which
is left projecting from the nostril, and secured  by a
thread to the nightcap of the patient. Eight, ten, fifteen
or twenty days commonly suffice for the  removal of the
polypus; though the time  required for this purpose will
be proportioned to the volume of the tumour.
   We may substitute a simple waxed twine for the wire,
with which  we also make  a loop and fix it to the button
of the stylet; but this loop is with difficulty kept open:
the following mode of passing the  ligature would be
better.
   Introduce Bellocq's director between the pedicle of
the polypus and the external or internal  wall ol  the na-
sal fossa; we then push the spring into  the mouth, to
which we attach one end of the twine  which is to be
brought out through the nostril.  The director  is then
to be passed between the  other side of the polypus  and
nasal surface,  when the spring is to be again  pushed
forward through the mouth, and the other end of the liga-
ture attached to the button, and brought back in the same
manner. The tumour is then encircled, and the ligature
is gradually tightened to  strangulate the tumour as in
operating with the wire.  Instead of the double canula
many surgeons prefer the knot tier of Roderick.  The
two ligatures are passed through  the lower ring of the
instrument, which is then introduced on  the floor of the
nasal fossa, till it arrives at the pedicle of the polypus,
which is strangulated with a greater or  less  degree of
force.  The  constriction should at first be  moderate; it
is  increased  every two  or three days  by pushing  the
instrument, at the same time the ligature is tightened,
                          K 
%
 110
 the extremities of which are secured around its supe-
rior extremity. The instrument is left in the nasal fossa
until the polypus falls oft*.


   Extraction of Polypi from the Maxillary Sinus.

  These tumours have always been attacked since their
existence has been known, whatever be their size or spe-
cies, either by extirpating them  with polypus forceps,
through a fistulous opening, enlarged for the purpose, when
there was one, or by an opening made or enlarged when
the polypus presents towards the alveoles of one or more
teeth fallen or  drawn out, or  finally by perforating the
maxillary sinus below  the prominence of the  cheek
bone, or the depression behind the canine tooth.
  When  we wish to  enter the sinus by the breach
through the gums made  by the natural or  artificial re-
moval of the third anil fourth molar teeth, which corres-
pond precisely to the middle of the lowest part of the
sinus, inbulate the surrounding portion of  the gums by
four incisions, two of which are longitudinal, one  on
the outside, the other within; two transverse, one anterior
and the other posterior, which cut the two former at right
angles.  The portion of alveole thus circumscribed and
insulated is removed by forceps, whose jaws are strong
and studded with»asperities.   This operation  is alto-
gether  free from pain.
  After this  we perforate  the alveolar surface  with a
pointed perforator with a squared handle, which is work-
ed by turning it round  and round.   This  first  instru-
ment is intended to prepare the way for another perfo-
rator, whose point is truncated and rounded, for  the
purpose of enlarging the first opening without danger
of interfering with the superior wall of the  sinus.  The
opening should be sufficiently  large to give entrance not 
llf
only to the jaws of the forceps, but to the polypus caught
between them.  Af;er the sinus is opened to a proper
extent, we introduce the closed polypus forceps into it;
but if the tumour present immediately over the orifice,
the jaws of the forceps should be opened.  The polypus
is seized, and the forceps are slightly twisted to  detach
the tumour which is brought out. Should  the whole of
the tu nour not be brought away, at  the first effort, or  if
there are several tumours, the forceps are repeatedly in-
troduced.  The  finger is  then  passed into the opening
to ascertain whether  the  whole of the tumour has been
extracted, and  to  discover the place  where it grew.
Wh^en nothing but the  root of the polypus remains  it
should be destroyed with caustic, or still better with the
actual cautery, in different forms, introduced by means
of straight or crooked handles, according to circumstan-
ces. This cauterising is indispensable, if we wish to pre-
vent the repullulationof the polypus excrescence.
   If the walls of the distended maxillary sinus, never-
theless, preserve their integrity as well as  the teeth, the
perforation  should  be performed at a point where the
bones are thinner and more distended.
   If, on  the  other hand, the  walls  of the sinus have
yielded  equally at all points, and  all the teeth are sound,
 we perforate the cheek bone in the depression below the
 infra orbitar foramen.
   To this end we commence laying the bone bare, by cut-
 ting concially through the integuments, and perforating
 it in  the manner  heretofore indicated,  that is to say,
 first, with the pointed perforater, and then with a blunt
 and  truncated  one.  We should also have another in-
 strument, curved at the point, to remove the asperities
 which the trephine may have produced.  We extirpate
 the polypus, as when we open the sinus from the alveo-
 lar edge.
   When the operation has been  carefully performed, 
%
 lis
the sinus becomes covered with florid granulations, the
osseous walls approach, and gradually resume their na-
tural  condition; but the  complete  cure  cannot be ex-
pected for some months, or even years.  If pis or other
matters accumulate  in  the sinus during the  course of
the cure, we clean  it o-it by  occasional injections of
emollient or other substances from the external wound.
if  it be not yet closed.

           Extirpation of Uterine Polypi.

   We remove these polypi by excision, extirpation, and
ligature.   Excision is a bad method, difficult to be per-
formed without injuring the neck of the uterus, unless
it  be  brought down to the orifice of the vagina, with a
double hook, which  cannot be done except by fixing
the hooks into the substance of the organ.
   The extirpation of the uterine  polypus is only prac-
ticable when its pedicle is small; in this case the opera-
tion may produce a considerable laceration, which may
be followed by a dangerous hemorrhage.  The following
is  the mode of performing the operation.
   The patient  lies supine, so that the pelvis projects a
little  beyond the  edge of  the  bed; the feet are each
placed on a chair, the thighs being separated from each
other.  The surgeon  kneels on the right knee between
the thighs of the patient, and introduces the fore finger
of the left hand  into the vagina  as far as  the polypus:
with the  right hand he introduces the polypus forcepy,
with rather large jaws, which he glides along  his finger
until  it attains its extremity.  He then opens the for-
ceps  to  seize the polypus, gives them a slight twist to
detach and draw it out, by withdrawing the forceps and
linger at the same time.
   It  is not absoulutely necessary to place the patient 
n.r
in the position above stated: we may operate as well with
the patient standing up, or lying down in the ordinary
manner, the thighs being separated, and slightly flexed
on the pelvis.
  If the operator wish to act with more precision, there
is nothing to forbid the use of the speculum uteri.
  The  hemorrhage is  arrested by  injections of cold
water; if the flow of blood be copious, and if this does not
suffice to check it, we render the injection slightly styp-
tic, by the  addition of some astringent substances, as
sulphate of  alumine, sulphate of zinc, &c.


             Ligature of Uterine Polypi.

  This is the surest  mode of all, and the one most ge-
nerally employed.

                [desault's method.]

  We shall  dispense  with the description of Desault's
instrument for tying  polypi  of  the  uterus, since  it is
"•enerally well known to surgeons.  Two separate ca-
nulfe,  receiving each a moveable  steel  rod, having an
elastic rin<x, which opens and shuts at pleasure, one of
Roderick's knot  tiers,  a  waxed ligature not  twisted,
about three  feet long, passed through the elastic rings,
forms the whole of the aparatus.*
  The patient being disposed, as in the preceding case,
the surgeon  introduces, parallel to each other, both the
canul* provided with the ligature, whose ends are fixed
to the ring", between  the tumour and  the  walls of the
vagina, on the side where there is the least resistance,

  * The student will find in Gibson's Surgery, excellent repre-
sentations of most of the instruments referred to in this work.
                         r 2 
                        114

and glides  them by slight movements, to the superior
and anterior part of the  pedicle.  He detaches the ends
of the ligature, fixed as we have stated, takes one of the
canulse in each hand, making  them meet together, by,
describing the circumference of the tumour, he forms  a
loop around the pedicle, with the middle of the ligature,
which he gradually relaxes  in proportion  as it is em-
ployed to encircle the tumour.
  When  the two extremities of the canulte meet, arriv-
ing from opposite  directions,  the points  are made to
cross  each other, in order to embrace the tumour more
completely. We may also hold the left canula?  steady,
while with the right, we move round the whole circum-
ference of  the tumour.  This  being done, the surgeon
withdraws the canulse, carrying the ligature whose blades
separate  themselves, slightly downwards,  the rings
open, allow the  ligature they contain to drop, and the
instrument is then  withdrawn entirely. We then intro-
duce the two ends of the ligature, with the ring of a
canula,  whose  length ought to be proportioned to the
height of the polypus.   We  then push this ligature up-
wards, at the same time that the two ends of the liga-
ture are  drawn down, and when the loop is sufficiently
tightened, we fix the two ends to the groove of  the ca-
nula  remaining in  the  vagina, until  the  tumour falls
off.  The ligature is to be tightened every two or three
days, or  even every day, after having detached the ends
fixed  to  the canula,  and drawing  on them at the same
time that the canula is pushed upwards,


                   Laryngotomy.

   This operation is divided into laryngeal and tracheal.
 When the larynx is cut, it is  called laryngotomy; and
 tracheotomy, when the trachea is operated on.  It  is 
i 15
first performed,  to allow the access of air to the lungs*
the second  for  the  removal  of  foreign bodies fallen
into the trachea.
   When there is imminentdanger of suffocation, whether
in consequence of disease, as  the croup* or other irri-
tation, or from  the  presence of  foreign bodies  in the
windpipe, it becomes  necessary immediately to perform
one of these operations. They have also been resorted to
in some cases of asphvia, when there is no other mode of
inflating the lungs.
   Laryngotomy. The patient lies supine, or is placed in
a chair, the head being inclined as far backward as pos-
sible, without danger.  The surgeon  being on the right
side, seeks for the space which exists between the cry-
coid and thyroid cartilages,  then makes a perpendicular
incision from above  downwards,  through the middle of
this space, from the  inferior edge of the thyroid to the
superior edge of the cricoid cartilage.  This first inci-
sion should only extend through the skin. We then place
the fore finger  of the left hand on the ligament which
separates the two cartilages  just mentioned, to direct
the blade of the bistoury into the windpipe, making a
very small incision from above downwards, or from be-
low upwards,  in the same direction.  We  may also
make  a transverse incision, by separating the edges of
the wound.
   If this be not sufficient  it is necessary to enlarge it,
by prolonging the incision to the lower edge of  the cri-
coid cartilage, which is thus divided. A canula is ordi-
 narily introduced into the windpipe, through the wound,
 and its orifice covered with a piece of gauze, to prevent
 the introduction of foreign bodies.  This canula occa-

   * In croup, the operation is necessarily unavailing, inasmuch
 as the inflammation  and  effusion extends over the mucouE
 membrane, lining the whole of the air passage.—J. D-  G. 
116
sionally irritates the mucous membrane, so that it would
be better to leave the opening free, and place the gauze
simply over the wound.
   Tracheotomy. The patient being placed as in the for-
mer operation, the surgeon places his fore finger on the
thyroid  cartilage, and makes a perpendicular incision
from above dow nwarcU, for an inch or an inch and a half,
in front of the middle part of thetrnchea, and beginning
near the lower edge  of the cricoid cartilage.  This inci-
sion exposes  the ring of the trachea.   The operation is
suspended until the blood ceases to flow.  The surface
being sponged, we then open the trachea from below
upwards, to  the point where  the incision was begun.
By following these directions,  we are  never exposed to
the inconvenience of allowing the blood to flow into the
trachea, which would unquestionably happen, if the se-
cond  incision were  made immediately after the  first.
We must be  careful  not to wound the superior thyroid
artery, nor the thyroid gland.*  If the air expelled  by
the lungs be  insufficient to drive the foreign  body  from
the trachea, we endeavour to extract it with the forceps.
After it is removed, we unite the edges of the wound by
the first intention, by means of adhesive straps and  vest.

                  QZsophagotomy,

  When a foreign body exists in the oesophagus, which can
neither be extracted with the  fingers or forceps, nor be
pushed into the stomach, by means of an elastic catheter
br the probang;  and  when  this foreign  body impedes

  • The incision,  when extended so as to divide  the cricoid
cartilage, will  in a majority of instances, divide the isthmus of
the thyroid gland, and produce a dangerous hemorrhage.  The
operation is not even as  sate as opening the  trachea below the
istbmus of the gland.—J. D. G. 
117
deglutition, and  exposes the  patient to the danger of
suffocation, by pressing against the posterior part of the
larynx or trachea, we should practise cesophagotomy,


                [LISFRANc's METHOD.]

  The patient is seated on a chair, having his head in-
clined backwards  against  the  breast of an  assistant.
The surgeon  placed in front and holding his bistoury in
the first position, commences an incision over  the inter-
nal edge of the left sterno-cleido-mastoideus, as high as
the superior edge of the thyroid cartilage, and  continues
it down to near the lower edge of  the cricoid  cartilage.
If the foreign body project entirely on the  right, the
operation should be performed on  that side.   An assis-
tant  presses the carotid artery towards the left side of
the  wound to prevent  its being injured by the edge of
the knife, while the surgeon dividing the cellular tissue
with caution, exposes the oesophagus at  the point where
it projects beyond the  left side of  the trachea.  A lancet
canula, resembling a female catheter, except that it is
longer and contains a  moveable stylet, having a groove
on its curvature, is introduced through the mouth into the
oesophagus, the inferior extremity of it  being directed
towards the left side, and made to project at the wound. •
Then the stylet is pushed, to pierce the membranes of the
oesophagus; the surgeon passes the point of the fore fin-
ger over its concave surface in order to discover whether
there are any considerable arterial or nervous branches
over the course in which he must cut; and after he has
taken these precautions he introduces the point of the
bistoury into the  groove of the stylet,  carries its edge
turned  upwards along this groove, to open the oesopha-
gus  for an extent proportioned to the supposed volume
of the body to be removed. 
118
  During this operation an intelligent assistant ought to
use ihe sponge after  every stroke of  the bistoury, and
if an artery be cut, it should be immediately taken up,
however inconsiderable  the hemorrhage may be. other-
wise the blood will render the rest  of the operation
more difficult.
  In using  the lancet canula  in the  manner we have
pointed out, it often happens that the end ofthe instrument
slides through the incision  made by the bistoury on the
groove of the stylet as soon as the incision is commenced,
which  may  prevent  us from making it of sufficient ex-
tent,  without injuring the po-,te-ior  wall  of the oeso-
phagus. Mr. VaccaBerlinghikri, professor of Surgery
at Pisa, has devised a canula with a spring stylet, termi-
nated  by an olive-shaped, instead  of a pointed  extre-
mity.  Tho groove of "he  canula which gives exit to
the stvlet,  is not more than two inches in extent. After
having introduced  this instrument  in the  ordinary
manner until the end of it elevates the oesophagus,  we
push the stylet which separates itself from the extremity
of the canula by its elasticity, and raises the oesophagus
without passing* through it. We then  introduce the bis-
toury  into the groove of the canula,  to cut  the portion
of the oesophagus comprised between that and the end
of the stylet
   The wound is  healed by the first intention, applying
a slight bandage.  The patient should  be kept quiet:  He
should be nourished for some days by  means of a gum
elastic catheter introduced into the stomach; or better
 still, he should be nourished by the injection of nutritive
 substances.

                   Of Gastrotomy.

   When a  foreign body has passed entirely into  the
 stomach, and the life of the patient is in danger, without 
                         US

the possibility of procuring the expulsion of such body,
the following operation should be performed.
  The patient lying supine, the surgeon armed with a
convex  bistoury, which he holds in the third position,,
makes an incision for  about three inches over the linea
alba in the epigastric region,  and in the direction of the
muscles, or at the point where the foreign hody projects.
An assistant separates one of the lips of the wound with
the end of lie fore finger; after havingdivided the integu-
ments, cellular tissue, and fascia, the surgeon penetrates
with caution into the stomach, by continuing to cut in
the same direction.
  For fear of passing through and through  the  stomach
would it not be better  to make first, a very small open-
ing through  the anterior wall of the stomach, capable of
receiving a director, upon which the incision might be
finished?  In performing this operation we ought especi-
ally to avoid dividing  the  arteries which surround the
greater and  lesser curvatures of the  stomach.
  If the foreign  body present at  the opening, we extract
it with the fingers; if not we seek for it with the forceps.
We heal the wound by the first intention, using adhesive
straps, or by means of  the  quilled suture, as in  case of
wounds of the stomach.
  There  are  numeious cases which demand artificial
opening^, for  the extraction of  foreign bodies  in the
abdomen, the  intestines, the  anus, vagina,  canal of the
urethra, &c. but as these accidents are  very variable, it
would be impossible to describe in  this manual the sort
of operation which would be required for each of them. 
120
 Operation for the evacuation of pus contained in a tu-
        mour produced by QZdematous Angina.
   This disease  sometimes advances with such rapidity
 that the patient perishes from suffocation, if the pus be
 not  promptly  evacuated  which accumulates within the
 wallsof the larynx. "Convinced," says Lisfranc, "by dis-
 sections, that scarifications made about the larynx would
 evacuate the serosityor pus, without necessity generally
 of resorting to pressure, I have thought that in the living
 subject, the tumour might  be scarified; this method I
 hav1 employed with the fullest success."
   We use a slightly curved bistoury with a long narrow
 blad**, firmly fixed in its handle; this we wrap with linen
 to within a line of its point.  The  patient separates his
jaws as widely as possible,antl they may be  kept in this
 position by the introduction  of pieces of  cork far back
 within  the teeth, one  of the extremities of which may
 be held by an a«,sistant   The  surgeon, placed before
 the  patient, whose head rests upon a pillow, or against
 the breast of  an assistant, introduces the fore and mid-
 dle finger of his left hand into the mouth, beyond the
 isthmus of the  fauces, arrives at the tumour produced bv
the quinsey: then holding the bistoury bv its handle  in
the third  position, like a pen, it is glided flatwise, on
the fingers within the mouth; arrived  at the  larynx, the
 edge is directed forwards and  upwards,  the handle is
elevated and  depressed so as to press lightly with the
point; thus the tumour  will be opened.  Possibly, Ion*
and acute angles may open the tumour. We should make
few punctures, because by the aid  of pressure, two  or
three small incisions are often sufficient.  If necessary,
these are multiplied;  we attempt  to make them at the
greatest possible distance from each other to avoid the
consequences of inflammation.
  These scarifications  produce the flow of the infiltra- 
121
 ted  matter, and sometimes a slight sanguineous  dis
 charge, which produces a salutary effect,

                   Of Catheterism.

   Before describing  the  operation for stone, we shall
 speak of the different methods of sounding the biadder,
 an operation to which the name of catheterism has been
 given.  However simple this operation  may appear, we
 continually meet  with untoward accidents,  resulting
 from inexperience.
   Common method.—Catheterism in man. The patient
 lies  supine upon  a bed, with the thighs slightly flexed
 upon the pelvis, or rather he is placed on a table, if the
 operation for stone  is  to  be performed.  Suppose the
 surgeon  to  be placed on  his  left side.  He takes the
 middle of the penis between the middle and rin<> fin°-er
 of his left  hand, the thumb and fore finger of this hand
 are  applied  over  the gland to bring back the prepuce,
 and  present the canal of the urethra to the beak of the
 sound or the catheter.  Having thus laid hold of the
 penis, he holds it inclined downwards so as to make
 with the axis of the trunk,  an angle of about 45°.   He
 then takes  the catheter in  the right hand, by applying
 the thumb upon the side of its ears which correspond to
 its convexity, the  index and middle fingers on the op-
 posite side.  The extremity of the catheter is then in-
 troduced into  the canal  of the urethra, by holding the
right hand  in  semi-supination; with  the left hand he
draws the   penis upon the catheter by  carrying it to-
wards the abdcmen,  so that the penis and catheter de-
scribe two arcs of a  circle which  enter each other by
moving in opposite directions.  When  the point of the
catheter  has reached  the arch  of the pubis, the surgeon
brings it perpendicular to the axis of the body, without
exerting  the slightest pressure. He slightly raises the 
122
instrument to avoid the  folds which form upon the mu>
cous membrane of  the urethra before its extremity.  At
the same  time he  pushes it forwards to make it glide
under the arch of the pubis, and enter the bladder. The
catheter is no longer kept perpendicular; he inclines it
towards the thighs, making  a strong movement of pro-
nation with the hand guiding it.   When the surgeon is
placed on the  right of the patient, he takes hold of  the
penis with the right, and the catheter with the left hand,
and proceeds in the way above mentioned.  Should any
false passages exist, in  which the point of the catheter
may be entangled, or rather should the introduction of
this  instrument become difficult  from  any  other cause
situated near the neck  of the bladder, which makes it
deviate^ we grease  and introduce tho fbre finger into the
rectum, to direct  the catheter through the membranous
part of the urethra, and the portion of it embraced by
the prostate.
   The master-stroke.—The patient being  placed as in
the precedin"-  case, the catheter is introduced with its
convexity  towards the  belly until it arrives at the root
of the penis.  We then  give the instrument a half turn,
by bringin°-the hand conducting it in front of the abdo-
men, and finish the introduction as  in the ordinary way.
   Abernethifs mode.— The patient lies across a bed or on
the side of a table, as if to be operated on for the stone.
The lcs are pendant, and sufficiently separated to allow
 the surgeon to stand between them. The surgeon then
 takes the penis between the middle and ring fingers of
 the left hand,  uncovers the gland with the thumb and
 fore finger of the same hand, by placing them at some
 lines distant from the orifice of the urethra.  He lower?
 the penis upon the scrotum, and  holding the catheter in
 the ri°-ht hand, with the thumb on the side correspond-
 in"- to its convexity, and the lore and  middle fingers on
 the opposite side, he introduces it  so that the concavity 
1S5
«f the instrument corresponds exactly  to the direction
of the raphe.  He raises the penis and catheter until the
point  of the instrument touches against the symphysis
pubis.  He then once more lowers the handle of the ca-
theter between the  thighs ?t a right angle with the body,
arid passes it  into the bladder, continuing  it in that di-
rection by gliding  it under the pubis; he then gives it
the  master stroke  to bring it to the ordinary position.
These different movements are made in a few seconds.
   Amusat's mode.—This  consists in the employment
of a straight  catheter, which  is passed  into the bladder
by keeping it constantly in the direction of the passage
through the neck ol the viscus  The author of this mode
thinks  it may become  useful to saw a calculus in the
bladder, by allowing of  the introduction  of a saw and
an instrument to lay hold of the stone, through  the ca-
theter.*
   The catheter often  meets with obstacles, owing to
stricture  of   the urethra  which are at first  invincible.
 Mr. Dupuytren advises,  that for some time a compres-
sion should be made against these obstacles, by which
 it often happens, that they are overcome.  For this pur-
 pose the catheter is fixed in the following  manner: we
 have  ready   a small iron ring covered with cloth, the
 circumference of which  slightly exceeds that of  the pe-
 nis;  we  pass the penis and catheter through the ring.
Four strings  of tape on its upper edge, equally  distant
 from each other  are fixed  above to the ears of the cathe-
 ter.   Four other tapes are fixed  upon the lower edge
 of the ring, two of which  passing below each thigh are

   * AH the world has heard of the instrument devised  by Mr.
 Civiale for this purpose. It is feared, notwithstanding all the
 improvements made upon this instrument, that it will by no
 means  equal  the expectations  originally formed of it.  Dr.
 Hornf.r has given a description of a very superior instrument
 devised by that ingenious artist Mr. Isaiah Lukejss. See Phila-
 delphia Med.  and Pbys. Journal, vol. i, new series.—J. D. G- 
iM
brought in front of the abdomen, and fixed with pins to
a  bandage round the body, or better still to a suspen-
sory.   The two other tape9 are earned in front of the
pubis, and fixed in the same manner.   We may employ
the same  means for  keeping the sound in the bladder;
introducing a cork into its external opening.
   Catheterism in the female.—The patient lies supine,
with the thighs separated, and slightly flexed  on the pel-
vis.  We then separate the labia and nymphfe with the
thumb and fore  linger of the tight or left hand, as the
position may require,  in  order to discover the meatus
urinarius.   The  catheter being held  as  heretofore  di-
rected, we introduce  its lower  extremity  into the canal
of the urethra, and push it on until it enters the bladder.
Nothing i- easier than this operation.
                  LITHOTOMY.

  This operation, which consists in the removal of one
or more stones from the bladder, may be  performed ac-
cording to difl'erent methods, which have each a particu-
lar name.
  If we open the bladder from the perineum, it is called
the  lateral operation; above the pubis, the high opera-
tion: by the rectum, the rectovesical operation. In the
female we cut between the rami of the pubis.

      Lateral operation with the litliotome cache.

  The patient is  placed  on the edge of a table, with
his back supported  by a mattress; his thighs separated,
and  flexed upon the abdomen, and holding the soles of
his  feet with the palms of his hands, we  pass a turn of
the  bandage across the back of each foot, anil round
each hand to bind them to the feet.  We  may then pass
a roller under each knee and over the shoulders, to be 
125
tied on the back of the neck. Instead of all this, an as-
sistant placed on each side, and standing outside of the
thighs, may hold them  apart, and flexed to the neces-
sary degree.  The perineum should be shaved.
* The surgeon  then, taking an oiled staff  between the
thumb and two  first fingers of the  right hand, introduces
it into the bladder in the manner heretofore indicated.
He  then once more assures  himself of the  existence of
the calculus, by moving the  staff in different directions,
if the stone be not touched at first.   He then gives the
handle of the catheter to the assistant on the left side,
who holds it perpendicular to the axis of the trunk of
the body,  nevertheless having its groove a little to the
left; the other  assistant raises the scrotum.  The sur-
geon then places himself between the thighs of the pa-
tient, kneeling  on his right knee.  Then taking a straight
bistoury, which he holds in the first position,  he makes
an  incision through the integuments and  cellular tex-
ture, by commencing twelve or thirteen lines in front of
the anterior edge of the anus, immediately over the ra-
phe; he continues this incision downwards and outwards
in the direction of the line, which, (supposing the space
between the tuberosity of the ischium and anus divided
into three equal parts) would pass through  the junction
of the middle with the external third, and stop at ano-
ther right line,  passing from the tuberosity  of the ilium
to the centre of the anus.  In finishing the incision the
wrist is lowered. He again passes the bistoury into the
thickness of the perineum,  to cut in a similar manner
the ejaculator  seminis and erector penis, and  transver-
sus perinei, as  well as the anterior fibres of the levator
ani, by lowering the wrist still more than in the first in-
cision.
  The index finger of the left hand  is then introduced
into the superior angle of the wound, by directing down-
wards its radial edge, to place the nail  in the groove of
                         L  X 
1-26
the staff.  T,he  point of the  bistoury, still held in the
first position, is  conducted  along  this angle until it
reaches the groove,  of which we assure  ourselves by
rubbing the point of  the knife against the staff: the ure-
thra is then cut from above downwards for the distance*
of,five  or six lines, by raising the wrist.  The nail is
constantly held in the groeve of the staff to  serve as a
guide to the lithotome cache, which is introduced closed,
with its concavity turned upwards.  When we are satis-
fied that this instrument is  in  the groove, the surgeon
takes the handle of the staff in his left hand, and in
proportion  as he lowers it,  by making  it describe a cir-
cular line, he pushes the lithotome into the bladder along
the staff* until  it strikes against the  extremity of the
groove: the  staff* is  then withdrawn.  Then he places
the lithotome so that its blade corresponds to the direc-
tion of the external  incision. He then opens it by press-
ing  with the right  hand  on the spring,  after having
 placed under it which ever of the numbers engraved on
 the handle of the instrument he thinks proper: he  then
 withdraws it in the direction of the external incision,
 by supporting the sheath with sufficient force above and
 within the  wound  to avoid the division of the pudic
 vessels.  The  fore finger of the left hand is again intro-
 duced to serve as a  guide to the forceps, unless the gor-
 get be preferred.   In  this case Lisfranc advises the
 introduction of it with the concavity turned upwards,
 along  the palmar face of the left fore finger placed in
 the superior angle of the wound, instead of introducing
 it with the concavity turned downwards, and then turn-
 ing upwards, which  doubles the time and the pain. The
 forceps are then,introduced along the concavity of this
 instrument,  taking  care that one of the jaws are on the
 ijo-ht,  and the other on the left, so as to embrace the
 beak of the  gorget: we withdraw the later instrument
 in  the same  manner  it  was  introduced.   We  then
 seek for the  stone with the forceps closed; when it is 
                        i£r

found, the jaws of the forceps  are opened to-lay hold of
it according to its smallest diameter, if possible. When
the stone is secured we rotate the forceps in order to be
sure that we have not taken hold of the coats of the
bladder, and then extract it by moving the forceps from
side to side.                                       '
   Instead of using the lithotome, we may introduce the
blade of a bistoury into the bladder with the same pre-
cautions; then open it in the direction of the incision, by
strongly depressing the wrist, to avoid  the pudic arte-
ries.  This requires more experience  in  the  surgeon
than the lithotome cache.

           Lateral operation uith the knife.

                [liskranc's method.]

   The patient  being disposed  as before directed,  the
staff entrusted  to an assistant,  and the  groove slightly
turned to the- right or left,  according to the side upon
which we wish  to cut, as the choice  is indifferent, al-
though Mr. Lisfranc prefers the right.  The  surgeon
then, armed with a straight knife, of moderate  length,
plunges the point of this instrument into the perineum,
at the height heretofore mentioned, that  is about thir-
teen lines  in front of the anterior edge of the  anus, in
an adult, and somewhat lower  in a child, until it reaches
the groove of the staff,  of which we. are assured  by its
grating on the metal.   Seizing then the handle of the
catheter with the left hand, he depresses it, to introduce
the knife into the bladder,  in the manner we have de-
scribed,  for the introduction of the lithotome cache; the
wrist is then  lowered,  in order to make  an  incision
in  the  same direction, and  of the same length  as
that made through  the skin  with  the  bistoury; when
we operate with the lithotome cache, the only difference 
                         128
                                               *
 is,  that we enter the bladder at the first stroke.   The
 rest of the operatiou does not differ from what has been
 described  in the preceding article.
   We have  seen Mr. Lisfranc perform  this operation
 with an astonishing promptitude and dexterity: to operate
 iA this way, the surgeon should have clearly in his mind,
 the  arrangement of the different parts he is to divide;
 moreover, he should be exceedingly expert.


           Lateral operation with the gorget.

   Having cut the prostate with the point of the bistoury,
 and keeping the nail of the left fore finger in the groove
 of the staff, as at the moment when we are about to in-
 troduce the lithotome cach£, the surgeon  takes the gor-
 get  in his  right hand, its cutting edge being directed
 obliquely outwards  and downwards; he  introduces its
 point  into the groove of the staff, of which he is  assured
 by the grating  of the  metals against each other.   He
 then  seizes  the handle  of  the  staff',  with the  left
 hand;  lowers it at the same time that he pushes the gor-
 get into the bladder, until it strikes against  the extre-
 mity of the groove, and cuts the bladder in entering;
 the  staff  is  disengaged and  withdrawn.  Taking the
 handle of the gorget into the left hand, he  takes the for-
 ceps with the right, to introduce them into the bladder,
 using  the gorget as  a  conductor, as we  have already
 said, while speaki.ig  of the  lithotome cache.   The for-
 ceps being introduced,  and the gorget withdrawn, we
 finish as usual.
   The operation  ended, we remove the patient  to bed,
 bringing the thighs together, which ought  to be slightly
 flexed on the pelvis; the best dressing is to apply nothing*
 at all, unless there should be hemorrhage, in consequence
 of opening some artery.  In such case, we  use the com-
mon  compress. 
•
129
                 The high operation-

   If the size of the stone be too considerable to be ex-
tracted through the perineum, we open the bladder, by
cutting above the pubis.
   The patient lies on his back, having the thighs slightly
flexed upon the pelvis: the hair  is shaved oft' the pubis.
The surgeon, provided with a bistoury, which he holds
in the third posi'ion,  makes an incision over the linea
alba, which in the adult, extends from  about two inches
above  the  symphysis pubis,  nearly down to the angle
formed by  the skin in ascending to the penis. This first
incision  only goes through the skin:  a second deeper
incision divides the fascia superfkialis, and we separate
as far as possible, the bellies of  the pyramidal muscles.
We cut through the insertion of some of  these muscles,
at the arch of the pubis, as well as the fascia behind
them,  by making along this bone a  transverse incision,
which cuts the first at  right angles.   We begin a new
incision, starting from the last,  in  the direction of the
first cut: the fore finger of the  left hand is introduced
between the peritoneum and the fascia last mentioned,
which immediately covers it, and we divide it as high as
may be necessary.  By this  means the  bladder  is ex-
posed, if it be fully distended with fluid;  if not, the sur-
geon  separates with his  finger, the very loose cellular
texture which covers  it.  He then  introduces a lancet
canula by the urethra, much more curved than ordinary,
until  we perceive its point through the  membranes of
the bladder, then the  stylet is pushed  through that part
of the bladder,  corresponding to the external incision.
The bladder is pushed up towards the umbilicus, by
means of the canula and stylet which traverse it.  Then
the surgeon opens the bladder, from above downwards,
with a bistoury, whose point is directed along the groove, 
136
in the concavity of the stylet: then he forthwith intro-
duces the index finger into the bladder, to keep open
the  lips of the incision.  He withdraws the sound, and
seizes with his1 right hand  the forceps, to extract the
stone, which is commonly done with great ease.
  We keep a gum  elastic  catheter constantly in the
bladder through the urethra; and if we have performed
the high operation, after having in vain attempted the
lateral one, it is indispensible  that the catheter should
be passed in,  from  the wound through the perineum,
which is not to be finally withdrawn in either case, un-
til the wound is cicatrized.


               Recto-vesical operation.

^Sanson's method modified by prof. v. berlinghieri.j

  The  patient is placed as for  the  lateral  operation:
the  staff is held perpendicularly by an assistant, the
groove  neither being turned to the  right nor the left.
The surgeon introduces the fore  finger of the left hand
into the rectum, glides flatwise  on the  palmar face of this
finger,  the blade  of a straight bistoury; and after having
turned its edge upwards, he cuts by a single stroke from
behind forwards, and in the direction  of the raphe. ThiB
 incision extends equally through about an inch of the
intestine and raphe.  The inferior surface of the pros-
 tate gland, being thus exposed,  the  finger easily per-
 ceives through the inconsiderable thickness of the parts
 which separate the rectum and  lower fundus of the blad-
 der, which approach each other, the staff, which the as-
 sistant should always hold  in the same position.
   The surgeon passes the point of the bistoury behind
 the prostate, and again directs it from behind forwards,
 to make an incision through the prostate, urethra, and 
131
neck of the bladder, "by carefully avoiding to injure its
lower fundus.  By this method, the incision of the in-
testine will be found about an inch lower than the supe-
rior angle of the incision made through the neck of the
bladder, and the walls of the rectum form a valve which
prevents fecal matter from passing into the bladder.
  The ston • is then removed in the usual manner.
  We  neither introduce compress nor lint into  the
wound; and when the inflammation subsides, we touch
the edges  of the wound with lunar caustic,  to  hasten
the cicatrization.

           Operation  for stone in females.

  All  the methods  which consist in opening the canal
•of the urethra, in any direction, are most commonly  fol-
lowed by incontinence of urine; without stopping to de-
scribe  them,  we shall  give Lisfranc's  method, which
has the advantage of being free from all these inconve-
niences.
  The patient is placed, as for the ordinary operation;
two assistants separate the labia  and nymphae slightly:
the surgeon bein^ placed between the thighs, introduces
a common catheter into the bladder; when it has entered
this viscu.s, Witii  its  convexity directed  upwards,  the
handle  is given to  an  assistant, who  pressing  lightly
upon it, from above downwards, depresses the meatus
and vagina.  The surgeon, who is about  to operate be-
tween  the urethra and the symphisis, setks with his fore
finger, the  position of the rami of the pubis  and the  cli-
toris; then  holding in  his right hand, like a pen, a com-
mon bistoury, he makes an anteriorly or superiorly con-
vex semilunar incision, while with his left hand he sus-
tains the textures, and  marks with his  fore and middle
fingers, the places where the wound ought to begin and 
132
  end.  He commences on a level with the lateral surface
  of the meatus urinarius, passes alon^ the rami and sym-
  phisis pubis, at the distance of onc^ line, and  terminates
  on the side, diametrically opposite.  The handle of the
  bistoury should not be so  much raised as the point.  We
  may at the same time, in fact, penetrate to the bladder,
  and even into that organ; but this would be imprudent;
  it would  be much better  to cut the resisting textures,
  lay»r by layer, and  separate the cellular substance with
  the fore finger,  along which the instrument  is carried
 for greater security,  It  is extremely  necessary not to
 press upon the anterior suiface of the  exposed bladder,
 so as  to detach it from the body of the pubis.
    The surgeon, arrived at the anterior and inferior sur-
 face of the bladder, may cut it transversely, after having
 passed his bistoury into it; but the thumb and  fore fin-
 ger of the left hand should be introduced, the first into
 the vagina, the second into the wound;  by seizing the
 substance placed  between them, the  bladder will be
 tightened, and drawn  slightly  forward, and   then  the
 longitudinal or transverse incision will  become more
 easy and sure.
   If this mode of opening the  bladder be disliked, we
 may cut it upon the  convexity of the cathete.; or rather
 by substituting for it  a lancet  canula, and cutting on
 the groove of the stylet.
   The longitudinal incision is parallel to the axis of the
 muscular fibres of the bladder, but its superior angle is
about fifteen  lines from the peritoneum.
   The transverse incision  is perpendicular to the axis
of the muscular  fibres, but  it is situated  at a much
greater distance from  the  peritoneum;  it ought to be
preferred.
   The calculus is then removed, as in other cases. 
13;i
     Extraction of foreign bodies from the Joints.

   Concretions often  form within the  cavities of joints
of such  a nature,  as to  resist all  medical treatment.
When such concretions irritate the part, so as conside-
rably to impede the motions of the limb, and to endan-
ger the appearance of a severe inflammation, they should
be extracted.   We shall describe the  operation, for the
removal of a concretion from the knee joint:  This will
suffice to give an idea  of the manner in which  we should
act in other cases.*
   The patient lies supine,  on  a bed or table, the limb
being extended, to relax the  capsular ligament.   The
surgeon  causes the concretion  to approach  the  inner
side of the joint, if possible, by seizing  it between  the
thumb and fore finger of the  left hand.  An assistant
tightens the skin towards the patella,  in order that the
integuments may  resume their place immediately after
the incision, and prevent the air from  having access to
the joint. After having thus disposed the  parts, a  longitu-
dinal incision is made over the concretion, with a  straight
bistoury, for an extent proportioned to  the size of this
body.  We then extract it with forceps,  and if  more
than one concretion exist, they are  to be successively
removed.  The wound is healed by the first  intention,
by means of adhesive straps and a roller bandage. The
limb should be kept extended.

                     Trephining.

  This operation is performed, for the removal  of frag-
ments of bone, or  other foreign bodies,  driven into the

  * See Gibson's Surgery, vol. 2d.  for the description of a very
interesting case.in which a concretion of great size, was suc-
cessfully removed by that learned and dexterous surgeon.
                         m                 J. D. G. 
134
cranium, or to allow pus or other fluids effused between
the skull and  dura mater to be evacuattd,  or even Iroin
within the substance of the brain, provided it be at an
accessible point. There arc  cases, in which it  is neces-
sary to make  several  openings;  for instance, when the
fissure traverses a suture;  because the dura mater ad-
hering to  the  suture, the effusion takes place  on each
side,  and absolutely requires two openings to evacuate
it.
  The trephine may be applied at all parts of the cra-
nium, excepting the middle and inferior  parts of the
frontal* region,  the inferior and anterior angles of the
parietal bones, and over the  sutures.
  The place of operating being decided on,  the patient
is placed  on  a  low chair,  and  the  head rendered us
steady as possible, by the hands of one or two assistants;
we  then proceed in the following manner:—
  The surgeon  holding a straight convex bistoury, in
the third position, makes a crucial, or V incision, through
the scalp down  to the  pericranium,  he  dissects up the
flaps, raises them,  and removes the pericranium,  by
means of a rugine.  lie then covers the raised flaps with
a fine compress, to prevent them from being ii.jured by
the trephine.
  When this  is  done we slip down and fix the pin of tiie
trephine, and  then place it upon the centre of the part
to be perforated.   We then turn the trephine gently


  * By using a large trephine, to cut through the outer, and a
.smaller one to  cut through the inner wall, we may treplnne
very securely, over any pari of the frontal region  The sutures
need not constitute  a serious objection, as the adhesion of the
dura mater to  the  bone, may  be divided after  the circle of
bone is cut through, by first removing with Scultet's saw,
a portion of the circle made by the trephin-:, on each side of
the suture.—J- D- G. 
135
from  right to left, the point of the perforator enters the
bone, and  when the trephine has cut to the depth of a
line or a line  and a half, the centre pin is slipped up
and secured by its screw. The trephine is then carefully
moved in half circles as before, occasionally removed to
ascertain the depth to which it has penetrated, and to
remove from the groove  it has sawed the bony particles
with  a  brush.  The nearer we are to  the end of the
operation,  the  more slowly do we move.   We incline
the crown  to the side on which  the section is the least
advanced, so that the whole  circumference may be cut
thro'igh  about  the  same time.   When  we believe the
section  nearly completed, we attempt to detach the cir-
cle of bone by  means of an instrument introduced in
the hole made by  the centre pin, which sometimes is
sufficient for its removal; but when the circle is movea-
ble, as  it does not offer resistance enough to allow any
thing to be fixed in its  centre without the  whole being
depressed, we  raise it  by means of elevators passed
under its edges.  A sort of  spatula used as a lever of
the first order is  the most commodious instrument we
can use  for this purpose.  When the circle of bone is
removed, we cut with a  lenticular the asperities left on
the edges of the opening through the cranium.
   If splinters of bone  are driven in on the brain, we
remove  them with forceps.  If a purulent collection, or
one of any other fluid exists between the bone and dura
mater, the motions of the brain will be sufficient to dis-
place  it; but should the collection be between the mem-
branes and that organ, we introduce  the  point of a
bistoury through the membranes into the tumour, and
if  this simple  puncture  be not sufficient to give issue
to the  matter, we  make  a crucial incision to enlarge
the opening.  The numerous experiments  which have
been  made  recently on the brain do not  allow us to
doubt but that this organ may be wounded  without en- 
J Jb
 dangering  the  life of the individual.   We are far from
 wishing, however, to induce practitioners to be rash, es-
 pecially  when they have to do with such delicate parts.1
   The dressing  after trephining  consists in placing a
 piece of fine  linen called a sindon over the opening,
 without allowing it to pass between the dura mater and
 bone, which  might cause a useless and  dangerous  irri-
 tation.  Over the sindon fine lint is placed, a light com-
 press,  and an  easy  bandage.   The  patient  is then so
 placed in bed  as to allow the fluids  an easy escape
 from the orifice.t

                 Operation for  Cataract.

   The object of this operation is to remove the lens
 from  the axis of vision when  its opacity prevents the
 entrance of light.  Two methods are chiefly employed,
 those of  depression and extraction.

   * In a case trephined by the celebrated DururrREpr, with-
 out discovering any fluid either between the dura mater and
 cranium, or between the membranes and brain, he introduced
 his bistoury for a considerable depth into the substance of the
 brain, and evacuated some purulent matter without immediate
 injury to  the  patient,  who died, however, soon after.  The
 brain has also been punctured in order to evacuate fluids ef-
 fused within the ventricles, in cases of hydrocephalus inter-
 nus, with  safety and advantage.  But the practitioner should
 by no means imitate Dupuvtren, for fear of exposing himself
to the charge of unreasonable temerity, and bringing the pro-
fession into disrepute.   When an abscess in the substance of
the brain evidently projects after the bone is removed, the pro-
 priety of evacuating it cannot be doubted.
  f In the original the directions given are for the use of the
trepan, an instrument resembling a joiner's wimble.  As this
is not employed in this country, we have modified the directions
to serve for the application of the trephine.—J. D. G. 
137
               Depression of the Lens.

  To perform this  operation, no  other  instrument is
necessary but the couching needle.  This needle is of
steel  mounted on a handle of ivory or  ebony,  cut in
polygon, having some  black or white spots, answering
to the convexity, or the broad  part of the needle. Vari-
ously shaped needles  are used; those of Scarpa, Hey,
Saunders, and Sir William Adams are commonly placed
in the cases of couching instruments.
   If the left eye is to be operated on, the patient is seated
in a low chair, fronting a north light, but so  arranged
as to  make  it fall  laterally on the eye to be  couched.
The other eye is covered  up,  that the sight  of the  sur-
rounding objects may not excite motions which will pro-
voke  corresponding movements in  the other  eye.
  An assistant, placed behind the patient, is charged with
raising  the  upper eyelid, with the pulp  of his left fore
finger, which he applies on the free  edge of the lid, to-
wards its middle, so as to press lightly between the lid
and the globe of the eye, at the same time that he  lifts
it upwards.  The surgeon is seated in front  of him, and
a little  to his left side, in a chair, raised so as to bring
his mouth  on a level with  the eye upon which he. is
to operate.  He places his right foot  on a stool, in order
to raise his knee,  which serves to support his right el-
bow, in order that the motions of the hand may be surer
antl more precise.   He then depresses the lower lid, by
applying the end of the left middle finger, slightly flexed
upon the middle of its free edge; the fore finger remains
open and extended, parallel to the middle one, near the
external  angle of the eye,  its internal  edge being in-
tended to serve as a point of support to the blade of the
needle, at  the moment of its introduction.  The  ring
and  little fingers  are applied to the cheek of the oppo-
                         m 2 
138
site side, so that the nose is placed between the middle
and ring finger.  We request the patient to turn the eye
towards the nose.
  Then holding the needle by its handle, like a pen, be-
tween the thumb and two succeeding fingers of the right
hand, the  point being  turned forwards,  the operator
thrusts its  point perpendicularly through the sclerotic
coat, a line and a half or two lines at  most,  according
to the size of the eye, from its union  with the cornea,
towards  the  external angle, and  upon a plane which
will transversely divide the globe  of  the eye into two
equal  parts. The  sclerotic being traversed at a single
stroke,  we raise the handle of the instrument without
makingany pressure, to carry it horizontally in the direc-
tion of the line indicated. The black points on  the handle
being turned forwards, we penetrate,  by fol'owing this
direction,  into the posterior  chamber of  the eye, be-
hind tho iris, and when we perceive the convexity of the
point of the  needle, by the opening through the pupil,
we give  the  needle some semi-rotatory movements, to
lacerate  the  capsule  of the  lens.  We then turn the
black spots on the handle upwards, depress the ban ile,
and  push dexterously, until the concavity of  the needle
arrives at the upper part of the lens. We th\n raise the
handle, without changing the position of the black spots,
and by a motion which should be directed so that the point
of the needle shall be lowered, somewhat from  behind
forwards, we depress the lens, and carry it below the axis
of vision}  into  the  vitreous humour.  We hold it in
that position, for six or seven seconds.   During the last
movement, we direct the  patient to  turn the  eye up-
wards, without moving the head; we then give  the needle
a slight  degree of rotation,  to disengage  it;  bring the
handle  to  the  horizontal position, and if  any fibres of
the capsule  remain in the  posterior chamber, we break
t'-em away with the point of the needle, and pass them 
139
into  the anterior chamber.  We then withdraw it at
first horizontally, until the edge arrives at the sclerotica,
the black spot being turned forwards;  we then  lower
the handle,  and bring out the  instrument in  the same
direction  it entered.   The  motions for  this operation
are reduced to the thirteen following:—
   1st. Traverse the sclerotic coat  at one  stroke, with
the handle lowered, the black spots in front.
   2d. Carry the  handle horizontally; the black spots in
front.
   3d. Penetrate  as far as the posterior chamber; the
black spots in front.
   4th.  A slight rotatory movement to lacerate the cap-
sule of the lens.
   5th.  Lower the handle of the needle; the black spots
upwards.
   6th. Push the  needle upon the upper part of the lens;
 the black spots upwards.
   Tth. Motion for depressing the lens, by elevating the
handle, and carrying it slightly forward.
   8th. Slight  rotatory  movement,  to  disengage  the
 needle, the black spot in front.
   Ot'.i. Bring the handle to a horizontal line; the b^ack
 spot  in front.
   10th. Break down the fragments of the capsule, and
 push them  into the anterior chamber.
   11 th. Withdraw the needle horizontally, as far as
 the sclerotica; the black spot upwards.
   13th. Extract the needle.
   When we operate on the right eye, the needle is held
 in the left hand, and the operation is performed  in the
 same manner as for the left eye.
   The patient should immediately be secluded from the
  lio-ht, to avoid inflammation of the eye.
    Should inflammation supervene, which it rarely does,
  we  treat it like ordinary opthalmia. 
uo
  If cataracts exist on both eyes.it will be better to al-
low some time  to  elapse between the  operation on the
first and the second.
  Nothing but a very light  bandage  need be  placed
over the eye.  The bed curtains should be kept closed,
to exclude the light more effectually.
  We do not remove the bandage for ten or  twelve
days, when we very gradually accustom the patient to
the light.
  This  method is  preferable to that of extraction, not
only because  it is more easily executed, but because we
can always attempt the  latter, in case  that the first be
not crowned with success.
              Extraction of the Cataract.

   The patient and surgeon being placed, as in the ope-
 ration for depression, the upper lid raised, and the lower
 one depressed, the operation is thus performed, suppos-
 ing that the left eye is the seat of disease.
   To  perceive the point, where  the  knife ought to  be
 passed through the cornea, it is necessary to suppose a
 vertical line,  which passing through the centre of the
 pupil,  would divide the globe of the eye into two equal
 parts,  one right and the other left; a second line drawn
 transversely from one angle to the other, would cut the
 first at right angles; it is in the middle of the external
 and superior right angle, that the knife should be intro-
 duced. This point being ascertained, the surgeon hold-
 ing Wenzel's knife in the right hand, like  a pen, and
 the edge turned towards the palm, with this elbow sup-
 ported  on his knee, as  in  the operation for depression,
he carries the  point of the instrument placed perpendi-
cularly upon the cornea, at a line, or half a line from its
union with the sclerotica in the line we have pointed out. 
141
 As soon as the cornea is traversed, we gently raise the
 handle of the knife, to carry it backwards, gliding the
 blade obliquely, between the iris and cornea, which  is
 pierced inferiorly, at a point diametrically opposite that
 by which it was entered, and at the same distance from
 the  sclerotica.  We then  turn the edge  of the  knife
 slightly in front, and by continuing to push in the same
 direction, we finish the division of the cornea.
   It sometimes happens that these movements are im-
 peded, because the eye often is directed inwards at the
 same moment that the cornea is pierced; in this case, it
 is necessary to direct  the  patient to turn  the eye out-
 wards, and we take advantage of this moment to plunge
 in the point of the knife.
   When  the cornea is cut, we take the knife in the left
 hand, with which  we apply the back of the blade upon
 the edge of the flap, and raise it.   With the right hand
 we introduce through the pupil a cystotome, or a couch-
 ing needle, carefully to lacerate the capsule.  This be-
 ing done, we press gently the globe of the eye, between
 the thumb and fore finger of the right hand,  and thus
 produce the  discharge of the lens.  If the pressure be
 too great, we may squeeze out the whole or part of the
 vitreous humour, which may lessen,  or completely pre-
 vent the success of the operation.
  Some oculists who wish to appear expert, open the
 capsule of the lens with the point, when bringing out
 the knife.  But this trick is  of no utility,  and serves
 oAly to confuse the assistants.
  As this operation is rarely  practised on one eye, and
 we ought to wait until both are are affected, before at-
tempting it, it is positively prescribed that we must not
finish  with one  eye  before  b-ginning with the  other.
 \\ hen the cornea  of one eye is  cut, we suspend this
 first operation; then we complete  that on the other eye,
 and afterwards finish the first. 
142
  We cover the eyes with fine compresses, which are re-
tained by a l>g'-t bandage,and the patient is put to bed,
lying on his back, to prevent the escape of the vitreous
humour. The chamber should  be as much as possible
darkened.  We bathe the eyelids daily, with cool water;
and should inflammation supervene, we treat it as in ordi-
nary case.  It is not until the end of ten or twelve days
that the patient is allowed  to see the light, to which he
should be very gradually accustomed.


            Operation for artificial Pupil.

  The pupil, which is closed by a membrane, during the
first months of life, may remain closed, so that the child
is born without sight.  To remedy this malformation,
we make  a crucial  incision in the membrane which
closes the pupil.   For this purpose,  we first cut the
cornea,  as in  the operation  for the  extraction  of
cataract,  and then cut the membrane with an edged
needle, introduced  from  the  anterior chamber.   But
when the pupil is obliterated, in consequence of a  dis-
ease, or of the operation  for cataract, we  attempt to
make  an artificial one.  Different methods have  been
devised to effect this purpose.

               [maunoir's method.]

   The patient lies down, and the eyelids are separated;
the surgeon cuts the cornea, on the side of the external
 angle with the common instruments for cataract, about
 a line from the sclerotica, and  for the extent of about
 three lines.  Very fine scissors, curved  in their length,
 the blades of  which are  not  more than seven or nine
 lines long, one of them being very acute, and the other
 terminated  by an olive-shaped button,  are introduced 
143
flatwise into this opening.  When they have come be*
tween the anterior face of the iris and the neighbouring
surface of the cornea, we turn them in such a manner as
to bring their blades perpendicular to the cornea and iris,
and the blades being separated, the pointed one traverses
the iris in which the desired opening is made.

                 [_scarpa's  method.]

  The patient is seated and fixed  as in the operation
for cataract; then with a very slender couching needle,
we pierce the sclerotica at the external angle of the eye,
about one or two lines from  the union of that membrane
with the cornea,  and we  carry the point  upwards and
inwards to the internal border of the iris.  We go very
near to the ciliary ligament; perforate upwards the inner
edge of the iris until the  needle just shows itself in the
anterior chamber of the aqueous humour. As soon as the
needle is there perceived, we press the iris with it from
above downwards, from the internal towards the  exter-
nal angle, as if to carry  it parallel to the anterior face
of the iris, in order to detach a portion of its edge from
the ciliary ligament.  This being effected, we lower the
point of the needle to rest it on the inferior angle of the
principal opening, which we prolong at will, by  pressing
on the iris towards the external angle of the  eye, from
front backwanls, in a direction parallel  to the anterior
face of that membrane.
   If after the operation, some opaque flocculi appear, we
break  them  in  pieces with  the point of the  needle, to
push them through the new  pupil into the anterior cham-
ber, where they are  gradually dissolved  in the aqueous
 humour and absorbed.
   The blood which  is necessarily  effused by this opera-
 tion, into the anterior chamber of the eye, clouds the
 transparency of the aqueous humour; but Ibis  accident 
144
is not alarming, :<- the blood will bo certainly absorbed,
and the eye regain its previous brilliancy.
  Should the cornea be opaque throughout a great part
of its extent, and preserve its transparence at a certain
point, it is through the part of the iris opposite to this
point, that the artificial pupil should be made.
  The operation  being  finished, we lay over the eye
some soft lint and a light easy bandage.  Should inflam-
mation supervene, it is to be treated by the antiphlogis-
tic method, as in cases of acute opthalmia.
PARACENTESIS.
               Paracentesis Abdominis.

  When a great quantity of fluid has accumulated with-
in the peritoneum, where absorption cannot be induced
by the  administration  of medicine, it is necessary to
draw it off' by the present operation.
  However  simple this may appear,  it is not entirely
exempt from danger, since  the epigastric artery has oc-
casionally been wounded,  and patients  have died in
consequence.
  »The patient is seated on the edge of the bed, a little
on the side which is to  be operated on.  If the abdomen
be not veiy much distended, we pa-s a towel around the
body in order to lighten the integuments and force the
fluid toward the lower  part of the belly.  But at what
point should the puncture be made?  Authors direct us
to choose the middle of  the space between the umbilicus
and the anterior superior  spine  of the ilium; but in 
N   14a
following this direction we are not always certain of?
avoiding the epigastric artery, because the relative situa-
tion  of the  umbilicus is by  no means constantly the
same in every individual.  In consequence of this, Lis-
hiano advises us to draw a  line from  the inferior ex-
tremity of the ensifonn cartilage to the symphisis pubis;
at about two-thirds of an inch below the middle of this
line, we draw a second, to the anterior superior spine of
the ilium. The puncture should be made at the middle
of this second line.
   It is almost indifferent whether we  operate on the
right or left side, though  the, right is most generally
prefered, because the great  omentum descends lower on
the left than  on  the right side, and the small  intestines
floating also in greater quantity on the left, we run less
risk of wounding them by operating on the right.
   The surgeon takes a straight (or even a curved trocar,
if he have no other)  in his  right hand,  placing his fore
finger on the canula to direct it and limit the depth  to
which it should be introduced.  He tightens the skin
with his thumb and  finger of the left hand, and when  he
has placed the point of the instrument where he intends
to make the  puncture, he pushes the trocar at once
through the  walls of the belly, and ceases to press as
soon as the want of resistance  informs  him that he has
entered the  cavity.   He then withdraws the  trocar and
allows the fluid to escape into the vessel intended for
its reception. In order to  evacuate the abdomen com-
pletely, the patient should  raise the pelvis, first on one
side and then on the other; in a word,  he should  move
the body in  every direction which can assist  in moving
the  fluid towards the canula.  The compression is also
to be gradually increased by  means of  the towel passed
round the body.
   If the orifice of the canal is obstructed by a part of
the omentum, we introduce a blunt probe  through the
                          M 
145'
 canula to push  away the obstruction  preventing the es-
 cape of the fluid.  After the whole of the fluid is evacu-
 ated,  the surgeon takes the  canula between  the fore
 finger and thumb of the right hand, and  withdraws it
 slowly,  while with the same fingers of the left hand he
 presses  upon the edges of the wound. A soft compress
 is placed over  the  opening, and a large flannel roller
 around  the abdomen; for which, muslin or linen may be
 substituted,  when the first is not to be had.
   Tapping may also be performed in the following man-
 ner:—
   The patient being seated in a high  chair,  and a towel
 passed  round the body, above the umbilicus, we make
 the puncture through the linea alba,  about an inch and
 a half below the umbilicus.  The fluid is evacuated by
 exerting gradual  compression with  the  towel passed
 round the belly   In other respects the operation resem-
 bles the one above described.
   This  latter  method, most  commonly employed  in
 England, is attended by some serious inconveniences:
for although we have the advantage of certainly avoiding
the epigistric arteries,  we may wound the great arterial
trunks which course sometimes along the line.  We may
pierce the anterior  wall of the bladder, as in numerous
instances its extends nearly to the umbilicus; moreover,
its  anterior  suiface  sometimes adheres to the anterior
wall of  the abdomen.   Before performing the operation
in this way,  we should  sound the bladder in every case,
in order to  ascertain  how high  it ascends.  All  these
 considerations are certainly not  in favour of operating
 on the linea alba,  and we only perform it there in  those
 cases in which the tumefaction of the  liver or the spleen
 prevent us from attempting it at the situation first indi-
 cated. 
147
               Operation for Empyema.

   Practitioners having had occasion to observe frequent-  -
 ly, that wounds penetrating the chest were not constantly
 followed by mortal accidents, and  that a radical  cure
 was effected of the greater part of them, were induced
 to puncture the chest to evacuate fluids effused within it.
   It would not be prudent, nevertheless, to attempt this
 operation in every case of hydrothorax. * If this affection
 results from an acute inflammation, as pleurisy or pneu-
 monia, or the suppression of any habitual  discharge;
 should the patient be young, robust, and  sound in other
 respects, it is a fit case for the performance of the ope-
 ration.
   The opening ought to  be made on the external and
 superior surface  of  the  chest, between  the  third  and
 fourth rib, on the left side, and  the fourth and  fifth  on
 the  right, counting from  the  last lower rib,  and at an
 inch and a half in front  of the angle  of the ribs.  If a
 tumour filled with serosity, projects between the ribs, we
 should operate at this  point.   We do not employ the
 trocar, which would expose us to the danger of wound-
 ing the diaphragm or lungs, and we employ a  simple,
 straight, and narrow bistoury.
   Operation.  The patient being seated upon a  bed  or
 chair, the surgeon aided by an assistant, makes over the
 place we have pointed out, a fold  in the integuments,
 parallel to the  axis of the intercostal space, to raise the
 skin, cellular substance, and edge of the latissimus dorsi,
 if possible; then he makes on  this fold, an incision, two
 inches long, parallel  to the intercostal space.  Having
 made this  first incision,  he holds the bistoury in  the
first position, and gently  cuts, layer by layer, the inter-
costal muscles; he then carries the end of his left  fore
finger under the  lower edge of the superior  rib,  where
 the opening should be made,  to  avoid  the  intercostal « 
148
 urteiy, which ordinarily passes along the inferior edge
 of each rib, except in some anomalous instances, when
 the artery is divided  into two branches, one of which
 runs along the superior, and the other the inferior edge
 of the  ribs.  Then he  penetrates  through  the  pleura,
 which he cuts for the extent of two or three lines, with
 the point of the instrument, taking care not to go too far
 forward,  for fear of wounding the viscera of the chest.
 Tn passing the bistoury through the pleura,  the surgeon
 should be careful not to cut too close to the upper edge
 of the inferior rib, lest he should open the artery, in case
 the irregular distribution of it  exists.   He withdraws
 the bistoury, and closes the opening accurately, with the
 flaps  or with the finger, then cautiously  introduces the
 canula, without allowing the air to rush into the cavity
 of the pleura.
   Should there be a very large quantity of  fluid within
 the cavity of the chest, we  evacuate it partially,  and
 place a compress on  the wound, until next day, when
 we evacuate the rest, in the same manner.
   By this means, the compressed lungs gradually return
to their natural condition, and we easily avoid the intro-
 duction of air into the cavity of the pleura.
   Should the collection of  fluid exist on both sides of
 the chest, we perform the operation on both  sides sepa-
rately, but at different times, otherwise the patient may
be suffocated, by the introduction of air into both sides
at once.
   We place a fine square compress over the  wound, be-
cause flakes of lint might get into the wound; over this-
we apply a graduated  compress and  a bandage, or rather
a corset or jacket.  We remove the dressing, whenever
we wish to evacuate more of the fluid, and we dress the
wound daily, or oftener,  if necessary; in placing  the
compress  we have mentioned, we must be careful not to
allow it to get into the chest, through  the wound, which
 often happens, when mere lint is employed  to cover it. 
149
              Tapping  the Pericardium.
  k
  In his treatise on Surgical Diseases, Boyer observes,
that when it is deemed  prudent to attempt this opera-
tion, Professor Skielderuf's  method ought to be pre-
ferred  to all others, as  least dangerous.  It consists in
making a crucial incision on the sternum, removing a
part of the bone with a trephine, and  puncturing the
pericardium.  This operation should be performed im-
mediately below the point where the cartilages of the
fifth ribs join the sternum.  There the two pleura leave
between them a triangular space, which constitutes the
anterior part  of the mediastinum situated more to the
left than to the right, and is filled with cellular texture.
The apex of this triangular rises as high as the fifth rib,
and  its base extends  to the diaphragm.   After  having
trephined the sternum  at  the point specified, we may
open the pericardium without wounding the pleura. The
crown  of the trephine used should be of sufficient size
to make an opening,  which will allow of the introduc-
tion of  the  left  fore finger, to serve as a guide  to the
blade of the bistoury, in piercing the pericardium.  The
bony circle  is  strongly fixed internally, by the internal
ligaments,  so  that we are obliged to detach them with
the bistoury, after using the trephine.
  If any hemorrhage occur, we must suspend the ope-
ration until it has ceased. Before  making the puncture,
the patient should incline the trunk forward. After the
evacuation of the fluid, we dress the wound, as after the
operation for empyema.

       Paracentesis or puncture of the Bladder.

  In cases of retention of urine, in which we cannot re-
lieve the patient, nor use the catheter, the bladder be-
                       '  n -2 
15(3
comes distended, and if it be not evacuated, the bladder
ulcerates or gangrenes, the urine escapes into the cavity
of the abdomen,  a violent  peritonitis  comes on, and
generally produces the death  of the patient; to prevent
these consequences, we puncture the bladder.
  This operation may be performed in three ways, above
the pubis through the  perineum, and from the rectum.
  1st. Puncture of the bladder above the pubis.—Thi*
mode is most employed in France.
  The patient lies supine, on the  edge  of the bed,  the
thighs being slightly flexed on the pelvis. The surgeon,
placed in front of the patient, or on the right side, may
see, if the patient be thin, the circumscribed elevation,
formed by the distended  bladder; he places the fore fin-
ger on the point, where he wishes to make the puncture,
about an inch above  the symphisis  pubis, in the linea
alba.  He then takes  a curved trocar in his right hand,
placing bis fore finger on the canuln, to limit the depth
of the puncture, which ought to be four or five inches,
more or less, according to the corpulence or size of the
patient.  After having traced out the proper point, he
pushes the trocar at  once,  downwards and  forwards,
holding its convexity towards the pubis, according to the
direction of the axis of the bladder. The want of resis-
tance, and the flow of a  small quantity  of urine, shows
when the trocar  has  entered the  bladder.  We then
withdraw the  trocar with the right hand,  while we re-
tain the canula with the thumb and two first fingers of
the left hand.  The patient is placed on his side,  and
inclined in such a manner, as to facilitate the flow of
urine, t is necessary to push in the  canula, in proportion
as the bladder empties itself,  lest  its extremity  should
escape from this viscus, and allow an effusion of the urine
into the abdominal cavity.  As soon  as the urine is en-
tirely discharged, we stop up the catheter, with a piece
of cork; two tapes, passed through the ears of the cathe- 
151
ter, are  carried round  the  pelvis,  to  retain it in  the
bladder.   As at the end of seven or eight days, concre-
tions  may form about its extremity, it  is withdrawn,
having first replaced it, by means of a gum elastic cathe-
ter, introduced through the canal of the first, in the same
manner as we would introduce the trocar.  The prin-
cipal  objection we can make to this method, is  that the
canula may escape from the bladder, which may cause
an effusion of urine into the cellular tissue; another in-
convenience, is the  continual  presence  of this instru-
ment in the bladder.
  Mr. Abernethy in performing this operation, sepa-
rates  the pyramidal muscles, after having made  an inci-
sion about three inches  long, through the skin and in a
line corresponding to the  direction of these muscles.
By this mode,  the bladder is easily perceived,  and  the
trocar is  passed  into the bladder,  as  above described.
The  danger  of urinary infiltration into the adjoining
cellular substance, is less, because the fluid  escapes
easily through the external opening.


    Puncture of the Bladder through the Perineum.

  The patient is placed, as for the lateral operation; an
assistant presses on the bladder above the pubis, to force
it  downwards.  The surgeon  is  placed between  the
thighs of  tie patient, kneeling on the right knee, and
holding in the right  hand, a  common bistoury, in the
first position; he commences an incision over the raphe,
at the same height, and in the same direction, as in the
lateral operalion;  this incision  should  be about an inch
and a half in length.  Arrived at the bulb of the  urethra,
he carries the fore finger of the left hand into the supe-
rior angle of the wound,  presses  upon the bulb, and
searches for the prostate gland,  and the projection pro- 
152
duced  by the distended bladder.  He then introduces
the trocar, (which ought not to be less than three inches
long) into the  bladder, towards  the  left side, and  the
base  of the  prostate gland.  He withdraws the trocar
with the right hand, retains the canula with his left, and
empties the bladder. The canula is then removed, and a
female catheter introduced in its place, which is secured
by mean9 of tapes fixed to the ears of the catheter, and
pinned to a bandage round the body.
   This method  is  the most difficult of all; it  demands
many precautions, an exact knowledge of the disposition
of the  parts, to avoid the lesion of the vasa deferentia,
the seminal vesicles, the ureter, prostate  and rectum.
Without these precautions, we might pass the trocar be-
tween  the bladder and rectum, and withdraw it without
evacuating the urine.
   6d.  Puncture of the bladder from the rectum.—The
patient is placed as for the  lateral operation; an assis-
tant presses the bladder downwards by placing his  left
hand above the pubis, and raises the scrotum with his
right.   The surgeon, placed as in the preceding opera-
tion, introduces the fore finger of his  left hand, lubrica-
ted with oil or mucilage,  tie feels behind the prostate
for the space which exists between the prostate and the
seminal vesicles, which, when  found, he keeps his fore
finger  fixed upon that point, and glides along its palmar
surface, a curved trocar from four to five inches long. He
plunges it into  the bladder in  the direction of a line
which  would terminate at the linea alba between the um-
bilicus and the  pubis.  He then withdraws the finger,
and the trocar retaining the canula in its place with the
thumb  and two  first fingers of the left hand; the urine
is then evacuated.  The canula is  commonly left a day
or two into the bladder, and the urine continues to flow
through the wojnd if the passage be  not yet closed.
  It is objected against this method, that the seminal 
155
vesicles may be wounded, that the presence of the ca-
nula in  the rectum  and bladder may cause inflamma-
tion: moreover, the fecal matters may be forced into the
bladder,  and form the nucleus of a calculus.  In  addi-
tion, the passage of the urine through the wound .pro-
duces excoriations in the neighbouring parts, and may
cause a recto-vesical fistula.

               Operation for Hydrocele.

   The patient lying supine upon the edge of the bed or
a table, two assistants hold the thighs sufficiently apart;
the surgeon takes the tumour in his left hand, so as to
press the testicle upwards and  backwards at the same
time that he  presses the fluid towards the anterior and
inferior extremity to render this part prominent. Hold-
ing then his hydrocele trocar in his right hand, with his
fore finger on the canula to limit the depth of the punc-
ture he is to make, he plunges it from below upwards,
and slightly oblique from behind forwards, through the
parts rendered prominent by the pressure.  The  want
of resistance, and the flow of some drops of fluid along
the opening made by the trocar, informs  us when the
instrument has entered the cavity of the tunica vagina-
lis.  We then withdraw the trocar with the right hand,
and the canula is kept in its place with  the left hand to
evacuate the fluid.   We press lightly on the scrotum to
facilitate the discharge, taking care to avoid wounding
the testicle with the end of the canula.
   When the tumour is evacuated, an assistant adapts the
canula of the trocar  to the spout of a syringe, holding
a half pint of  port wine and water, and throws this li-
quid into the tunica vaginalis, and the surgeon applies
his thumb over the opening of the canula, which he sus-
tains with other hand  to keep the wine in the tunica
 vaginalis during the lapse of two or three minutes, in
 order to cause a slight degree of irritation on the surface 
154
of this  membrane.  He  allows the wine to escape at
the end of this time; he makes a second injection in the
same manner; and a third, after a similar lapse of time.
When  the tunica vaginalis is  distended with the warm
wine, the patient complains of a violent pain, as it  the
testicle was strongly  compressed; but the practitioner
aware  that this  pain  will not be less during the opera-
tion, must not be intimidated at  the  patient's fainting
occasionly during the injections.
  The canula is withdrawn  when the tunica vaginalis
is entirely evacuated, and we cover up the scrotum with
compresses wrung out of the fluid used for the injection.
  At the end of two days inflammation appears: we re-
place the compresses soaked in wine by emollient cata-
plasms, and then by compresses  soaked  in some emol-
lient liquid,  and the  testicle recovers its  proper size
after the 24th day, if the operation succeeds.
  If both testicles are simultaneously affected, we do
not operate on the second until the first is cured. If the
operation by injection be contra indicated, we open the
tumour from above downwards with a bistoury, to allow
the water to escape, and place some  lint in the wound
to cause the irritation necessary  to procure the adhe-
sion of the parts.


         Paracentesis of the globe of  the Eye.

  The circumstances  which demand this operation are
hydropthalmia,  or a purulent collection  in the cavities
of this organ  or a staphyloma. We should never resort
to the operation as long as there is any  hope of preserv-
ing the eye.
  During a long time, fluids morbidly secreted within
the globe of the eye  were evacuate I by performing the
paracentesis with a small trocar which was passed through
the sclerotica at two lines from its union with the cornea. 
155
This method is bad, and should be rejected: it has bec»
displaced by the following operation, with the intention;
of completely evacuating the globe of the eye without
fearing the recurrence of the disease, which frequently
happens when we treat  a simple dropsy, by cutting the
transparent cornea, as in  the operation for extracting
the cataract; but we must carefully remove the  flap to
prevent its re-adhesion.  We may  also make  in the
cornea a crucial incision with the point of a lancet.
  Scarpa describes his method in the following manner:
  "The  patient being  seated, I direct an assistant to
fix  the  head  properly, then with a knife like that used
in extracting  the cataract,  I traverse the  staphyloma
from  one part to the other at a line and a half or two
lines from the centre of the apex of the tumour, in the
direction from the external to the internal  angle of the
eye, and by gliding this instrument in the direction in-
dicated for the extraction of the cataract.  I cut semi-
circularly, and below the point of  the tumour, remove the
segment with forceps, and turning the edge of the  instru-
ment  upwards, finish by cutting the summit off circu-
larly, so  that the portion removed shall be three  or four
lines in diameter, according to the  size of the tumour."
  This may be used in cases of  hydropthalmia and hy-
popion.
  The eye being emptied, the tunics collapse, and pro-
duce  a  moveable stump, on which  we may adapt an
artificial eye, in the manner heretofore indicated.
  No application is necessary but the lids themselves;
if inflammation cdines  on  we lessen it by leeches and
emollient cataplasms, applied over  the outside  of the
lids.

       Paracentesis cf the  Jlembrana Tympani.

   This operation was  fiist performed  by Asiley Coo-
per, for the cure of deafness produced by an obliteration 
130
of the eustachian tube. It has since been repeated with
success in many other cases of loss of hearing.
  The patient  being  placed  in a strong light, before a
window,  his head  is to be inclined to the side opposed
to that on which the operation is to be performed, and
supported against  the breast of an assistant, in such a
position as to permit the rays of light to pass freely to
the bottom of the  auditory canal.   The assistant is to
steady the patient's head by means of one hand applied
to the forehead, whilst with  the other he raises the ear,
in order to overcome the curvature of the cartilaginous
portion of the canal.  The puncture of the membrane is
performed with a very  delicate  and slightly  curved
trocar, the blade of which should not be  more than one
line in breadth, or capable of passing more than a line
and a quarter beyond the extremity of the canula; this
instrument is to be passed with great care along the
inferior side of the auditory canal, taking care to keep
the  concave part of it lowermost; when  it touches  the
membrana tympani, the  canula is to be  held  firmly be-
tween the thumb and index finger of the left hand, and
the trocar pushed out with the right, so  as to pierce the
membrane at its inferior and anterior part; by perforat-
ing it in  this spot, the chorda tympani,  and the handle
of the malleus  are avoided.   This operation  requires no
dressing, but it is advisable to place a square compress
of silk over the external opening of the ear, that the
patient may not be inconvenienced by noise, a circum-
stance which sometimes  happens in the cure of a deaf-
ness which has existed for a long time.

Perforation of the Maxillary Sinus, to evacuate morbid
               accumulation of fluids.

   This operation is similar to that  already pointed out
for  the extraction of polypi from the maxillary sinus'
,'See page 110.) 
15?
FISTULjE.
         OperatioUfJor Fistula Lachrymalis.

         [method of j. l. petit modified.]]

  The instruments Jbr this  operation  are, a.  straight
bistoury with a narrow but firm blade,  a flexible silver
stylet, a common  grooved director, strong  unwaxed
thread, a seton,  or  rather a cord formed of several cot-
ton threads, which  must be progressively augmented in
size.
  These being at hand, the patient is to be seated op-
posite a window, with his head resting against the breast
of an assistant.  If the operation is to be performed on
the left  side, the  surgeon in front of  the patient is to
place the index  finger of his left  hand on  the internal
angle of the orbit of the eye, and the thumb on the ex-
ternal, in order to stretch the eyelids, and thus  render
the tendon of the orbicular muscle more promine.it; then
passing the index finger of his right hand along  the in-
ferior edge of the orbit from the external to the internal
an"le, he will ascertain the exact situation of the supe-
rior orifice of the nasal canal.  Mr. Lisfranc  has ob-
served, with great truth, that the tendon of the orbicular
muscle is not a sufficient guide  in  finding this canal,
although most writers have designated  it as such; for in
 subjects where  the base of the nose is large, the internal
 angle of the  eyelid  encroaches on the nasal process of
 the maxillary bone, and consequently the tendon is at-
 tached entirely to this bone; in such cases it  would be
 useless to search for the lachrymal casal under  it,  as it
 is  placed  exteriorly.  If, oh the contrary, the  base of
                           o 
15S
the nose be narrow, the tendon of the orbicular muscttf
runs some distance past the prominence alluded to above,
and the nasal duct will be found interior to the extremi-
ty of the tendon—hence it is by no means a sure guide,
and the mode indicated by Mr. Lisfranc is decidedly
to be prefered.  The exact spot for the incision being
thus ascertained, and the fingers of the operator placed
in the position  already  indicated, he is to pierce the
skin in a perpendicular direction until he is warned by
the want  of  resistance,  that the knife has reached the
nasal duct;  in  doing this, it is to be held  in  the first
position, with the edge directed to the nose; the handle
is now to be raised and carried towards the internal
angle of the  eye, until  the  point penetrates the duct;
this  movement will be sufficient to  form an incision of
about three  lines, of which the direction should be ob-
liquely downwards and outwards. The bistoury is then
to be inclined  slightly outwards, and a small grooved
and  probe-pointed stylet passed along its back in order
to clear the  canal; the  knife is now to be withdrawn,
and  the stylet  pushed down till it reaches the inferior
meatus of the nasal fossa; this may  be ascertained  by
the sensation of tickling it produces, or by the flow of a
small quantity of blood from the nose.—This stylet, or
sound, serves as a director  for a second  stylet of thin
and  flexible  silver,  to the superior extremity of which,
is fastened an unwaxed thread.  The sound is to be with-
drawn as soon as this stylet reaches the nostril,—a com-
mon grooved director, introduced into the  nostril,  will
serve to conduct the inferior  extremity  of the stylet,
which, from  its flexibility will easily bend on meeting
with this obstacle,  and may be then seized with a pair
of forceps and drawn out through the nostril, bringing
with it the attached thread.—Such is the method indi-
cated by the ingenious editors  of the " Medicine Opera-
toire" of Sabatier, 
159
  This being done, a dossil of lint or cotton is to be
attached to the inferior extremity of the thread,  and
drawn up till its superior portion is fixed in the lachry-
mal sac,  taking care, however, that it does not enter the
outer incision—a thread is  also  to be fastened to the
lower part of this dossil, in order to remove it when
required.  The  operation being finished,  the superior
thread is to be fastened by twisting it round a pin at-
tached to the cap of the patient, whilst the inferior one
is clipped off' close to the nostrils.  The wound is to be
dressed with a small pledget of fine lint, secured in its
place with a strip of adhesive plaster.  The size of the
seton at  first, to be composed of a few threads of lint or
cotton must be gradually augmented in  order to dilate
the canal; this treatment must  be continued for several
months,  and in some cases  for years, as the seton must
not be relinquished till one of the size of a goose quill
can be easily introduced; after removing the seton  it is
better to leave the thread in the wound for a few days
in order  to renew the seton  in case the tears do not take
their natural course.

   [another method of introducing the seton.]

  After having cleared the nasal canal by means of the
probe-pointed stylet, this same instrument will serve as
a director in  introducing a canula, either of silver or
lead,  about eighteen lines in length, and of a diameter
proportionate to the age of the patient; this canula is to
be slightly curved to fit  the direction of the nasal canal;
an elastic stylet, made of a watch spring, and terminated
by a small bulb of gold or silver, and pierced at its su-
perior extremity with a hole, is to be introduced through
the canula; owing to the elasticity of this stylet, it  rea-
dily passes out  at the nostril;  a linen  thread is to be
passed through the eye at the upper extremity, and the 
108
stylet and  canula withdrawn.  The after mode of pr«
cedure is similar to that above mentioned.
  Some surgeons prefer a leaden tent,  or  a  piece of
catgut, instead of the seton; but this practice is not ge-
nerally followed.

              [method of dupuytren.]

  The patient being placed, and the lachrymal sac open-
ed, as has already been described, the operator is to in-
troduce a small punch inclosed in a gold canula, of the
form and length of the lachrymal canal; to effect this, the
blade of the bistoury  is gently to be raised, whilst at the
same time the punch is pushed down; to keep the canula
from slipping off the punch, the surgeon should  maintain
it in its place by placing the index finger of his hand on
the small rim with which it is furnished; the bistoury is
now to be  withdrawn  and the punch forced  into  the
nasal canal, which the canula  should completely fill in
such  a manner, that the rim engaged in the lachrymal
sac is entirely covered by the lips of the external inci-
sion.  The  punch is now withdrawn, and the canula is
kept  in its place by pressing it down with the index
finger.  The  patient must be ordered to make a strong
expiration  with his mouth and  nostrils closed,  the blood
escaping at the superior orifice of the wound wjll prove
that the instrument is properly placed, and  that  the
communication between the nasal fossa and the lachry-
mal, sac again restored.  The wound is to be dressed with
a small piece of court plaster; cicatrization will readily
take place.
   This mode is evidently the best of all hitherto indi-
cated; the worst consequence that can arise  from it is
the irritation which the canula  may produce, even in
such cases which are, however, rare; it answers the pur-
pose  of the seton, the leaden tent, or the catgut, and it 
161
can readily be withdrawn by means of a*slight incision
over the rim, and a wire introduced into the canula.

                 [METOD OF SCARPA.]

  When fistula lachrymalis cannot be cured by dilating
the nasal canal, Scarpa advises that a route for the tears
be afforded by perforating the os unguis in the following
manner:
  The  patient  being seated in a chair opposite a win->
dow, with his  head  resting against the breast of an
assistant,  the operator is to make a transverse incision
of a few lines in length, with a common straight bistoury,
over the external side of the lachrymal  sac; the wound is
to be filled with lint for forty to forty-eight hours; after
this it is withdrawn; a silver canula is to be introduced
through the opening to the os unguis, through which an
iron stylet, heated to a white heat, is to be passed;  this
perforates it  at once,  as well as its  lining membranes.
By  this means, a real internal  fistula is substituted  for
the morbid  external  one,  and the tears  flow  freely
through it, particularly  if it be made downwards  and
towards the lower end of the sac.
  Striking as this method may appear, it does not offer
all  the advantages that may be supposed, as nothing is
more common than a return of  the disease after such an
operation.

             Fistula of the Parotid Gland.

  This  disease is  the  almost  inevitable result of an
opening in the  duct of Steno, whether  produced by an
abscess, by gangrene, or a wound. The great aim in tie
treatment is to  re-establish the passage of the saliva from
the gland  to the  mouth, either by clearing the natural
jKissage, by makiug an  artificial duct  by means of a
                      o  2 
162
seton, or by us'yig such compression either on the duct,
between the fistula and the gland or on the gland itself,
as will paralyse it,  and thus hinder  the  secretion  of
saliva.
  If the seton be resorted to, the patient is to be seated
in a  chair, with his head resting against the breast of an
assistant; the surgeon is to introduce into  the fistula a
small trocar, such as is used in hydrocele; this is to be
passed obliquely from below inwards, in the direction
of the salivary duct.  The blade of the trocan is now to
be withdrawn, and  a linen thread  passed through the
canula  into the mouth; to this  thread is to be fastened
a small seton  of lint or cotton,  after which,  the canula
is to be removed, and  the  seton drawn into the  new
opening, taking care, however, that it does not interfere
with the lips of the  external wound, through which the
thread only should pass; this is  to be fixed to the cheek
by means of a strip of adhesive plaster.  The seton is
to be renewed every day, and enlarged  by the addition
of a few threads of lint.  The wound is to  be  dressed
with lint, retained in its place by a compress and  ban-
dage,  or by small strips  of adhesive  plaster.  After a
few weeks, if the seton passes easily and without giving
pain, it may  be laid aside; the thread  must, however,
remain for four or five days longer; if the operation  be
 successful, the external wound will heal  readily, and
the  saliva  pass freely into the mouth.  During the time
of treatment  the patient keeps his jaws  in a state of
 ibsolute rest.

                 [by cauterisation.]

   The external opening is to be touched with nitrate of
 ^ilyer, the eschar produced is to be covered with a piece
 of  adhesive plaster. The  saliva being thus prevented
 from passing externally, forms for itself a passage into 
163
the mouth; to prevent the eschar from drying too quick-
ly, it should  be occasionally moistened  by the applica-
tion of compresses wet with some emollient liquor. This
method, although extolled and practised by Louis, is
attended with several objections; the disease is apt to
return on the eschar being  detached,  and also in leav-
ing a large and ugly scar in the middle of the cheek.
   The two  methods we  have indicated  are, neverthe-
less, preferable to  the use of a temporary canula, to
serve as a passage for the saliva, as some surgeons have
proposed; we therefore  shall not attempt to describe
this mode.

                Operation for Ranula.

   This disease is a tumour  formed under the tongue, by
a collection of thickened saliva in the salivary ducts of
Wharton.  The method of cure consists in opening this
tumour and preventing a reaccumulation of the fluid.
   " Mr. Dupuytren proposed many years since, to keep
open the incision made in the tumour, by placing between
the lips of the wound, some, substance which could  re-
main there always. The instrument which he constructed
to fulfil this  indication, consists of a  rounded piece of
either gold,  silver, or platina, about four lines in  length
and about four in breadth, having at each of its extremi-
ties an oval plate, slightly convex on one side, and con-
cave on the  other; one  of these little  plates is to be
introduced into the  tumour, whilst the other remains in
the cavity of the mouth.  Instead of this instrument,
Mr.  Dupuytren at  first  made use  of a  double canula,
but he relinquished  it, as he found that the food was apt
to choke the opening of  the instrument, and that the
saliva passed between the  canula and the lips  of the
wound. 
164
   " The opening into the tumour having been made, by
 puncturing it, or if it be large, by an incision, Mr. Du-
 puytren permits the contained fluid to escape, and waits
 before fixing the above described  instrument, until by
the contraction of the tumour, the orifice is merely suffi-
cient to permit  the passage of it.  This mode of treat-
ment has constantly been followed with success; it  is
simple and  easily  employed, and the patient is not  in
the least inconvenienced by it, after wearing it for a few
days."  (Sabatier Medicine Operatoire, edition of San-
son and Begen.)

                   Fistula in Ano.

  This disease  may be divided into those which ought
not, and those which are to be cured; and those that may,
or may not be cured without inconvenience.  The first are
those accompanied  with chronic inflammation of the ab-
domen or thorax; the  second, those which are callous,
and secrete so  much matter as to exhaust the  patient
and place his life in danger; the latter  are those which
are not callous, and pour out but little matter.
  In this operation the patient is to be laid on his face
or  side, and the surgeon is to ascertain  whether the
fistula is complete;  that is, open at both extremities:  to
do this, a grooved staff is to be introduced  through the
ex'ernal opening, to the rectum; if the  internal orifice
be not too deeply situated it may be passed  out at the
anus.  In such a case, the point of a strong and straight
knife is then to  be  inserted in the groove  of the staff',
and an incision made  from  without  inwards,  by raising
the handle of the knife, the point serving as a fulcrum  in
the groove of the staff.  But  if the internal orifice of the
fistula be deeply situated,  it  is impossible to pass the
extremity of the director through the anus; in  such cases
a gorget of box-wood or ebony is to be  passed into the 
165
rectum, having previously, however, warmed and rubbed
it w'tfh simple cerate; the concavity of this instrument
is  to be turned  towards the orifice of the  fistula;  a
grooved director is then to be introduced through the
external orifice of the sinus, and pushed on till its'ex-
tremity comes in immediate contact with  the  concave
face of the gorget; an incision is then to be made along
the director from without, inwards, till the knife meets
the gorget, these two instruments are then to  be with-
drawn together, forming  necessarily a greater or less
angle.
   When an  occult internal fistula, that is  a fistula
which opens  only into the rectum is to be operated on,
the index finger of the left hand previously smeared with
oil or mucilage is to be introduced into the rectum, till
the orifice of the fistula be felt.   With the right hand, a
staff is to be passed along this finger till the point pe-
netrates the orifice of the sinus; withdrawing the finger,
the sound ia to be pushed along the fistula tijl it raises
the  skin exteriorly; a transverse incision is then  to be
made directly over it, so as to expose  the extremity  of
the sound, and thus to convertan incomplete into a com-
plete fistula. The operation after this, is to be performed
as in the preceding case.
   The operation  being finished, it is to be dressed, by
introducing either a dossil of lint between the lips of
the wound, or a simple strip of  linen;  a few days after-
wards it is to be dressed with pledgets of lint  secured
by compresses and a T bandage.  Some surgeons close
the wound at once, and apply strips of adhesive plaster
that it may heal by the first intention.  If the  hemorr-
hage is great, the wound is filled with lint; opening the
fistula by the knife is much preferable to passing a lead-
en wire through the fistula, so that the two ends may be
twisted together and  gradually tightened, for perhaps
twenty days, in order that it may slowly ulcerate a pas- 
166
sage through; it is only to be used in those cases where a
patient  will not submit to the knife: it is, however, an
almost certain method, when executed with proper skill.
  If sinuses exist above the coccyx or thighs, they are
to be opened with a bistoury.

                Recto-vaginal Fistula.

  This  fistula may be known  by the passage of feces
from the rectum into the vagina; it is rarely that a cure
of it has been effected; nevertheless, Mr.  Dupuytren
has accomplished it by the following method:
  The patient is to be laid on her back at the  edge of a
bed, with her  thighs apart and flexed on the pelvis; the
surgeon standing between them is to introduce with the
right hand a  speculum ani, in  order that the orifice  of
the fistula may be viewed; then taking the handle of the
speculum in  his left hand,  he cauterises the orifice of
the  fistula with nitrate  of silver; an  eschar will be
formed  and slough off,  the inflammation which super-
venes, tends to unite the edges  of the sinus and cicatri-
zation sometimes takes place; the caustic must be used
several times, as one application will never suffice.

         Vesicovaginal and Urethro-vaginal.

  This  has sometimes been cored by the use of cathe-
ters, but the safest mode is to cauterise them, according
to the method we are about to explain.

                   Urinary F'istula.

  Method of Mr. Ducamp. " It has generally been sup-
posed in France,1' says Mr. Ducamp,  "that an urinary
fistula is ouly to be cured oy leaving a catheter in  the
bladder, which, in giving  issue to the urine, at  the samf 
167
time prevents its passing by the fistulous opening;  Ifc
advises, if there exist  a stricture anterior to the fistula,
which  obstructs the flow of the urine, and forces it to
pass by the morbid opening, to destroy it by the method
we shall indicate in treating of  strictures of the urethra.
  " A  catheter permitted to remain permanently in the
urethra,"  observes  this ingenious author,  " hinders the
cicatrization  of the fistula; 1st. because it irritates and
inflames the  canal, and the morbid opening which ex-
ists. 2d.  It causes a great  secretion of  mucus, which
constantly bathes the wound, and by  this superfluous
moisture retards the  cure; 3d.  The catheter acts on the
fistula, as a pea does in an issue.  These  inconvenien-
ces are  to be obviated, by  not permitting the cathe-
ter to  remain permanently in  the urethra, and  the de-
sired  effect  is answered: namely, that the urine should
not pass by the fistulous opening, by introducing a gum
elastic catheter whenever  the  patient wishes to urinate.
   In  those  cases  where the urine passes freely by the
fistula, and not by the meatus urinarius, the canal of the
urethra anterior to  the fistula is often completely ob-
 structed  by  the cicatrization of the  anterior portion of
 the fistula.  Instead  of destroying this obstruction by a
 trocar introduced  into the urethra, as  advised by some
 surgeons, or of passing a  sound and  cutting on its point
 the parts which form the obstacle in order that it maybe
 pushed onwards to the bladder, Mr. Ducamp is of opi-
 nion  that the  desired effect  may  with more certainty
 be produced by means of  the  armed  bougie of Hunter.
 This  is a wax bougie, to one extremity of which a small
 portion of nitrate of silver is attached,  in such a way
 that  the extremity  only  of the  caustic  is to  be seen.
 In making use of it, a common wax bougie, of the same
 size as the  armed one, is to be passed into the urethra;
 when it arrives at the obstruction, a mark is to be made
 with the nail to ascertain its distance from the mouth of 
168
the urethra; this is to he likewise marked on the armed
bougie, in order to show the distance it must pass before
reaching the obstruction; it  is then  to be  introduced,
having been  previously well lubricated  with  oil, and
when from the resistance opposed to its further passage,
and  the  mark  indicate that it is pressing against'the
strict ire, it is to remain for twenty or thirty seconds in
this position, at the same time a slight pressure is  to be
made against the obstruction; it may then be withdrawn.
This  operation must  be  repeated every two or  three
days until the obstacle to its further passage be entirely
removed.   A large bougie is  then to be introduced, and
suffered to remain for a few days, when it will be found
that the canal  is re-established,  and that the  urine
ceases passing by the morbid  opening: if the cure of the
fistula is then to be conducted according to the  rules al-
ready laid down,  cicatrization will speedily  take place.
The use of the  armed  bougie is nevertheless dangerous,
and should only be resorted to in urgent  cases.


       Treatment of Strictures of the  Urethra.

  Method of Mr.  Ducamp. To destroy the  morbid dis-
position of die parts which form the obstruction, and to
render this part of the canal  as level as tht rest, are the
double indications purposed by Mr. Ducamp, whose plan
we will briefly explain.
  Lunar caustic is the agent he makes use  of to  fulfil
the first indication;  but his  method of using it is per-
fectly new.
  This caustic, to be  employed  to the greatest advan-
tage,  should  touch the stricture alone, and thus  only
destroy the part which forms  the obstruction to  the flow
of the urine; hence, before  using this  substance, the
exact situation and extent of  the stricture should be a? 
169
certained; to do this, a model or impression of the stric- ,
ture is to be obtained by means of what  the  author
terms an " explorative sound."* "I use," says he, " for
this purpose, a hollow bougie of gum elastic, No. 6, upon
which  the divisions of a foot measure are marked;  in
introducing this bougie, I can at  once perceive to what
distance it passes into the urethra, and when it is arrest-
ed, the exact number of inches and lines the stricture
is from the meatus. • Having noted  this with  care,  I
immediately seek  for further information; that is the
exact  situation  of the opening in the stricture; to ac-
complish  this,  I make use of  catheters, No. 8, 9, 10,
open  at both ends, and upon which the divisions of a
foot are likewise marked; the anterior opening of these
catheters ought  to be one half greater than the other. I
take a piece of flat tapestry silk, in which  I make se-
veral  knots, that  I dip in me'ted  wax, which  I then
make  round.  I  pass this silk by means of a  string,
through the catheter,  commencing at the larger end;
on reaching the other end, the ball formed by the knots
covered with wax is arrested whilst the silk itself passes
through, and forms at the extremity of the catheter a
strong and  fine  downy tuft.  This  tuft I dip in a mix-
ture of equal parts of yellow wax, diachylon, shoema-
ker's wax, and rosin; of this mixture I apply as much  to
the tuft of silk  as  will render it the same  size as the
catheter, I  then  permit this wax to harden, after which
I  mould it with my fingers, and then roll it on a polished
surface. I cut this species of bougie added to the gum
elastic catheter about two lines from  the  latter, and
mould  the  wax  into the form  of the  extremity of  a
sound.  I pass one  of these sounds into the urethra;
when  it reaches the stricture, 1 permit it to remain for
a few moments, in order that the wax may  become
warmed aid  softened, after which I again push it for-
w aid; the wax finding itself pressed between the sound
                         r- 
l:o
and the stricture, fills all the  depress;ons  of this fat'
ter a id enters the  opening, taking an impression of
the shape it presents.  If the morsel of wax which has
entered the stricture is in the centre of the mass of the
same  materal which terminates the sound, I know that
the projecting parts which form the obstacle  are equally
distributed around the  opening, and that the whole cir-
cumference must be cauterised.  If the projecting por-
tion is on the upper part, the stricture to be removed is
situated at the inferior part of the canal; if,  on the con-
trary, it be on the inferior portion, the caustic must be
applied to the superior  part of the canal; the same is to
be  observed as regards the sides.  The same wax can
be made use of several times, by remoulding it."
  Having obtained the necessary information respecting
the situation and shape of the stricture, its length must
be ascertained.  To accomplish this, several threads of
flat silk must b1 taken, which are to be dipped in the
above melted wax; they are then to be twisted round a
bougie,  and the whole rolled  between two polished and
flat bodies.  The bougie, thus prepared, is to be passed
into the urethra, and  permitted to remain  for  a short
time;  when it is withdrawn, it will be found to have
received an exact impress of the extent and shape of the
stricture.   This  mode of  ascertaining the  size of a
stricture is only applicable to those cases where a bou-
gie can  be passed through the obstruction. To introduce
a bougie fn those difficult cases, which have so often
baffled the  best surgeons, an  instrument termed a con-
ductor has been made use of; this is a gum elastic cathe-
rer open at both ends, which, as in all the instrument-
made use of by our author, is  marked with a  scale to in-
dicate the depth to which it can be passed:  this instru-
ment  is to  be passed  to the stricture, and when  the
opening is in the centre of this latter, it will  correspond
fo that in the conductor.
   When it is above, below, or on one of the sides, ano- 
in
ther conductor is used,furnished with an eminence or en-
largement on one of its sides near the extremity; this
eminence being turned  to the lower part of the urethra,
if the opening in the stricture be situated above and vice
versa ;by this means the  opening in the. conducting cathe-
ter can always be made to correspond with that of the
stricture, so thata bougie introduced through the catheter
passes the opening of the stricture with great ease; we are
thus enabled to direct the point of the bougie at will, to
any point of the  obstruction  in  which an  opening may
exist, and  then introduction  becomes simple and easy.
Having thus acquired a perfect knowledge of the nature
of the obstacle, Mr. Duoamp applies the caustic to it with
precision  and confidence, by means  of an instrument
he terms Port-caustic.
  This instrument is composed of a very flexible gum
elastic  cathether, No. 7  or 8, of about eight lines in
length, and a tube or  socket of platina of eleven lines
in length,  and of the same  diameter as  the catheter.
This tube is furnished on the outside, at about four lines
from  one extremity, with a female  screw, by means of
which it can  be  adapted firmly to the catheter; at the
other end is another  screw of  about two lines and a half
in extent, upon which is fixed a small capsule rounded
at its  anterior extremity and pierced in the centre, in
order to give passage to a bougie.  The interior of the
tube presents two projecting ridges, which occupy about
half its circumference,  and run  from one extremity to
the other, leaving between, on each side, and diametrical-
ly opposed to each other, a hollow space or channel.  A
cylinder of platina  of  ten lines in  length and.one in
diameter, attached to a  gum elastic bougie  of eight in-
ches  and a  half long,  completes the instrument; this
platina cylinder is furnished  at about five lines from
its anterior extremity, with a pin, which projects about
a quarter of a line; at  about half a  line below this pin
is  a deep  groove of three lines iu  length, and three 
172
quarters of a line wide. When the bougie contained iu
the catheter  is  pushed forward, the little  cylinder of
platina  projects  beyond the tube or  socket, and  the
groove for receiving  the caustic becomes visible, its su-
perior extremity being on a line with, and even a little
covered by the platina.tube which terminates the bougie.
The capsule of platina being  three  lines in diameter,
cannot  enter  the stricture, but must press against its
anterior  surface, whilst the small platina cylinder can
enter the opening and apply to it the three lines of caus-
tic, which may be directed to any part of  the opening,
so that the whole  extent of it or merely a portion of
its circumference can be cauterised, by making a greatr
er or less revolution with the bougie.
  By taking a mould  of the stricture after the fall of
each eschar, it will immediately be evident to what part
the caustic is again to be applied; by this mode of pro-
ceeding, the stricture is cauterised in  its whole extent,
and destroyed in the most favourable direction for the
enlargement of its caliber, from within outwards: some-
times two applications are sufficient, but in general three
are required; it  is  rare that a fourth is necessary, al-
though Mr. Ducamp only employs about half a grain  of
nitrate of silver at each operation. The applications of
the caustic should be at about  three  days interval per-
mitting it to remain  in contact with the stricture about a
minute at  each application.  Caustic must not be made
use of if there is any inflammation of  the part, and no
force must be exerted  in passing the bougie.
   The stricture being destroyed,  the great object is to
obtain a cicatrix of the the same size as the canal, when
in a healthy state, namely, about four lines in diameter.
Mr. Duoamp fulfils this indication, by means of two in-
struments, one  of which  he terms  a dilator, and  the
other a bellied bougie.  There  are three kinds of dila-
tors, the first and second are formed of the verniform
 process of the  cracum, and the third with a  cat-gut. 
173
These articles being properly prepared and cleaned, are
used  in the following manner: a piece  of the gut, about
 twenty lines in length, is pulled over a small silver staff,
terminated with a rounded head, the closed end of the
gu  being properly extended  on the head of the staft^  is
tied below the head,  with a  silk thread.  This  staff' is
then  passed into a canula of the same metal, of eight or
nine  inches  long, having at its anterior extremity, a
deep groove, in which the open extremity of the guf  is
to be firmly tied with the silk thread. The silver canula
has a rim,  furnished  with a female screw at its  extre-
mity; the silver should extend  to a small  distance be-
yond this rim,  and  not exactly fill up the cavity of the
canula.  This  instrument is about the size of a  bougie,
No.  2, when it is empty, and  three lines in diameter,
when it  is full. The  third dilator,  made with the gut
of a  cat, of four lines and a half in diameter, is prepared
in the same way.
  The manner of using these dilators is;—having taken a
mould of the  stricture,  the dilator is to be  moistened,
lubricated with oil, and  introduced  like a sound, with-
out using any violence; then a syringe, furnished with a
stop cock, is to be adapted, by means of a screw, to the
rim of the cautila, and air gently forced into it, till some
resistance  is experienced; the stop cock is now turned,
and a syringe filled with water, and again fixed to the
canula, and water forced into the dilator, to supply the
place of the air; by this means, a greater degree of dis-
tension is produced, than if air alone were used;  the in-
strument thu6 filled,  remains for some time; on  open-
ing the stop cock, the  water will escape, and the  instru-
ment may be withdrawn, with great facility.
  But the best method is to  use the bellied  bougie.—
The  strictured part of the urethra, being the only spot
that it is necessary to enlarge,  if this can  be accom-
plished alone, the patient will escape much uuncessary
                        r2 
1,-4
pain, and the cure be much hastened: the bougies hitherto
made  use of, do not fulfil this end.  Mr. Ducamp has,
however, lately invented gum elastic bougies, which
present near their extremities, a swelling or enlargement
of twelve to fifteen lines long, and from two lines and a
half, to four lines  in diameter, whilst the uniform size
Of the rest of the instrument is only two lines; with these
bougies, the strictured part can be enlarged to the size
we wish, without implicating any other portion of the
canal.
  The following will show the manner, in which Mr.
Ducamp makes use of them.
  " Three days after the application  of the nitrate of
silver," says Mr.  Ducamp, " I introduce a dilator  of
three lines in diameter; I fill it with air, and permit it
to remain for five minutes; the next day, I introduce the
same dilator, and distend it as much a9 possible, with
water, which I permit to escape at the end of ten minutes,
and  replace  it by a bellied bougie of two lines and  a
half in diameter, which is permitted to remain twenty
minutes; this bougie is  again used on the following day,
for the same length of time, in the morning and evening;
the next day I pass a second dilator of about four lines
in diameter,  which is  withdrawn in ten minutes, and
replaced by a bellied bougie, of three lines  in diameter.
This bougie is used  the  next  day,  in the morning and
evening, for  fifteen  or twenty minutes; I make a fresh
dilation with the same dilator, on the day following; two
days  afterwards, 1 pass a third dilator of four lines and
a halt in diameter, and replace it by a bellied bougie of
three lines and a half; two days afterwards,  1 renew the
 use  of the same  dilator, and pass a bellied bougie of
four lines in diameter, which is permitted  to remain a
 • ■uarter of an hour, night and morning; at the end of a
 v.ejk, the bougie is only introduced on«..>-,and kept in but
 a few minutes, four or five days afterwards, the patient 
175
is to  introduce it once a day, and withdraw it imme-
diately; by this time, in all probability, the cicatrix will
be formed, and of four lines in diameter, as the rest of
the uretha."*


            [METHOD OF  MR. DUPUYTREN.]

   This professor introduces a gum elastic bougie, until
it is in contact with  the stricture; it is now secured by
the method heretofore indicated.  At the end  of some
time, the presence of a foreign body determines a mucous
secretion,  the tissues relax, and  the  bougie gradually
overcomes the obstruction.  The continuity of the canal
"being re-established, a sound is passed, which is per-
mitted to  remain till the  canal is  sufficiently dilated.
A long experience has  proved  that in most cases, the
course of  the  urine  can be restored by this method, at
least, in those cases, where there is no unnatural  desire
to urinate, and when it is performed  according  to the
rules  laid down  in the  article Paracentesis of the
bladder.

   * All the elastic  bougies invented  by Ducamp, as well a9
most 01 the  improved French instruments, may now be obtained
of Mr. John Horer, in Arch street, Philadelphia-  It is but
justice to say of this enterprising artist, that the cutting instru-
ments he manufactures are not excelled, nor indeed are they
often equalled, by  those of any other workman  in  America,
either for excellence and  durability of temper or high finish.
Having during the  last five years, been very much in the habit
of practically comparing his dissecting knives, and with those
of a great variety of manufacturers, 1 can speak of them with
full conviction, that they will allow of any degree of commen-
dation.—J. D. G. 
176
HERNIA
            Reduction of Inguinal Hernia.

   By taxis is to be understood, that operation which
consists  in  replacing  any viscus,  which  has  escaped
from the abdomen.  In order that this operation may be
perfectly understood, it  is necessary to bear  in mind
the structure of the inguinal  canal.  This canal follows
the direction of a line, which commencing at the spine
of the pubis, would  pass  an inch and a half within the
anterior superior spinous process of  the ilium  of that
side.  This direction being known, the hernia is to be
reduced in the following manner.  The patient is to be
laid on his back, having his thighs flexed on the pelvis,
and  his head flexed on his breast: if these are extended,
they would cause a tightening of the tendinous aponeu-
rosis,  and  consequently  contract the opening of the
canal;  some surgeons however, prefer placing the patient
in a standing posture.
  The tumour  is to  be grasped with  both hands, and
compressed  laterally,  and not in the direction  of its
length, or of its base, and always in  the course of  the
canal we have described; for if the base of  the tumour
be compressed,  its bulk will  be augmented, the reduc-
tion  rendered  more difficult; the same will  take place,
if the pressure be not made in the direction of the canal:
it is to be pushed through the ring, with the index fin-
ger,  beginning with  those parts which are in  contact
with it.
  The hernia being reduced, it  is retained in its proper
place, by a spica bandage, or what is better, by a truss
or elastic bandage, the size of which must be accurately
adapted to the part; it is applied as follows:— 
                         177

  The patient must retain the visera in the abdomen;
by placing his hand over the inguinal ring; the surgeon
then  places the  pad over the opening, and tightens the
truss, by fastening the leather band to the hooks or but-
tons  on the pad, taking care that the  skin under the
truss be not thrown into folds.  The patient should be
made to cough; and  use some exertions, in different
positions, in  order that it be observed,  whether the
hernia perfectly keeps in its place; the  use of the truss
should be continued without intermission,  till a perfect
cure is effected, otherwise the disease will return.

           Operation for Inguinal Hernia.

  When the parts  concerned  in the hernia, are found
to be compressed  to such a degree,  by  the  ingui-
nal ring, that strangulation takes place, reduction must
not be resorted to; and if an operation  be not speedily
performed, in  order to overcome this stangulation, in-
flammation will take place, and the most fatal  conse-
quences ensue.  Before  resorting to an operation, re-
duction must always be attempted, and it is only when
foiled by a reiteration of useless trials, that the former
must be executed.  This is  done as follows: the patient
is laid on the  right  side of a bed, or on a table, covered
with a mattress and pillow; the assistants placed at the
head  and feet of the  patient, secure them firmly; the
surgeon placed at the  right of the patient, on which ever
side the hernia maybe, pinches up the skin which  covers
the inguinal ring, with the thumb and index finger of his
left hand;  this is also done by one of the assistants, so
as to  form a fold, in an  oblique direction, crossing the
inguinal canal at right angles.  The surgeon now hold-
ing a curved   bistoury in the fifth position, divides the
fold  from the middle to the base; he then enlarges the
incision; the  assistant raising the internal, whilst he 
178
himself manages  the  external  lip  of the  wound:  any
artery that is cut, should be immediately tied, as if they
were  neglected, until  the operation  be finished, then re-
traction would  render it difficult; an assistant sponges
the wound after every cut of the knife, that the parts
may be clearly  perceived.
  The incision  through  the skin being made, that of the
hernial sac is next to be undertaken:  the operator still
holding the bistoury  in  the  same way, must cut with
great  precaution,  and  layer by layer, for fear of injuring
the intestine, if  it is an enterocele, or the epiploon, if
it should be an epiplocele; an  injury of the latter is, how-
ever,  much less dangerous,  than that of the former.  The
tissues, which  form  the sac, should not  be raised by
means of  forceps, and then divided by curved  scissors,
as some surgeons have advised, as by this method, the
intestine itself  may be raised and cut.  To enlarge  the
opening of the sac, instead of dividing the membranes
on a grooved staff", it  is  better to use the index finger of
the left hand: as a director,  in such  case,  the bistoury
should be probe pointed and  very narrow.
   The hernial  sac being  opened,  and the parts  con-
tained in it  exposed  to view, the next object is to free
the intestine: this part of the operation consists in en-
larging the opening of the inguinal ring.   The question
now arises, whether the division should be made on the
outer  or inner side of the gut? It has been  asserted, that
when the  hernia takes place  directly through the ingui-
nal ring, that the  epigastric artery is always situated on
the inner side of the tumour; in this case, Scarpa advises
that the incision should be made on the outer side,  but
if it escapes on the internal side of the canal, the artery
will be foudd  on the outside. Scarpa here advises the
cut to be  made on the inner side; this latter mode, it is
true,  is very rare, but it is sajd that it may always be
distinguished by  its  descending vertically, whereas, in 
179
the former case, it follows the obliquity of the canal.
But these principles are erroneous; it being impossible
to distinguish, if an inguinal hernia is interior or exterior
to the artery; and consequently,  the  direction on the
inner or outer  side,  is  not certain, and exposes us to
the danger of cutting the artery, and should therefore
be rejected.  The proper method is to cut directly above,
between the pillars,  for in  sucb a case, the epigastric
artery will recede before the knife* as  is always  the
case, when it is applied  in the longitudinal direction of
the blood vessel.
   A probe pointed bistoury is to be made use of, in this
part of the operation, but no staff or  director;  the bis-
toury is to be introduced into the ring on the index fin-
ger of the  left hand, taking care that  its point does not
project beyond the end of the finger; by this means the
opening is closed, the intestine prevented from coming
in contact with the edge  of the knife; a slight but dis-
tinct sound, and feeling that the resistance is overcome,
will give notice that the operation has been successful.
The extent of the incision should  be three lines at the
 most,otherwise the inguinal rising will, in all probability,
be so  much  weakened,  that the patient will be subject
to a return of his complaint, to a greater degree than that
 which it has been attempted to relieve.
   Instead of the common probe pointed bistoury, it is
 better to use the bistoury of Astley Cooper: this instru-
 ment has  the blade terminated, by an oval button, and
 is only furnished with a cutting edge, of about four lines
 in length, at about  an inch from the extremity of  the
 blade; this  bistoury can  be insinuated with great ease,
 between the intestine and the superior angle of the ring,
 without the fear of cutting the former.  By cutting di-
 rectly upwards,  as we have already observed, a sawing
 motion  with the knife, must be avoided, as this method
 would in all probability, cause a wound of the artery, 
f8t>
   but the bistoury must be merely pressed directly up-
   wards; by this means, it will divide any substance that
   offers a firm resistance, w hile  the spermatic chord and
   blood vessels will not be injured by it.
     The ring being divided, the epiploon  or intestine that
   has been strangulated  is to be drawn out and examined,
   to  ascertain if gangrene has taken place,  or  whether
   any stricture exists, capable of opposing the passage  of
   the faeces.
     If this  be found in a sound  state, the next object is
   to  reduce the tumour; in doing  this, the fingers should be
   oiled, and the same rules observed, as have already been
   premised; but if on the contrary, the  strangulated por-
   tion has become  gangrenous, which may be known  by
   its purplish gray colour, or is much contracted, a com-
   plete division  of the whole tube is to be  made; thus
   establishing an artificial anus, as is the case in penetrat-
*  ing wounds of the abdomen; in some cases it is sufficient,
   that the intestines be  nearly opened,  and cleansed of
   fecal matters contained in it; this wound in many in-
   stances, gradually closes, and  a complete cure ensues.
   The after treatment  consists  in  covering  the  wound
   with a  fine compress, with  soft lint retained in  place,
   by  several compresses, a T bandage, and  one passing
   over thegroin; the patient must remain on his back, and
   follow a strict antiphlogistic regimen, during the progress
   of  his cure, and should continue to wear  a truss for
   a long time.
    It is impossible to enter into a detail  of the plans to
   be pursued, in  cases where  the adherence of the parts
   among themselves, or with the hernial sac,  or their
   great bulk prevent their being replaced  in the cavitv of
   the abdomen.   In the first  of these cases, if the bond
   of union be only an albuminous lymph, it may readily
   be  destroyed by  the  fingers, but if  the adhesions are
   formed by cellular and vascular  membranes, many prac- 
181
titioners advise, that they should be permitted to remain,
as their division by the knife is apt to produce inflam-
mation, and their reproduction; in such a state of affairs,
after the ring is divided, the tumour must be supported
by a suspensory  bandage; by such means it may gra-
dually re-enter the abdomen, or at all events, diminish
considerably in size; in the latter case, after the division
of the stricture, an attempt must be  made to reduce as
much as possible of the tumour;  the part that remains
unreduced, is to be covered with compresses, steeped
in some emollient liquid, and supported by an inguinal
bandage; the patient must be kept on an antiphlogistic
diet, and at the end of some days, another attempt must
be  made to effect the gradual,  and  if it be possible, the
entire reduction of the tumour.  If any foreign body  is
contained in that fold of the intestine, forming ths  her-
nia, so as to obstruct the passage of the fseces, or  pro-
duce inflammation, a longitudinal incision is to be made
in the gut, and the substance extracted, after which, the
wound  of the intestine must be kept in apposition  with
that of  the external parts, until cicatrization takes place;
this may be accomplished,  by making a suture in the
 mesentery.
             Reduction of Crural Hernia.

   In undertaking this operation, a perfect knowledge of
 the direction of the  crural canal is requisite.  It  follows
 a line  commencing at the  centre  of  the  orifice of the
 canal,  about one inch from the spine of the pubis, passes
 an inch and a half or two inches within the anterior su-
 perior  spinous process of the ilium of the opposite side;
 this line cuts nearly at a right angle that of the inguinal
 canal.   This being remembered, the reduction of the
 tumour is to be  performed by making all the pressure in
 the direction of the canal, the patient lying  on las back,
 with the thighs slightly flexed on the pelvis; in other re-
                         ft 
182
spects the same rules are to be followed as in inguinal
hernia.

            Operation for Crural Hernia.

  After having divided the integuments and opened the
herniary sac, in the same manner  as has been directed
when treating of inguinal hernia, the next object is to
divide the stricture at the entrance of the canal.
  With respect to the proper spot for doing this, there
exists some diversity of  opinion; most surgeons, how-
ever,  agree, that it should be effected on the inner side,
in the direction of the  horizontal process of the  pubis,
on Gimbernat's ligament; but in cutting at this place,
there is danger of wounding the obturator artery,  which
sometimes is given off by the epigastric, and passes be-
hind Gimbernat's ligament; this occurs once in twenty
times; it is also by no means unusual to find an anasto-
mosing artery  between the obturator and epigastric, also
running beneath the same ligament.
  If the cut be made directly upwards, there is risk of
wounding the  spermatic chord, although  Bouchet, of
Lyons, has several times operated with success by this
method.
  Dupuytren's mode is, however, to be preferred; that
is, to cut in the direction of a line, which, commencing
from t^e centre of the crural canal, passes an inch and
a half within the anterior superior spinous process of the
ilium of the same side, always bearing in mind that the
incision is to  be made by pressing the bistoury on the
part  to be divided, rather than by cutting,  for  if the
epigastric artery be met with, it would be in an oblique
direction, and consequently would recede  before a knife
used  in this manner.  Mr. Lisfrano is of opinion, that
a stricture may thus be divided over Gimbernat's liga-
ment, cutting upwards and inwards. It is unnecessary to 
183
repeat here the principles which are to guide an opera-
tor in the introduction and use of the knife; but we must
insist on the superiority of the bistoury of Astley Coo-
per, in all  cases where there is any danger of the intes-
tine being wounded; this has already been described  in
the article  on the operation  for inguinal hernia.  In fe-
males  the  operation is  the  same as in males, although
some surgeons recommend that the division of the stric-
ture should be made directly upwards, alledging the
round  ligament may be wounded without danger;  an
opinion we cannot accede to, especially as this ligament
is oftentimes accompanied  by an artery of a size that
would  be dangerous to cut.

Reduction and Operation for other Abdominal Herniee.

  The reduction of umbilical, ventral, and other abdo-
minal  herniee, by the taxis, are  to be conducted on the
same  principles we have laid down  when speaking  of
inguinal hernia.  The  essential  point  is  an accurate
knowledge of the  direction of the canal by which the
tumour has escaped, and to direct the pressure accord-
ingly,  always  taking care to  reduce those parts  first,
which  are nearest the opening through which they  have
passed.  As to the operations for these herniee, when
strangulated, present fewer difficulties than in inguinal
and crural  herniee,  the  principal  point is to remember
the situation of the arteries, and avoid them accordingly.

                   Prolapsus Ani.

  The most frequent cause of this disease (to which chil-
dren and the aged are most subject,)  is the relaxation of
the mucous membrane of the rectum, as it is connected to
the muscular coat by a very weak cellular tissue, is apt
to be protruded from the anus, where it forms a tumour. 
                        184

Mr.  Dupuytren has  treated this  affection  with great
success, by cutting oft" some of the folds of the mucou-
lnembraue of the rectum from  the prolapsed part, by
means of scissors  curved  laterally. The reduction is
then to be  made, beginning with the part nearest the
anus; whilst doing this, the patient must be laid on his
back or face, with his  thighs a little flexed on his pelvis;
the gut being replaced, it is retained and supported by
means of a pessary and bandage, which are to be taken
off when the patient goes to stool, and immediately re-
applied.
  These excisions  have not only the good effect of les-
sening the size of the  protruded intestine by disgorging
of blood, and thus facilitating the reduction, but also by
the inflammation which supervenes in the  wounds,  a
stronger adhesion takes place between the mucous and
muscular coats, thus preventing a relapse, a result which
it is often impossible to procure by the ordinary mode
of treatment, which consists in simply reducing the tu-
mour, and applying a  pessary, compresses, and bandage
to support it-

                Prolapsus Vagina?.

  This disease has great analogy to the preceding, and
is to be treated in the same manner.

                 Prolapsus Uteri.

  The uterus may fall into  the vagina, or even protrude
from its orifice and form an oblong tumour  of a nearly
cylindrical  shape,  between the  thighs. The indication
to be fulfilled, is to replace this organ  in its proper po-
sition, and retain it there.
   To obtain the first  result, the patient is to be laid on
her back on the edge of a bed, as in the operation tor
stone, each foot supported  by a chair,  the thighs a pur1. 
185
and flexed on the pelvis. The surgeon having his fingers
lubricated with oil  or  mucilage, is to press the tumour
upwards, at first in  the direction of the axis of the infe-
rior strait, and afterwards  in that of the superior.  In
ordinary cases the reduction is effected with great ease,
the patients often  accomplishing  it themselves  The
uterus is to be maintained in ^its  place  by a pessary;
this instrument, made of gum elastic, is a kind of oval
cushion, and is to be introduced as follow?: after choos-
ing one of a proper size, it is to be  dipped in oil and
passed into  the vagina, in its smallest diameter; when it
is introduced,  it  is fixed with the oval in a transverse
direction, so that its two  extremities  correspond with
the internal side of the tuberosities of the ischium. The
pessary should be removed and cleansed every four or
five days, and  be renewed whenever its surface becomes
rough and uneven.

                 Retroversio Uteri.

  This accident seldom  happens,  except after a deli-
very; if the  retroversion be not complete, it is merely
necessary tn push  the womb upwards,  into its proper
position. But when it is complete, the difficulty of re-
medying it becomes much greater.  After placing the
woman  in the posture described in prolapsus uteri, pres-
sure is to be made with the fingers, previously well oiled,
on the sides of the uterus, pushing it upwards, and com-
mencing with  the part nearest the vulva, as in prolapsus.
  To prevent a recurrence, the patient should be kept
in bed,  in a supine  posture, with  her thighs closed and
her pelvis elevated, for several days; after which, a pes-
sary is to be introduced. 
                        1*'
                 Procidentia Iridis.

  When there is a protrusion  of  the  iris through an
opening in the cornea, it is recommended that it should
be replaced by pressing it back with a strong probe, and
afterwards keeping the  patient  lying on his back in a
perfectly horizontal position, at the same time exercising
a light pressure on the eye, by means of a bandage,  in
order to prevent a recurrence of the protrusion.  If the
iris cannot be replaced,  it must be cut oft' with small
curved scissors, and  the eye dressed  with astringent
washes, in order to hasten the cicatrization of the wound.

              Fall of the Upper Eyelid.

  When this disease  arises  from an incurable paralysis
of the elevator muscle, the  following operation must  be
resorted to.
  The patient is to be seated in a  chair, with his head
supported against the breast of an  assistant; the eyelid
is seized about its middle, with a pair of forceps, both
by the operator  and an assistant, so as to form a longi-
tudinal fold parallel to  the  tarsus.  The surgeon,  with
a pair of slender curved  scissors, is to remove this  fold,
cutting from  without inwards.   The lips of the wound
unite and cicatrize, and of course the lid is shortened.
The part removed ought to be of sufficient size, to pre-
vent the lid from covering the pupil, when cicatrization
takes place.

               Inversion of the  Eyelids.

   In this disease, Scarpa and many other surgeons ad-
vise that a longitudinal portion  of  the  lid be removed,
as in the preceding case; this loss  of substance  causes
the  lid to resume its natural position  when the lips of
the wound unite.  When this means  is insufficient  to 
187
restore the lid to its proper place, and the ciliee continu-
ally rubbing against the ball of the eye, cause great pain
and irritation, they must, therefore, be removed as di-
rected in the article on Removal of the Eyelashes.

              Eversion of the Eyelids.

  To remedy this deformity, that portion  of the con-
junctiva which forms a prominence on the free edge of
the lid, must be removed. The patient is to be seated
opposite a well lighted window, with  his head  resting
against the breast of an assistant; the surgeon placed in
front, is to raise the enlarged conjunctiva with a pair of
slender forceps, and if he is not able to command a suf-
ficient quantity,  he is to be assisted by an aid;  he is
then, with a pair of curved scissors, to remove the fold
at one cut, as in the above mentioned  cases.   When
the eversion is great,  Scarpa advises that  the  conjuc-
tiva should be dissected  off from the tarsus to where it
is reflected over the ball of the eye, and afterwards to
remove a fold with the scissors. The hemorrhage is not
great, and is arrested by lotions of cold water.
   A perfect cure is effected in a few days; if inflamma-
tion should supervene, it must be reduced  by the com-
mon antiphlogistic means.

 Operations to facilitate Reunion in Wounds of the Soft
                        Parts.

   Sutures are useful  in inducing the union of wounds,
 in which the lips are thin  and apt to be displaced, as
 often takes place in divisions  of the cheeks,  lips, eye-
 lids, nostrils, &c; in wounds of the  intestines, and par-
 ietes  of  the  abdomen,  in some of those of  the scalp,
 in lacerations of the perineum, &c.
   There are  several kinds made  use of,  but those most
 commonly employed are, the interrupted suture, the 
188
 looped suture, Glover's suture, the quilled suture, and
 rhe twisted suture.

                 Interrupted Suture.

   The wound being cleansed, and  its edges brought to-
gether by an  assistant, the surgeon taking a threaded
curved needle in his right hand, and placing the thumb
on its  concave surface, about the middle of its length,
while the fore finger is  placed upon its convex surface,
parallel thereto, he plunges through the substance about
one, two, or three lines from the  wound, and near one of
its angles, in order that the edges of  the wound  shall
correspond exactly throughout their whole length. When
he judges that the point of the needle has arrived at the
bottom of the  wound, he elevates the point by depress-
ing his hand; the opposite edge is traversed from within
outwards, and the needle conies out opposite the point
by which it entered, and at an equal  distance from the
edge of the wound. To render the  passage of the needle
less painful, we place the extremity of the thumb and
fore finger of the left hand upon  the points it is to pene-
trate.   We  then  take one, two, three,  or more stiches,
according to the length  of the incision, or the extent of
the flaps we wish to unite.  The stitches should be equi-
distant. When all the stitches are passed  through, we
cover the wound with a pledget of  dry and fine lint, and
bringing the ends of the threads  together,  we tie  them
separately,  making first a simple and then a bow knot.
The suture  should be neither too tight  nor too loose;
should it be too tight, the swelling  produced by the in-
flammation will  render the parts painful and may make
the stitches cut through  the texture: when too loose, the
union cannot take place.
   The knots are placed at the least dependent part of
the wound, in order that they may not  be much soaked
in the  pus which flows.  We remove the stitches at the 
189
end of four or five days after the operation, if nothing
interrupts the cure.   The patient should be kept in a
proper position, and  the bandage be applied  for some
days, in most cases, after the stitches have been removed.

                   Looped Suture.

  To make this suture, we take as many straight or
curved needles, according to  the parts  upon which we
are to operate, as we intend to make stitches;  each
needle is threaded with an unwaxed thread. The needles
are passed through the lips of the wound, in the man-
ner which has been indicated, for the interrupted suture.
When all the threads are placed at the distance of some
lines from each other, we remove the needles,  and we
bring all the ends of the threads into one mass,  and
twist them together,  so a3 to make but one cord.  By
this method, the  divided parts are puckered,  and the
union of the edges of the wound is exactly maintained.
This suture, which has been particularly used for wounds
of the stomach and intestines, is attended by many in-
conveniences; hence, we are advised to relinquish it for
the following suture, which is thus described in the new
edition of the Operative Surgery of Sabatier, by Messrs.
Sanson and Begin.
  " The wounded part is held between the fingers of
the surgeon  and those of his assistant; the two lips of
the wound are then pierced, at a line or line and a half
from their edge, with a straight needle, carrying a single
waxed thread.  A second is introduced, at the same dis-
tance from the side at which the first comes out. Continue
thus to  introduce them, until all  the points are ranged
on the same line. By operating in this manner,  the lips
of the wound will be united, and present without inter-
position to those of the integuments, with which nothing
impedes their union, and when they have united, the 
190
threads may be withdrawn, without fear of pulling the
parts asunder."


                  Glover's Suture.

  When the textures upon which we  operate are very
delicate, we make use of a straight and slender needle;
in cases of the opposite kind, we employ a curved one.
The edges  of the wound are brought together, and re-
tained  by an assistant, while the surgeon holds them
himself, near the extremity where  he wishes to  com-
mence  the suture; he pierces then obliquely,  from right
to left, at one or two lines distant from one of the angles
of the wound, and at the same distance from  each of its
edges.   He draws the thread until within a few inches
of its extremity, and he again passes the needle  in the
same manner, and from the same side as at first, and at
the  same distance from the edge of  the  wound.  He
continues to use the needle in this way, introducing the
needle  always on the same  side,  until he reaches the
other angle, where he finishes, by taking care to leave
some inches of the thread unconfined, as he did in be-
ginning.  After four or five days, we remove  the thread
thus spirally arranged, cutting on one  side, close  to the
flesh, and pulling gently at the other end, with the right
hand, while the thumb and two fore fingers  of the left
are   applied to the edges of the  wound, to prevent
tearing.
  This suture employed in the same  cases as the pre-
ceding, is very generally rejected, because it commonly
happens  that  the  presence  of the threads, which pass
over the edges of the wound, at every stitch, prevent
their union, with the adjoining integuments, which is
very desirable in wounds of the stomach and intestines. 
191
                  Quilled Suture.

  This  suture is commonly used in wounds of the ab-
dominal  integuments and walls.   An  assistant brings
the lips of the wound together; the surgeon uses a curved
needle and thread, exactly as in the interrupted suture.
The only difference is, that the threads are so doubled,
as to leave a loop at one of their extremities.  When all
the doubled threads required by the extent of the wound,
are passed on the same  line, and  the  loops being all
placed on the same  side, we pass the barrel of a quill
through these loops, and another quill barrel between
the threads on the opposite side.  We then tie the open
ends of the threads over the last mentioned quill,  by a
bow-knot, having tightened them so as to bring the edges
of the wound into contact; if it be proposed to unite them
by the first intention. The knots should always be tied
on the least dependent side of the wound, in  order that
they may be less soaked  in pus.  The threads are re-
moved at the end of four or five days, by cutting them
on the lower side of the wound,  and cautiously with-
drawing them on the other.  This  is one of the most
excellent and least irritating sutures.

[for the twisted sutures, see operations  for
                     HARELIP.]

          Other modes of procuring Union.

   The application of sutures to parts thicker than those
we have spoken of, to the muscles for instance, is not
only  useless but even  dangerous, because it  irritates
without being able to produce adhesion.  If  the wound
affects  parts externally situated, the approximation of
which may be easily maintained,  without many efforts,
sutures again become useless, and should not be resorted
to, whenever it is possible to do without them.   If then 
192
  the incision be large and deep, we employ the uniting
  bandage, if it be superficial we use simple adhesive straps.
    It is impossible in this place, to enter into all the de-
  tails, which a description of individual cases, requiring
  the employment of sutures and uniting bandages.  We
  shall  confine ourselves to the operation  for  harelip and
  the staphyloraphia.  In relation to have indicated them,
  as the understanding  of the surgeon must direct him
  to the most proper choice of means  to be employed.

                Operation for Harelip.

   This malformation is single  or double.   When it is
  double, it is better to operate o > but one side at a time,
  and uot attempt to unite both fissures at. the same time.
  However, when the free portion is very narrow, we may
  remove it, and then  unite them, as if it were a single
  harelip.   When this centre portion is not very large, we
  may cut it into a triangular form, by taking off the loose
* point, and making the edges raw on  each side.  The
  edges of the  fissure being then made raw, we apply
  them against those of the triangle, and keep  them in
  contact, by the mode now to be described.
    As  the harelip is  commonly congenital, it has been
  asked, at what period of life it is most advantageous to
  perform  the operation.  Some  think it  best-to wait till
  the patient is five or  six  years old, before operating;
  others say the  operation  should be  performed  six or
  seven weeks after birth.   But at present, this opinion
  is generally abandoned, as convulsions often  come on,
  and endanger the lives of infants operated on, at that
  tender age.  Hence, we generally wait until  the child
  is one or  two years old, before we perform this opera-
  tion;  but success is still more certain, if  we wait until
  the patient is six or seven years old, because the lips of
  the wound bear the  sutures better at that  period, and
  are less exposed  to  ulceration, which would require  a 
193
repetition of a painful operation.   In England this ope-
ration is commonly performed with the knife, and the
wound  is united  by means of stitches;  in Paris,  most
frequently the bistoury is used, and  the  lips of the
wound  are brought together, by means of harelip pins,
having a thread passed  round their ends, in the form of
a figure of 8; each of these modes has its advantages;
yet it must be agreed, that the operation done with scis-
sors, ought  to  be less  painful, more expeditious, and
occasion less hemorrhage, a circumstance which deserves
to be taken into consideration, especially if the subject
is very young.
   Operation for harelip with the bistoury.—The patient
is seated upon a chair, or placed upon the lap of another
person,  if it be a child.   The  head  is  strongly held
against the breast of an  assistant, who placing his  hands
upon the patient's cheeks, pushes the upper lip forwards
with the fore fingers, in order to bring together the edge
of the fissure.  Then the  surgeon,  with a straight bis-
toury, cuts all the unnatural adhesions which unite the#
lips  to  the gums; he places under the right side of the
wound a small  flat piece of wood or sheet  lead,  which^
he retains with the fore and middle fingers of the left
hand, while  the thumb  presses on the lip.   He carries
the point of  the bistoury, held in the first position, to-
wards  the  septum of  the  nose, and  cuts  from  above
downwards  the  edge of that side of the lip.  Placing
then the little piece of wood or the sheet brd under the
opposite side, similar  to the first, he removes the edge
of the lip, as in the first instance, so that these t'yqhv:
cisions may correspond at all parts.  The English RJWte
the wound generally by the interrupted suture'^ this rtftsde
is now most commonly rejected.             /■  ~<t/
   Operation for harelip with the scissors.—Tli^patient
being placed as  in the foruu-r ca^e, the  surgeon takes
hold of  the right side of the  wound  by its inferior part,
                        R 
194
 with the thumb  and fore finger of the left  hand, and
 placing the edge of this side of the wound between the
 blades of strong; scissors,  he  removes it at one stroke
 from one side to the other.  He performs the same ope-
 ration  on the oppo>ite side, by taking  care that the two
 incisions correspond exactly, and terminate at the same
 point of the angle of the wound.
   The  needles are  next to be. applied, to keep the cut
 edges in contact.  We  may, indeed, make use of com-
 mon pins, as  has been done for many years in the Hotel
 Dieu of Lyons;  most commonly we employ steel pins,
 with lance-shaped  moveable points;  or  when circum-
 stances permit, we may  employ pin> of platina or gold.
 After  having greased the  point of the pin, the surgeon
 takys it by the middle,  between the thumb  and middle
 finger  of the  right  hand,  while the fore finger is sup-
 ported  on the head; the edges  of the wound being ex-
 actly approximated, he  thrusts the pin into the thick-
 ness of  the lip on the left side, about an inch and a half
 from the edge of the wound, to  make it come out at the
 same distance from the wound, through the opposite side
of the  lip, taking up near the two anterior thirds of its
 thickness.  The first pin  should  always be inserted
towards the  inferior  part of the lip; the first needle
ought to be placed, so as to secure  the edges of the in-
cision being made to correspond at  all  points.
  This first needle being placed, we pass a waxed thread
once under  each of its extremities;  the ends of the
thread  are then given to an assistant, who draws lightly
on them from  above downwards, in order to approximate
the edjes of the  incision throughout their whole length.
A second needle is then passed  near the middle of the
incision, by commencing on the same side, and conclud-
ing in  the same manner as in the preceding case: Fi-
nally, we  pass a third towards the superior angle, and
 always with the same precautions. 
195"
  When all the pins are placed, we then take the two
ends of  thread, confided thus far to the assistant; we
cross them to bring tliern in  front of the first pin, and
then carry them again under its extremities.  We pass
them in  like  manner, under the other pins, forming so
many figures of 8., After doing the same on the upper
pin, we  lie. the two ends of the thread in a bow  knot;
then place a soft compress on each side of the wound
under the pins,  for fear that they may irritate the subja-
cent parts.  The sorts of rings formed by the pins and
loops of thread, should neither be too tight nor too loose.
  In cases where the lips of the  wound are too far se-
parated to allow of their being brought together as some-
times happens,  especially after  an  accidental harelip,
we detach the lips and cheek internally from the max-
illary bone, as we are occasionally obliged to do after the
removal of a cancerous tumour of  the lower lip.
  If we  wish to associate with the suture adhesive plas-
ters, as a secondary mode of reunion, we do it in the
manner directed by Professor Roux. We apply on each
side of the cheek a square piece of strongly adhesive
plaster  on each  cheek, the anterior edge of which is
pierced with holes, through which two or three  threads
are passed; after having passed  those  of  one side
through  those of the other, so as to make them cross
the lip between  the pins, we draw them in  opposite
directions, to bring  forwards the cheeks, to which the
two plasters  are attached. We then fix the threads to
the cap of  the patient.  This mode will suffice in a young
patient, but for an adult we should have recourse to the
uniting bandage, which we apply as follows:
   The head of the patient being covered by a cap fixed
by some circular turns of a bandage, we place across ifc
on the top of the head, a narrow and long compress,;
whose ends are at first pendant to the base of the lower
jaw; we place  then on  the  ends of this band or coin*- 
19G
press, two thick graduated compresses, which an a>>i.^-
tant holds for an instant with  his two hands, at the
same time that he pushes them forwards.  The surgeon
applies  the  middle of  a double-headed roller on the
forehead; the two  ends are then carried over the lateral
parts of the head to the occiput, where they cross each
other.   They are then  brought  to the front, over the
graduated compresses to the upper lip, where they are
again crossed  and  carried over  the  compresses, and
around the head. After having  been twice or thrice car-
ried  in this direction, we then  fix the ends of the ban-
dage to  the cap; after this we raise the pendant ends of
the band under the graduated compresses on the cheeks,
and fix them in the same manner  to the lip, with pins.
We then apply to the chin the middle of a four-tailed
bandage, which sustains the lower jaw, and contributes
at the same  time  to support the graduated compresses.
The  ends of this  bandage  are  also raised upwards, and
fixed to the bandage on the head.
  The patient must avoid  speaking or laughing, and
must eat such  food  as  will not require the motions ne-
cessary  in mastication.
  The pins are  not withdrawn until the end of three
days, by commencing with the upper one; then taking
out the lower, and lastly, the middle pin.  It  is  unne-
cessary  to disturb the thread before removing the pins.
We ought even to allow these loops of thread now glued
to the skin  by the  effused lymph to remain  for some
days, as they will  perform the office of an adhesive plas-
ter.  When we withdraw the needle, we give it a slight
rotatory  movement  without moving the lip,  which is
avoided by pushing a little upon the ends of the pins to-
wards  the side they are to be drawn from.
  After the removal of the pins, the uniting bandage
is reapplied  during four or five days, more, after which
it is replaced  by one or two  adhesive  straps,  placed 
197
across the cheeks and lips. If the infant cry during the
removal of the pins, the assistant takes care to prevent
the retraction of the edges of the wound, by keeping
the checks pushed forward with the hands.

     Staphyloraphia, or Suture of the Soft Palate.

  As some individuals are born with the malformation,
designated by the name of harelip, there are others who
come into the world with  the soft palate, and  even  the
uvula bifid.  The latter deformity sometimes accompa-
nies the harelip, but it may also  exist alone.  In either
case the following operation has been devised by one of
the most distinguished surgeons  in France, Professor
Roux. The operation consists, as in the harelip, in ren-
dering the edges of the separated parts raw, and bring-
ing the edges of the wound together by means of sutures.
  The patient is to  bo seated in a chair, facing a strong
light, the head inclined backwards, against the breast of
an  assistant.  The  surgeon is placed in front of him,
and causes him to open the mouth  widely; to secure it
in this position,  he  places a  piece  of cork in each of
the angles of the jaw, between  the teeth;  these  are
steadied by an assistant,  for fear of some unpleasant
accident.  Every thing being prepared, the surgeon then
lays hold, first of the lower and  loose edge of the  left
portion, with a pair of dressing forceps, introduced by
the left hand into  the fauces; then, holding  a probe-
pointed and narrow bladed bistoury in the  second posi-
tion, he carries it to the back part of the mouth, to cut
the edge of the part of the palate, drawn tense by  the
forceps from below upwards.  Taking hold of the other
with the forceps  in  the right hand, he makes an incision
on  its edge,  similar to the first, so that these two inci-
sions  shall unite by an angle near the palatine arch.
Each of these two incisions should remove about a line
                      r  2 
198
 sf the substance from the edges of the soft palate.  Wc.
 then  introduce a curved needle, by aid of a proper han-
 dle, to the back  part of  the  palate, carrying a waxed
 thread, and pass  it through the soft palate from behind
 forward, at a line and a half from the loose edge, and at
 the same distance from  the  cut  surfaces.  A  second
 needle, the eye of which  receives the other end of the
 ligature, is introduced in a similar manner, and  passed
 through the velum palati at a corresponding point on the
 opposite side.  The ends of the ligature are then brought
 out of the mouth, and  are given to an  assistant, who
 avoids drawing with them in the  slightest degree, be-
 cause this would  bring together the inferior extremities
 of the wound, which would impede the  introduction of
 the other ligatures.   The other ligatures are  passed in
the same manner  as the first,  taking care to pass them
 as nearly as  possible, at an  equal distance from  each
 other.  Two ligatures appear to be sufficient in ordinary
 cases, one inferiorly and the  other in the  middle  part;
 but if the union  cannot be perfectly produced in  this-
 inanncr, we pass a third ligature through the palate, near
the superior angle of the incision.  We then proceed to
 tie  each of the ligatures, to produce the coaptation, by
commencing at the lower one. The ends of the ligatures
are cut ofl'ncar the knot.  The patient should, as much
 as possible, abstain from  swallowing during the four
 days which the ligatures ought to remain.  We support
 him during this time by the administration of clysters of
 nutritious fluids; or, better than this, we introduce  fluid
 aliment into the stomach through a gum elastic tube.
  This operation  was perfectly successful in the first
 case in which Professor Roux, its  author, performed it.
  The genius of the surgeon  may suggest an analogous
 operation in  case of division of the palatine vault, as 
199
well as in many other congenital or accidental divi-
sions.*
OF FRACTURES IN  GENERAL.
  All fractures may be divided into
  1st. Transverse.
  2d. Oblique.
  3d. Comminuted.
  4th. Simple fissures of bones.
  'I he displacement of fractured parts may take place
in many directions.
  1st  According to the thickness of the bones.
  2d. By the separation of the two fractured parts.
  3d. By riding on each other.
  4th. By elongation, as 1st, in some cases of paralysis;
2d, in some cases of oblique fracture of the neck of the
femur.
  5th. According to  the direction of the limb;  back-
wards, forwards, right, and left.
  6th. According to the circumference of the limb.
  Fractures may also be divided into
  1st. Simple, without lesion of  other parts.
  2d.  Compound; that is, accompanied by  contusions,
lacerations,  rupture  of the  muscles, tendons, vessels,
fccc. &c.                                           %
  3d. Incomplete; that is, of but one bone of the same
limb.
  4th. Complete,  or of both  bones of the limb at the
same time.

  * Physick's forceps will be found  a much better instrument
for the introduction of the curved  needles, in this operation,
than the common handle, or port-aiguille. 
200
   But we generally say fracture of the fore-arm, or of
the leg, when both bones are broken; and fracture of the
tibia,  fibula, radius, or ulna, when only a single bone is
broken.
   The existence of a fracture is generally known
   1st. By the displacement of the  parts, their elonga-
tion or shortening; this sign is obtained by the sight and
touch, and by measuring the limb, cither by a common
measure, or by placing them together.
   2d.  By the movements we can occasion at the frac-
tured parts.
   3d. By the crepitation or grating we hear when  the
limb is moved; first, by the aid of the ear simply: second,
aided by the shethoscope.
   4th. By the difficulty or impossibility of moving  the
limb.
   5 th. By the pain.
   The treatment of simple fractures should be,
   1st. To reduce the displaced parts;
   2d. To keep the fragments together;
   3d. To remove the obstacles preventing the consoli-
dation.
   The reduction should  not be attempted during  the
existence of much tumefaction.
   To  effect reduction, we generally have recourse to the
following means.
   1st. Extension.
   2d. Counter extension.
 '3d. Coaptation.
  Extension and  counter extension  are  not performed
for fractures of the patelia, os calcis, olecranon, &c.
   Extension and  counter extension are made by  the
hands of a greater or  less  number  of assistants, or if
this be impossible, or inconvenient,  we  make use of
bandages, towels, or sheets.
   In fractures of the neck of the thigh,  and of that of 
201
the  humerus, we fix to  some  permanent object, the
band used for counter extension.
   To  effect the  coaptation, the surgeon applies both
hands on the fractured extremities, and brings them to
their place, taking care not to press the soft parts against
splinters of bone, which may project.
   The patient should be  placed  on a narrow bed; we
generally put the limb in  a semi-flexed position, espe-
cially  when  the fracture  is  oblique.   Absolute rest is
indispensable, and should  be continued until the perfect
consolidation of the fractured bones. This is commonly
from thirty-five to forty-five days  in  an adult, for the
thoractic extremities, excepting  the clavile,  and  from
forty to forty-five, for  the  inferior extremities.  The
fracture of the patella, requires about two months and
upwards; that of the neck of the femur, from eighty to
a hundred days.  After this time,  we should not allow
the limb to  be used at first, as  if  it had not  been
broken.
   To keep the fragments in apposition, we employ ban-
dages, which are varied  to suit the condition of circum-
stances.   We seldom employ a  roller in fractures of
long bones.   The eighteen tail bandage is preferable.
   When this is to be used, we require the following
articles;  1st. two or three  tapes; 2d. a splint cloth; 3d.
splints of different length and breadth; 4th. a large num-
ber of strips of muslin, (sufficiently  long to surround
the limb, and three or four inches broad) disposed trans-
versely, and partially covering  each other;  6th. com-
presses to envelop the  limb, which are commonly wet
with some styptic liquor,  such as a solution of sugar of
lead, unless the limb be very much inflamed.
   Besides these, we should always  have prepared a
number of small splints.
   Every two or three days, the dressing is to be renewed, 
202
without moving the limb,* examining carefully, whether
the fragments have remained in contact.
  Should  we find  that there is displacement  on one
side, we place a graduated compress, and if this suffices
to depress the projection,  we suspend  the compression.
If we cannot succeed in giving the limb its proper direc-
tion, it may be even necessary to remove the splint on
the opposite side.  In  this  way, we  often prevent
shortening of the limb.
  Should  we apply leeches to allay irritation, it should
never be over the points where the splints will press.
  When  fracture  is complicated  with  luxation,  we
should,  if possible, reduce  the  luxation' first, and  the
fracture subsequently; otherwise we wait for the perfect
consolidation of the fracture, and then reduce the luxa-
tion, taking care not to  reproduce the  fracture.
  If the ends of the bone project through the skin, and
are not  too much injured, we enlarge  the opening, and
reduce them.   Should  there be exostosis and necrosis,
&c. we  saw the ends of the fragments oft', and then re-
duce them.
  In case of free suppuration, we make a large incision
through the soft  parts, to extract the splinters with
forceps.
   There is  no  inconvenience from  waiting  for five or
six days, before attempting  the reduction, for the adhe-
sive process which unites the bones never  commences
before this  time, except in infants.    This reflection is
very important, as it shows the surgeon that he has full
time to combat the inflammation, before attempting the
reduction.

   * This must be restricted to cases of transverse fracture, and
 to  motion of the  limb immediately, at the  fractured part.
In  cases of oblique fracture, the limb is extended as much as
possible, at each dressing, inasmuch, as the tendency to retract
 is almost continually operating. 
203
  There is another mode of retaining the reduced frag-
ments,  known by the name  of permanent extension.
This method intended solely for fractures of the neck
of the thigh bone, and oblique  fractures, should never
be used, except in cases  in which the other means  are
insufficient.
  The following are the rules according to which this
operation should  be practised.
  1st.  To wait always until the. inflammation about the
fragments of the  bone is reduced.
  2d. To apply the extending and  counter-extending
power upon the superior and  inferior parts of the frac-
tured limb.
  3d. To have the action  of  the power parallel to the
axis of the fractured bone.
  5th. To graduate the extension.
  6th. To employ concurrently, the common bandage,
excepting the splints.*

  * A very great difference of opinion has long subsisted among
surgeons, relative  to the mode  in which counter-extension
should be made, and a very great variety of machines have been
invented for the purpose of accomplishing it.  At present,
the most  generally  used apparatus, is some modification of
Desault's splint, or of the inclined plane, which are found to
be capable of effecting all that can be expected from machinery,
without  the risk and expense which many of  the more re-
cent splints, kc. produce.  See Gibson's Surgery, vol. 1. 
^04
FRACTURES  OF BONES  IN  THE  SUPERIOR
            PARTS OF THE BODY.
 Fractures of the nasal Bones, and the nasal processes of
            the superior Maxillary Bone.

   Mode of reduction.—Introduce a pair of dressing for-
 ceps into the nostrils, raise the fragments with them, and
 coaptate  the fragments with the  fingers  of the  other
 hand.   To keep  the bones  in place,  introduce a quill
 barrel, or an ivory tube, open at both extremites, having
 around it, a sufficient quantity of lint, to fill the  cavity
 of the nostrils, and sustain the fragments.

               Fracture of the Vomer.

   Reduction.—Introduce the jaws of a pair of dressing
 forceps, or a female catheter into one of  the nostrils,
 and establish  a point of compression on  the  opposite
 side, and thus bring the fragments into place. To retain
 them, plug the nostrils, so as to prevent the fragments
 from being displaced to either side.

            Fractures of the lower Jaw.

   These are divided, 1st. into fractures of the body of
 the bone;  2d. into fractures of its rami; 3d. of the coro-
 noid apophysis; and 4th. of its condyles.
   When the body or rami of the bone are broken;
   Reduction.—Take hold of the inferior edge of the jaw,
 and pres.-. it against the upper jaw.  If we find this to
 be difficult, introduce the middle and fore finger of one
hand into  the mouth, between the dental arch and the
 cheeks, and thus  aid the movement-, of the other hand.
 Apply the two dental arches against each other; should
 the jaw be toothless on one  side,  we introduce a piece 
of metul or box wood, to fill up the place left vacant, by
the loss of the teeth. If only one or two teeth be wanting,
this circumstance will be advantageous, as it will allow
the passage of the introduction of the nozzle of a syringe,
or a tube,  to  convey fluid  aliment  into the  stomach.
To retain the parts in apposition, apply two compresses,
one upon the anterior surface of the  neck and the infe-
rior edge of the lower jaw, which  passing  upon  the
cheeks and temples, is fixed upon the sinciput, where
the two ends cross each other; the other upon  the ante-
rior surface of the chin, which  passing over the ears,
supported by lint, goes to be fixed  over the occiput.
These compresses being  fixed,  we  apply  the  chin
bandage.
  This apparatus is preferable to the  double head cover,
which produces painful pressure on the head.  If the
lower jaw be divided into several fragments, shape, ac-
cording to Lisfrano's direcljon, a piece of cork, so as
to resemble  the semicircle of the lower jaw, piercing it
with as  many holes as there are  teeth, to receive the
latter.  A loop of waxed thread embraces each of the
pieces of cork, which separate the holes from each other.
This apparatus being fixed upon the lower jaw, we pass
the threads between the  teeth, and tie them on  the
outside.
   We then  apply the head bandage, especially in  frac-
tures of the condyles and coronoid apophysis of the
lower jaw.  In the  last case, we should also carry the
lower jaw somewhat forward, in order to bring the  mid-
dle  fragment into contact with the  lateral  portions.
Absolute  silence,  and entire immobility  of  the lower
jaw should  be enjoined.*

  * Dr. John R. Barton has devised an ingenious bandage
for fractures of the lower jaw.  A delineation of this may be
seen in Gibson's Surgery, vol. 1.
                          9 
206
             Fracture of the Os Hyoidet,.

   Reduction.—Place upon the sides of the neckgradu-
ted compresses,  keep them in place by a bandage, so as
not toint rrupt the circulation of the blood.  The head
should be kept perfectly stilly

              Fracture of the Sternum.

   There may be either fracture of the xyphoid cartilage,
or of the sternum itself.   Bandages are not applied for
the first mentioned  fracture.  If this appendix be frac-
tured above its ba^e, apply  compresses upon its point,
to prevent it from projecting externally, sustained by a
body bandage.
   2d. For the fracture of the sternum itself: should the
transverse diameter be greater than the antero-poste-
rior diameter, apply a body  bandage, which acting more
especially in  the direction of the latter diameter, car-
ries the  sternum forward'.  If the transverse  be  less
than the antero-posterior diameter, augment the extent
of the first by the aid of graduated compresses placed
upon the sides of the chest. Then apply a body bandage.
If this be insufficient, place  graduated compresses over
the superior and inferior fragments, on which the body
bandage acts.

               Fracture of the Ribs.

   Reduction, §c—Increase  the antero-posterior diame-
ter of the chest,  by aid of graduated compresses placed
upon the anterior and posterior part of the chest. Apply
a bodv  bandage,  which presses particulary  upon these
compresses, from before backwards, and being strongly
drawn, forces the ends of the fragments to project out-
wards, which  will prevent them from compressing the 
2or
 thoracic viscera injuriously.  We may then place gra-
 duated compresses over the fracture, and above the first
 bandage, for fear that the fragments should project too
 much; we then apply a second bandage around  the body,
 a little less tightly drawn than the first; these compress-
 es placed over the first  bandage will not  force the frag-
 ments into  the  chest as if   they were applied  to  the
 naked skin.  This treatment is applicable to cases in
 which the  displacement is inwards or outwards.

               Fractures of the Spine.

  The merely mechanical means for the  relief of such
 fractures, are very inefficacious; the prognosis is always
 serious, because  it is impossible to replace the fragments
 without injuring the spinal marrow. ' However, the pa-
 tient  should be  placed in a recumbent position, and
 with proper precaution, to avoid the accident referred to.

             Fractures of the  Scapula

  Are divided into
  1st. Fractures of the  acromion.
  2d. Fracture of the coracoid apophysis.
  3d. Fracture of the neck of the scapula.
  4th. Fracture  of its inferior angle.
  5th. Fracture  of the body of  the bone.
  1 st. Fracture of the acromion. Reduction.-—Raise the
humerus, with the precaution of sustaining the external
 fragment of the  acromion by means of circular turns of
a bandage applied horizontally, and by ascending and
 descending  turns.  Fix  the  humerus thus raised, by a
 body  bandage,  which at the same time, goes round the
scapula, and keeps it fixed.
  2d. Fracture of the coracoid  apophysis.  Use  nearly
 ti?(  same means. 
:os
   3d. Fracture of the neck  of  the scapula.  This is
extremely rare.  Reduction, $c— Place a small wedge-
shaped cushion in the axilla; keep the humerus against
the body and a little forwards, by a bandage, which sur-
rounding the whole body, also confines the scapula.
  4th. Fracture of  the inferior angle of the bone.—Re-
duction.—Bring the lower fragment in front of the su-
perior, by carrying the arm  inwards and forwards, to
bring the body of the scapula to  its inferior angle,  from
which it is  sometimes detached, by moving  it slightly
forwards. To retain it, place  in front of the inferior
angle a graduated compress  which is to be retained by
a broad band, the  first turn of which is applied over the
inferior part of  the.  humerus, and  the circular turns
pass round the body in such a manner, that in their as-
cent they shall cover  about a third or the half of the
bivadth of each turn,  in succession. If it be judged ne-
cessary,  we  may employ another bandage to sustain the
limb, the first turn of which passes over the  extremity
of the elbow, and  which ascends obliquely  under the
arm-pit of the opposite side.   This bandage should not
be tight,  otherwise it  is very inconvenient.
  Fracture of the body of the bone. Reduction.—There
is little displacement  whether the fracture of the  bone
be oblique or transverse. To facilitate the consolidation,
it is sufficient to keep the arm and scapula at rest.  Ap-
ply  the  arm to the trunk by  means of a simple sling,
and  its  motion may be entirely prevented by passing a
turn or two of a roller around the body, going over the
arm.

              Fracture of the Clavicle.

  Reduction.—Carry  the shoulder outwards and a little
backwards, by applying one hand on the inside of the
arm,  and seizing with the other its inferior extremity. 
209
This fracture is difficult to be kept in place. A wedge-
shaped cushion with  its thick end upwards is placed
in the arm-pit; at its two superior angles two tapes are
fixed,  which are tied  upon the opposite shoulder.  To
prevent  the cushion from causing too  much irritation,
Mr. Dupuytren covers it with compresses spread with
cerate, and  fixes the lower  part of the  cushion with
turns of  a bandage passed several times around  the arm
and chest, ascending from the elbow toward the shoul-
ders.*

             Fractures  of the Humerus.

   They  are divided into fractures of  the  middle, and
fractures of the neck of the bone.
   1st. Fractures of the middle of the bone. Reduction—
When there is displacement, make extension and coun-
ter extension; to do this,  one or more assistants draw on
the lower part of the  fore-arm, first in the direction  of
the displaced fragments, while another.grasps the stump »
of the shoulder with  both hands, and keeps  it fixed.
The surgeon, placed on  the outside of the limb, applies
both his hands over the seat of the fracture, and when
he  feels that the riding of the fragments no longer ex-
ists, he directs the assistants to bring the limb straight,
presses on the  muscles,  and brings the  fragments toge-
ther as much as possible.
   To keep the fracture in apposition, the  roller is a bad
bandage  for two reasons; first, because it  imperfectly
reduces the parts, and secondly, because it is more dif-

  * From our author's silence relative  to Desault's bandage
for fractured clavicle, we might suppose that this bandage was
no longer employed as formerly in France.   For a description
of this bandage,  the reader is referred to Desault's surgery,
&o.—J.D.G.
 
210
ficult to remove the dressing without disturbing the limb.
First apply  a circular bandage from the head to the el-
bow  joint; arrived  there,  half flex, and place a pledget
of lint  in the fold of the fore-arm; continue the circular
bandage  upon the arm.  Havirtg reached  the fracture,
make three circular turns, and continue them to the up-
per part of  the arm.   This is  resorted to  to prevent
infiltration.   Should inflammation exist, it cannot be
employed.   Apply then  the  eighteen-tail  bandage;
dress the limb every four or five.days, and  if there be
no danger of displacing the fragments, dress it daily, in
order to examine the progress of the union.  The limb
should  be kept perfectly still.
  If the fracture be compound, the eighteen-tail bandage
is not employed.   We are  advised generally to apply
a roller bandage with few splints; on the contrary, we
should  apply a great number, that is to say, instead of
four  we employ eight, but shorter,  four above and four
below  the fracture; these  splints are fixed by means of
circular  turns of  a bandage; then we place four other
splints of twice the length, outside the  first.  In this
way  the wound is free, and  not in  contact with the
splints, which are thus  raised by means of  those placed
below.   We then fix the whole  by means of  new circu-
lar turns of the same bandage first used. The limb mustf
be kept entirely still.

   Fracture of the (surgical) neck of the Humerus*

   Reduction.—Ledran directs that a  conical cushion
should be placed in the axilla,  to compress the head of
the humerus, and  thus  prevent  its displacement: apply
the arm to the trunk, and retain it there by a bandage,
continued  from above downwards, around  the  breast
and arm. 
211
       Fractures of the Bones of the Fore-arm.

   These are divided into,
   1st. fractures of both bones at the same time.
   2d. fracture of the radius.
   3d.  ■   ■---of the ulna.
   4th.------ of the olecranon,
   1st. Fracture  of  both  bones at  once.  Reduction.—
Perform  extension  and counter-extension:  an assistant
takes the arm  with  both hands, to  make counter-exten-
sion; one or two other assistants take hold of the hand,
and make extension.  The surgeon, placed on the out-
side of the limb, applies both hands over the fractured
part, and coaptates  it.  To retain  the fragments in ap-
position,  place graduated compresses  on the anterior
and posterior  face of the  fore-arm, in  the  direction  of
the interstice of the two bones, to maintain them in their
natural position, and prevent their approximation. Place
upon  each of  the compresses a splint,  whose breadth
exceeds  the transverse diameter of the limb;  fix these
splints by means of turns of a bandage, which we begin,
by applying it  around the  fingers and wrist, continuing
the turns upwards  to the arm.  In passing  over the
fractured part, we make three turns; having arrived  at
the upper part, we descend, and after making three
other  turns over the fracture, we secure the bandage
with a pin.  The dressing should be  repeated every
two or three days; to see whether the fingers be in dan-
ger of gangrene, and examine whether the fragments
remain in apposition.   When  there is a wound at the
same  place as the fracture, as in cases of gun  shot
wound,  it is said, that splints are not to be used.   Mr.
Lisfranc advises, on the contrary, to place four com-
presses and four splints, two  above and two below the
wound,  so as  to leave it exposed.  By this method, the
two bones are preserved in a state of sufficient separa-
tion, and the wound is dressed with the greatest facility. 
212
   2d.  Fracture of the Radius.   The displacement cm
 not be considerable, the ulna being uninjured, and keep-
 ing the limb in a proper  direction.  It is to be reduced
 as in the foregoing fracture.  To retain it, we apply a
 bandage similar to that  used for the  fracture of both
 bones, when the fracture is situated towards the  middle
 of the limb, but if it be near the lower extremity, place,
 according  to the direction of  Mr. Dupuytren, at the
 union of the lower third, with the two upper thirds, a
 little cushion of a lengthened square  shape.  Place on
 the inside of the ulna, and above the other apparatus
 an  iron  splint,  longer than the  fore-arm, curved at
 one  of its extremities, having  five or six buttons or
 knobs.  Make then over the fingers, two circular turns
 with a bandage, whose ends are to be  fixed to the but-
 tons on  the  splint.  Should this  apparatus make the
 fragments project too much outwards, we reject  it,  and
 apply some circular turns around the fragments, if they
 ^end to separate from the ulna.
  3d.  Fracture of the Ulna.  Reduction.—The same as
 in fractures of both bones, and  for that of the  radius.
The same mode  of dressing as for fractured radius.  If
the splint of Dupuytren be used, it should be placed on
 the inner side of the radius.
  4th.  Fracture  of the Olecranon.  Reduction.—Extend
the  limb, and  bring the upper fragment  against  the
lower,  with the  thumb and fore finger of  the right or
left hand, according to the side  injured, taking care not
to Crinkle the skin too much, which covers the olecra-
non.  To maintain the apposition, apply  the  uniting
bandage for wounds.  To do this, one tail of  the bandage
is placed on the arm, so that of the three  tails  which
are left, one  of  tjjem shall be directed downwards; a
graduated compress  is placed  transversely above  the
superior fragment; we bring the tails over this compress,
to pass through the intervals of the inferior tails: then 
213
draw on them, to bring the fragments  into perfect con-
tact; they are then fixed by means of a bandage, of which
we make many circular turns around the limb, from the
extremity of the hand up to the superior part of the arm,
this method  serves  at the same time, to fix the first
bandages, and to prevent  infiltration.   We then place
a little^ cushion of lint in the  fold of the arm, and apply
a splint  on  the aBterior suiface of the limb, which is
fixed  by some turns of a bandage.  This  splint cannot
remain long applied, without exposing the patient to
danger of anchylosis, especially if inflammation exist.*

            Fracture of the  Carpal Bones.

  The principal means we can employ in fractures of
this kind, is the employment  of the antiphlogistic treat-
ment,  to combat inflammation.  If any  bone project,
and there be no  external  wound,  which can scarcely
happen, we may apply graduated compresses and splints
over them, to reduce the fragments. Amputation of the
part, commonly becomes our only remedy for  this frac-
ture, which must be generally comminated.

          Fractures of the Metacarpal Bones.

   Reduction.—Variable, according to  the nature of the
displacement;  should this be  from  before backward

  * Two cases of fracture of the olecranon have fallen under
my notice, in which the power of flexing the arm was lost, in
consequence of a change taking place in the skin and cellular
substance, over the fold and back  of the arm,  giving it some-
thing of the appearance, and almost the stiffness of a  piece of
hide, which has been deprived of its hair, and in a great degree
dried.  The practicioner, under whose charge the cases oc-
curred, long and fruitlessly endeavoured to remove  this condi-
tion, which was most probably owing to the peculiar splints,
&c. used  for the fracture.—J. D. G. 
:14
make extension and  counter  extension, coaptate the
fragments, and place a large splint on  the  dorsal  and
palmar surface of the hand, keeping them on  by aid of
a circular bandage.   If  the  displacement be  lateral,
place two narrow graduated  compresses in  the interos-
seous spaces, one on the palmar, the other on the dorsal
surface  of the hand,  so  that they shall rise to such a
level, that the antero-posterior exceeds the transverse
diameter of the hand.  Place the  splints over the com-
presses, and fix them  by  means of a band.  If the first
or the last metacarpals be fractured, and the fragments
displaced outwards; that  is, towards the radial or ulnar
edge, we apply a splint on these  edges, which we fix
by a bandage.


             Fractures of the Phalanges.

  If the fracture be comminuted, as is most common,
we  should amputate the part. If it be a simple fracture,
an assistant sustains the  hand, the surgeon  extends the
finger, and places the fragments in contact.  To keep
them together, make  some circular turns with a little
bandage around the  fractured  finger.   Place three or
four splints on this first  bandage, and  confine them by
means of circular turns of the first used bandage.  Ex-
tend the other fingers, whether fractured or not, make
several circular  turns around  them, to confine them to
the fractured one; this should at least be done with those
immediately nearest to the broken finger.  Where there
is bruising or crushing of the soft parts,  Mr. Dupuytren
employs successfully, very small bandages, to produce
the compression. 
215
FRACTURES OF THE LOWER EXTREMITIES


            Fractures of the Pelvic Bones.

   These are divided into
   1st. Fracture of the coccyx.
   2d.---------of the sacrum.
   3rd.---------of the ossailia.
   1st. Fracture of the coccyx. Reduction.—Place in the
rectum a gruduated  compress, or rather a compress in
form of a little sac, which we stuff with lint in order to
support the fragment.  Keep the patient on a slight diet,
in order that the frequency of evacuation  shall not re-
quire the removal of the compress. Absolute rest must
be enjoined.
   2d.  Fractures of the Sacrum. Reduction.—Afterusing
general and local  blood-letting to calm the irritation,
introduce the fore finger into the rectum,  and if possi-
ble, replace the fragments.  If we cannot reach them^
and the bladder or rectum be not dangerously irritated,
leave the parts as they may be, and wait for the conso-
lidation to take place.  But, should there be danger,'ex-
pose  one  of the  sides of the posterior face of  the sa-
crum, below the sacro iliac symphisis; apply the trephine,
and then the ball-screw,in order to raise the lower frag-
ment to its natural position; the upper one  cannot suf-
fer displacement.
   3rd. Fractures of the ossa ilia.—We divide these in-
to fracture of the anterior superior spine;  of the iliac
fossa;  the  horizontal portion of the pubis, and that of
the tuber  ischii.  Reduction, Sac.—If  the anterior su-
perior spine be  displaced,  which is rare, some gradua-
ted compresses secured by  a body  bandage, will be suf-
ficient to prevent the displacement.  In the fracture of 
                         216

 the iliac fossa, the  displacement cannot take place; we
 do nothing but apply a body bandage.
   If the  horizontal portion of the pubis be injured, in-
 troduce the  fore-finger into  the  anus or vagina, (with
 the precaution of making no pressure against the splint-
 ers, should there be any, for fear of producing lacera-
 tions) and replace the fragments. But this not succeed-
 ing, should the bladder and surrounding parts be not too
 much irritated, we allow the fragments to become conso-
 lidated without reduction.  In the contrary case, expose
 the bone, apply the trephine and screw to bring the part's
 to  their natural situations; apply a bandage round  the
 body, and enjoin absolute rest.
   In fractures of the  tubera ischii, we employ the unit-
 ing bandage.
   Fractures of the small bones of the feet are ordinarily
 comminuted, and often require amputation of the limb;
 otherwise they  are to  be treated nearly as the fractures
 of the hand.


             Fractures of the Tliigh Bone.

  Reduction.—Two assistants take  hold of the foot
 with  both hands, or by  means  of  a towel, and make
 extension; two  other assistants make counter extension
 from the pelvis.  The  surgeon, standing on the outside
 of the limb, sustains it, and coaptates the fragments.
  To keep the  fracture in this condition, apply an eigh-
 teen-tail bandage;  place the limb in a half-flexed posi-
 tion,  to relax the muscles; apply compresses over  the
 fragments  on  the side where they are disposed to be-
 come displaced, and  secure  them by  some turns of a
bandage.  Should one of the fragments project into  the
ham, pltce a thick graduated compress, and apply over
this, which extends from the lower part of the joint ex- 
217
tends five or six inches above the fracture.  When tin-
great  trochanter is fractured, we place the thigh in a
state of abduction; to bring the inferior  fragment in
contact with the superior, apply the uniting bandage as
directed for fractures of the olecranon.  The patient
must be kept perfectly still.

        Fractures  of  the neck of  Thigh bone.

   Reduction.—.The patient lying  in bed, the surgeon
passes his right or left  arm, according to the side in-
jured, under the ham, raises the thigh to a state of se-
mi-flexion, and  extends  it to bring the fragments into
contact.   But  the  coaptation is speedily displaced, un-
less we make  permanent extension; for this we do not
employ the more or less murderous machines used for
this purpose.  Mr.  Dupuytren  contents himself with
placing the  limb in a semi-flexed  position.*  For this
purpose, we place  cushions  under  the  ham, raise the
thigh, and lower the leg.   We fix the limb in this posi-
tion, by applying on the leg a cloth folded like a cravat,
the two ends  of which should  be fixed  to the sides of
the bed.   From time to time,  the limb is  gently extend-
ed, to bring the fragments into contact, because they are
again easily displaced. The  patient is  kept in this po-

  * This treatment differs very little from that recommended
by the celebiated Pott, which has been very generally relin-
quished Although the machines in use are commonly imperfect,
the chance of having the fracture consolidated without deformi-
ty is much greater, from  the judicious application of a splint,
tban when  the limb is exposed to the danger of being displaced
by the slightest movement  of the patient.   With the most
improved  modification of Desault's splint,  and the use of
Coates's fracture bedstead, as employed in the Pennsylvania
Hospital, few cases of marked deformity will occur even after
•he roost oblique fractures.—J. D. G. 
J18
 sition from sixty to an  hundred day-., according to hi*
 age, and he should not walk  on it for many days aftei
 he has risen from bed.

               Fracture of the Patella.

   Reduction, <S"c.—Apply  the uniting bandage, as indi-
 cated   when  speaking  of fractures  of  the  olecranon.
 Extend the limb perfectly, to bring the  fragments  into
 contact.  To do this, lay the leg and thigh on a plane,
 inclined  from the feet  towards the trunk, so that the
 limb thus raised  forms, with the axis of the  body, an
 angle of about 45°.   The patient remains in this posi-
 tion from sixty to eighty days.
   This apparatus is intended for the transverse  fracture;
 should  it be longitudinal, which is exceedingly  rare, the
 treatment would be very much more simple.  It would
 be sufficient to keep tho limb in a state of extension,
 and at rest, upon its posterior surface, and  to place a
 graduated compress  on each side  of the fragments,
 which  are secured by means of a bandage.


                Fractures of the Leg.

  These are divided into
  1st.  Fractures of both bones at once.
  2d.  Fracture of the tibia.
  3rd.  Fracture of the fibula.
  1st.  Fracture of both bones at once. Reduction.__One
or two assi-tunts take hold of  the foot with both hands,
and  extend it; another  assistant  fixes the  pelvis, and'
makes  counter extension; the surgeon, standing on the
outside of the limb, coaptates  the fragments, by apply-
ing one hand on each  end of the fragments.  An appa-
• a,is is applied, similar to that pointed out for fracture.- 
219
of the tingh, except  that the splint which comes up
above  the  knee should descend  below the sole of the
toot.   A little  bandage, whose  first turn passes under
the sole of the foot,  is brought up, crossed over  the
incle, and  fixed by each of its ends  to the sides of the
-.prints.  By this the foot is kept motionless.  Place the
'imb in a state  of semi-flexion, as Dupuytren directs,
which is much preferable to permanent  extension, as
most authors advise.
  To  give the  limb the semi-flexed position, the leg is
laid upon its posterior surface, beneath which some pil-
'owsare placed.
  Two cloths  folded  like a  cravat, are passed, one
aroulid the upper, and the other around the lower part
of the limb, and are fixed  to the sides of the bed.
  When the fracture is oblique, the displacement of the
fragments will  much more readily happen: in this case,
we make use of small splints and graduated compress-
es to  keep the fragments in place, as was indicated
when speaking  of fractures in general.
  2d.  Fractures of the tibia. Reduction.—In general,
the same as in  fractures of both bones at  once.  If we
tear  the  displacement towards the interosseous space,
wc place over it some graduated compresses, as has been
mentioned in fractures of the fore-arm.  Other displace-
ments, which occur in spite of the ordinary dressing,
should be remedied by the application  of small splints
and graduated  compresses.  If there be a fracture of
the ancle, apply a graduated compress upon the inferior
fragment, then  a figure of 8 bandage;  place over this
dressing  a  hollowed splint, which embraces the inferior
extremity of the leg and superior surface of the foot; fix
this hollow splintby means of some circular turns ofban-
dage, or by  straps and  buckles. Examine the limb, from
time to time, to ascertain  whether the fragments are in
contact.
  ^rd. Fractures of the fibula. Reduction.—Extension 
:•<•)
 .ind counter-extension is not necessary.  Depress the ex-
 ternal ancle, if there be any separation, and bring it to
  he  natural  distance  from  the  internal one, by giving
 the inferior fragment a motion opposite to that by which
 it passed outwards.   Continue to keep  the parts re-
 duced„by using the common eighteen-tail bandage, with
 this  difference, that we dispose the  splints in  such  a
 manner that one  extends beyond the external edge of
 the foot, and pushes  this  part strongly inwards, by
 means of more than the ordinary  quantity of padding,
 while the other does not go  beyond  the internal ancle.
  The patient keeps this dressing on from thirty-five to
 forty days; at  the end of this time a roller bandage is
 substituted for it during some days.

             Fracture of the Os Calcis.

  Reduction, Sfc.—Apply the  uniting bandage as here-
 tofore  directed, extend the  foot by means of a slightly
curved  splint,  fixed upon  the anterior  part of the leg
and foot, the Ug being in a state of semi-flexion.  The
muscles of the calf of the leg are compressed by  the
turns of a bandage, which secure the superior extremity
of an uniting bandage. By this mode  the two fragments
remain in contact,  and the consolidation  may be expect-
ed about the fortieth or fiftieth day.
LUXATIONS.
  Luxation is  the displacement  of contiguous osseous
surfaces.
  The indications to be  fulfilled  in  cases of this kind,
am to reduce the luxation, preserve the parts, in place, 
221
guard against accidents, and combat  them when  they
have supervened.
  We shall  successively describe, in  a very succint
maimer,  the  manual treatment necessary in cases of
luxation.


         luxations op  the superior joints.

             Luxation  of the lower Jaw.

  Reduction.—Seat the  patient on a chair, and lean his
head against  the breast  of an  assistant.  The surgeon
wraps his thumbs with some linen, and  places them as
far back  as possible,  upon the  last molar teeth,  and at
the same time, he grasps the jaw with the fingers flexed
under the chin.  He brings the bone downwards, by
pressing with the thumbs on the molar teeth, carries it
backwards, to disengage the condyles,  and raises the
chin with his other fingers.  At the moment this is ac-
complished, he slips his thumbs between the teeth .and
check, in order to avoid being bitten, in consequence
of the sudden and violent action of the musles, bringing
the condyles into the glenoid cavity.
   The jaw should be confined  for a few days, by means
of a bandage, and the patient should for some time, ab-
stain from the use of food, which requires mastication.


   Luxation  of the oblique processes of the Vertebra?.

   Such  luxations should  not  be  reduced; the patient
had better  be allowed  to  remain slightly deformed.
rather than endanger his life, by attempting the reduc-
tion.
t 2 
■:2i2
                Luxation of the Rib*.

   Luxations of cither extremities of the ribs are so rare,
 i hat they have been doubted by numerous authors.  Some-
 times a displacement of the  cartilages of certain ribs,
 in this case, the reduction is extremely easy. The car-
 tilage  is slightly compressed, which  makes it project
 exteriorly.   If some  difficulty be experienced, we draw
 the trunk somewhat  backward.  A bandage is then ap-
 plied round the body, and the patient kept at rest.

             Luxations of the Clavicle.

  These are divided into luxation of the  sternal and
 luxation of the humeral extremity of the clavicle.
  1st.  Luxation of the sternal extremity.  Reduction.—
 The patient is  seated, and his body kept steady by an
assistant; the surgeon stands on the side of the luxation,
and places one hand  on the internal superior part of the
arm, and the other on the external inferior part;  push-
 ing then this latter part towards the  trunk, while he
moves the upper part outwards, he changes the  hume-
 rus into a lever of the first kind, which brings the cla-
\icle to its natural situation, by a mechanism similar to
 that by which we reduce a fracture of this  bone.  To
retain the bone  in place, we use  the bandage employed
lor fractures of the clavicle.
  2d.  Luxation of the humeral extremity.  Reduction.__
Carry the shoulder outwards, and  raise  it upwards, by
  suitable movement  of the arm, press over the humeral
extremity of the clavicle, to adapt it to the internal and
superior part of the acromion.
  This dislocation is as easily reproduced as replaced.
To retain the bone in its situation, apply the bandage
for  fractured clavicle, modified  so, that after  havin<r 
223
placed long find thick compresses over the humeral ex-
tremity of the clavicle, we carry the turns of the bandage,
which pass under the  elbow, over the shoulder of the
luxated side, and then over the opposite one.

              Luxation of the Humerus.

  Reduction.—Place in the hollow of the axilla, a cushion
stuffed with hair or wool, of a rounded form, and suffi-
ciently large, that the band employed for counter exten-
sion, shall not compress the tendons of the  pectoralis
major, latissimus dorsi,  &c.  too much.  The  band  is
made with a double napkin, passing one end behind the
shoulder, and the other in front of the clavicle; this is
to be secured to some fixed  point.   A towel folded
diagonally, is passed  round the wrist, and a number of
assistants are directed.to pull by it, proportioned to the
strength of the  individual.  The patient being seated,
the surgeon,  placed  on the outside of the arm, orders
the extension, which should be first made in the direc-
tion which the bone  has taken;  and  when  the surgeon
feels the bone yield  to the efforts,  he guides the bone
into its place, at the  same moment that he makes a sig-
nal to the assistants, to bring the limb to its  natural
position.  To keep it in place* fix the humerus  against
the trunk, by means of some turns of bandage near the
ulnar extremity of the arm, around the body, and  if
deemed necessary, we may place a cushion in the axilla.

             Luxations  of the Fore-nrm.

  These may be divided into, 1st. luxations common  to
both radius  and ulna: these are luxations  of the fore-
arm, properly so  called.  2d. Luxations of the superior
extremities of the radius. 3d. Luxations of  the inferior
extremity of the ulna. 
524
   1st.  Luxation common to the radius and ulna.   Re-
duction.—In the luxation backwards, in which the ole-
cranon ascends behind  the  humerus, an assistant  lay*
hold of the arm, and makes counter extension; another
takes hold of the wrist, and makes  extension, the sur-
geon grasps the elbow with both hands, so  that the fore
fingers of each, puss upon the inferior extremity of
the humerus, while he brings down  the olecranon with
the thumbs.   To maintain the  reduction, place the arm
simply in a slin^, first surrounding it as well as the
hand, with a  roller,  in order  to  prevent wdematous
swelling of these parts.  At the end of seven or  eight
days, when the swelling has ceased, make  slight move-
ments of the joint, in order to prevent anchylosis.
   As the luxation forwards necessarily supposes a frac-
ture of the olecranon, it does  not require a treatment
different  from  what  was  directed  for  fracture of the
olecranon.
   2d. Luxation of the superior extremity of the radius.
Reduction.—When the displacement is backwards, as
is mostcommon.the surgeon takes hold of the elbow with
one hand, and with the other the hand of  the patient,
which brings it towards a state of supination, at the  same
time that he presses from behind forward, on the luxated
extremity.   If the displacement is forward,  we  move
the hand in the opposite direction, while with the thumb,
we press from before  backward, on the superior extre-
mity of the radius.   Place the arm in a sling,  after
having surrounded it with a roller bandage, in order to
prevent oedema, and keep  the two bones in contact.
   3d. Luxation  of the inferior extremity  of  the  ulna.
Reduction.—The patient being  seated, and  the arm sus-
tained  by two assistants,  the  surgeon,  placed on the
outside of the limb, grasps the lower pTirt with both
hands, one of which is placed  on the  ulnar, and the
other on the radial surface, so that the two thumbs may be 
225
supported in the interval  of the two bones, on the side
of the displacement, and that the four other fingers may-
be placed over the opposite point. He then makes efforts,
as for the separation of the two bones from each other,
and directs the assistant,  who holds the hand, to move
it in the direction of supination, if the luxation be back-
ward,  and in that of pronation, if the luxation be for-
wards.  To retain the parts in place, use the same means
as in luxations of the radius from the ulna.

               Luxation of the Wrist.

  Reduction.—An assistant grasps the upper part  of
the fore-arm with both  hands, and makes counter-exten-
siOn; another assistant  grasps  the  metacarpus, and ex-
tends the wrist. As soon as the surgeon perceives that
the wrist yields to the extension, he pushes  with  both
hands  the convexity of the displaced  carpus towards
its place, and directs the assistant, who holds the hand,
to move it in a direction opposite to that which occurred
at the time of luxation.  To  retain it  in  place, if the
luxation be lateral, it is sufficient to surround the joint
with long compresses,  dipped  in some refrigerant solu-
tion, and retain them by aid of a roller.  But when we
have a case of luxation backwards or forwards, it is ne-
cessary to place two long compresses and two  wooden
splints, one anteriorly, and the other posteriorly, retain-
ing them with  a roller.


            Luxation  of the  Os Magnum.

   The os magnum is more subject to luxation  than  all
 the other bones Of the carpus.  The head of this bone may
 oscape from the cavity, formed for it by the scaphoides 
kl6
 and  lunare which receive it. Reduction.—Make a slight
 pressure upon the  head of the os magnum, which pro-
 jects on the  back of the hand.   To  retain it  in place,
 keep the hand in  permanent extension, by means of a
 wooden  splint, placed  in the palm, compress the pro-
 jecting  bone, by applying a graduated compress, on
 which we apply a small splint, held in place, by a roller
 bandage, surrounding the whole dressing.

           Luxation of the Metacarpal Bones.

    With the exception of the first metacarpal bone, which
. is solely articulated with the trapezius, the other meta-
 carpal bones, are so little exposed to external bodies, as
 scarcely to be susceptible of luxation.  Reduction.—An
 assistant draws by the thumb, while the  other fixes the
 hand, by acting upon the inferior part of the  fore-arm.
 The surgeon acts with his thumbs upon the superior ex-
 tremity of the luxated bone, and makes it re-enter the
 socket, whence it has escaped. To  retain it in  its place,
 surround the wrist with compresses, soaked in a refrige-
 rating fluid, secured by a roller bandage. Place  along the
 posterior part of the bone a compress, and over that a
 wooden splint,  which  is fixed by the remainder of the
 bandage.  If inflammation be present, we first reduce
 it by the antiphologistic treatment, and  then apply the
 bandage, &c.

              Luxation of the Phalanges.

    The first phalanges of the fingers being all articulated
 with  the metacarpal bones by  means of  arthrodia, or
 ball and socket,  and the other phalanges with each other
 by means of ginglymus or hinge, it will  be sufficient to
 describe  the treatment for one  of  these  luxations, to 
227
explain how the others should be treated.  Let us take,
is an example, the luxation of  the first phalanx of the
thumb. Reduction.—-An assistant takes holds with both
hands of the lower part of the fore-arm to make counter-
extension, while another assistant draws upon the thumb
to extend it, the  surgeon presses with his two thumbs
upon  the base of the phalanx,  and  pushes it forwards
and  downwards,  while  the  assistant, who draws upon
the thumb, brings it towards the flexed position.  When
the reduction is difficult,* we place a  pulley  upon it to
produce the extension.  When  it is  reduced, the same
mode of retaining  it in place may  be  resorted to as
those indicated in  the preceding article.
LUXATIONS OF THE INFERIOR EXTREMITIES
              Luxations of the Femur.

  This luxation may occur  in four different directions:
1st. upwards and outwards; 2d. upwards and forwards;
3rd. downwards and inwards: 4th. downwards and back-
wards. Reduction.—This is  nearly the same in all four
species. Place in the fold of the thigh on the sound side a

  * The luxation of the first phalanx of the thumb from the me-
tacarpal bone is always difficult of reduction, in consequence
of the situation of its lateral ligaments, and the large segment
of a circle it must describe on account of the projection of the
extremity nearest the palm, before it can he restored to its
place. It may occasionally be found nei.essary to divide a part
or the whole of the lateral ligament, in order to reduce the dis-
location- In Charlks Ei.ll's Operative Sur£«r», a very good
diagram is g;\en to show the nature of the obstacles here  al-
luded to.—J  P. G. 
228
counter extending band made with a doubled sheet, and
still better, place this  band over a cushion stuffed with
chaff, wool, or hair, nearly as we have stated in luxations
of the humerus.  Let several assistants lay hold of this
band,or fix it to some permanent object. Apply transverse-
ly, a second band made in the same manner over the crest
of the ilium on the side of the luxation; bring the ends
of this band  over the sound side, and let them be held
by assistants in order to prevent the pelvis moving to-
wards the injured side.  A greater or less number of
assistants make extension, by drawing first in the actual
direction  of the  limb, by means of  a napkin  folded
lengthwise, and applied around  the lower part of  the
leg.   The surgeon,  placed  on the outside of the limb,
presses upon  the great  trochanter, or  the  projection
formed by the head of the luxated bone, to direct it,
at the same  time that he  directs  the assistants who
are making the extension, to bring the limb into  its  na-
tural direction.   To maintain the limb in place, bring
the two thighs together, and keep  them in this  condi-
tion by means of circular turns of bandage placed just
above the. knees.  Keep the patient quiet for some days,
until  the  ligaments  have become united  after having
been ruptured, which almost always happens, except in
luxations downwards and inwards.*

  * The reader, who wishes to study the subject of fractures
and luxations to advantage, will find in Sir Astley Cooper's
work on the subject most ample descriptions of the varieties of
these accidents, and the necessary treatment.  Among other
things, this very  experienced surgeon proves  clearly  the
vast superiority and manageableness of pullejs as means of
extension over the manual exertions of assistants, who from
want of concert or of  patience, not unfrequently cause unne-
cessary delay and suffering.—J. D. G. 
(
                         229

              Luxation of the  Patella.

   Authors admit of luxations of the patella in four dif-
 ferent directions: upwards,  downwards, outwards, and
 inwards;  but the two first not  constituting a luxation
 properly  so  called,  we only treat of the luxations out-
 wards and inwards.
   Reduction.—Extend the leg  strongly on the  thigh;
 which should itself be flexed on the pelvis to bring the
 tendon containing the patella into  a  state of relaxation,
 then push the bone inwards or  outwards, according to
 the direction of the  luxation.  To  keep it in place, the
 limb should  remain extended; surround the knee with
 compresses squeezed out of some cooling fluid, applying
 a roller to retain them.
   The patient should for some time remain in bed.

     Luxation of the upper extremity  of the Tibia.

   Reduction.—In whatever  direction  the head of the
 tibia has  abandoned its relations with the tibia, we re-
 duce it in the following manner: an assistant takes hold
 of the lower part of the  thigh with  both hands, and
 makes counter-extension;  one  or  more assistants take
 hold of the lower part of the leg in the same manner,
 and  make extension, according  to the direction the dis-
 placement has given  to the limb. Thesurgeon, placed on
 the outside of the limb, grasps the condyles of the femur
 with one hand, and the upper extremity of the tibia with
 the other,  to make the reduction,  until he judges* that the
 extension is sufficient, and directs  at the same time the
 assistants who perform it to bring  lie leg to its natural
position.   After reduction, surround the knee with com-
 presses soaked in a refrigerant fluid; secure them by the
aid of a roller, and keep the limb extended. Should a re-
                          u 
                         230

currence of the luxation be feared, we apply the appa-
ratus  indicated for fracture of  the thigh.  It is not un-
common that injuries of this joint make it necessary  to
amputate the thigh.

              Luxation of the Fibula.

  Luxations of either the upper or lower extremities of
this bone are extremely rare,  as  they are more easily
fractured than luxated. To reduce them, it will suffice to
push the superior  extremity  of the tibia in a  direction
contrary to the displacement, and bring  the foot at the
same  time to its natural position.  To retain it thus,
we place  graduated compresses  on the  luxated side,
which are retained by a roller bandage.

               Luxation of the Foot,

   The luxation of the astragalus happens most frequent-
ly of all the displacements of the bones of the foot.  It
may take place inwards and outwards, backwards and
forwards.  The first is the  most frequent of all.  The
treatment  is very nearly  the  same in all the species.
Reduction.—The  patient lies on his belly; an assistant
takes hold  of the lower part of the leg with both hands,
to make counter-extension.   The  surgeon, standing on
the inside of the limb, grasps the lower part of the leg
near the ancles with one hand, while with the  other he
guides the  displaced bone into  its  cavity  as  soon as he
perceives that the ligaments and tendons yield  to the
extending  efforts, which ought first to be made in the
direction given  to the  limb by the dislocation, and  af-
terwards in the natural direction.
   After effecting  the reduction, surround the joints with
long  compresses soaked in some  cooling  fluid, and  re- 
231
tain them  by means of a roller bandage, applied in a
figure  of 8.  We  then  apply cushions of straw, and
splints along side of the limb, and fix them nearly as is
done in fractures of the leg, in order to keep the foot in
its natural  position.  Absolute rest should be continued
during several weeks.
  When the astragalus is luxated from the os calcis and
scaphoides at the same time as from the bones of the
leg, and is  thrown out so as to hang to the neighbouring
parts only  by a  few ligamentous fibres,  we should cut
them and extract the bone entirely, which we do by the
point of the bistoury or  with the  scissors.  We then
dress the wound,  and the bones gradually approaching
the os calcis, become united to that bone, and the patient
may recover although without being able to move the
foot on the ancle.
  When the astragalus  projects  through the  lacerated
integuments, oris so constricted by them, as to prevent
its reduction, we should enlarge the opening by an in-
cision,  to remove  the stricture, after which,  the bone
may be returned with sufficient facility.
  When other bones of the feet are dislocated, which
is infinitely rare, we should treat the accident nearly as
we  have directed, in case of luxations^of the carpus,
metacarpus, and phalanges.
RICHERAND'S OPERATION  ON THE RIBS, &c.

  Surgery is indebted to Professor Richf.rano for the
first essay, made to  perform this daring  and brilliant
operation: it was successful in the hands of this skilful
• urncon, and though the patient did  not  survive a long 
                        tig a

time, this accident should by no means, be regarded as
resulting from the operation, but from the reproduction
of the cancerous affection under which  the patient had
suffered.  We« quote the author's description of this
operation; and leave  it to the genius of the surgeon to
seize the particular indications in analogous cases.
  " Every thing being prepared—I laid bare the sixth
rib,  for about four inches of  its  length, with a  probe
pointed bistoury, the point of which I carried along the
superior and inferior edges of  the sixth  rib, cutting the
intercostal muscles; then I sawed through the bone, at
the two extremities of  the diseased  part, with a saw,
whose toothed portion was not more  than fifteen lines
long; when this was done, I detached the fragment thus
insulated from the pleura, by using a simple spatula. The
9eventh rib was laid bare, to the same extent, insulated
and  detached in the same manner,  but with greater
difficulty, and not without slight laceration. The pleura
then appeared evidently diseased, thickened  and fun-
gous.  Not to have excised it, would  have been to leave
the  operation incomplete, which had  lasted twenty
minutes.  Each of the assistants were prepared to ar-
rest the dangerous hemorrhage which  was to  be feared,
at the moment when  the intercostal  arteries were cut.
I cut out the portion of the pleura with scissors, curved
edgewise, and whether the section produced by this in-
strument, which cuts  less by sawing than by  pressing,
and bruises the textures it divides, produced the retrac-
tion  of the vessels,  or whether their  calibers had been
divided, in consequence of the antecedent cauterising,
not a drop of blood flowed.  But at  this  moment, the
external air rushed  into  the  chest with violence, and
compressing the left lung, which with the heart,  enve-
loped in the pericardium, was carried towards the open-
ing.   I  attempted, by applying my hand, to  moderate
the entry of the air, and  prevent suffocation,  which ap- 
233
peared imminent, while with  the right hand, I applied
over the  wound, a large cloth, spread with cerate.  The
entrance of the  air Mas  suddenly suspended by this
greased cloth, which  not  only covered  the wound, but
all the corresponding side of the chest.  Over this, I
placed a large thick pledget of lint, covered it with some
pieces of linen, and kept  on the whole  dressing by a
roller bandage,  moderately tightened,"  The patient
went into the country, on  the twenty-seventh day after
the operation.
u2 
 
APPENDIX,
                   CONTAINING


SOME OF THE LESS  IMPORTANT SURGICAL
                  OPERATIONS.
               Extraction of Teeth.

  1st.  Extraction of incision  and canine Teeth with
the forceps.  The patient being seated on a solid chair,
with a raised back, slightly curved outwards, the ope-
rator holding a straight  forcep in his right hand, seizes
the  tooth he wishes to extract, on a level with its neck,
without injuring  the gum.  He should not press too
hard for fear of breaking the tooth.  He then rotates his
hand slightly from right to left, to  loosen jthe tooth, and
withdraws it perpendicularly, to finish the extraction.
  2d. Extraction of the large and small grinders with
Garengeofs key,  or the  pullikins.  The patient is placed
as above directed, the operator, placed in front of him,
holds the instrument between the middle and index fin-
ger of the right hand, so that the handle of the instru-
ment shall be totally seized with the palm of the hand.
He introduces the key into the patient's mouth, and ap-
plies the extremity of the fang, which should be propor-
tioned to the size of the tooth, on its internal surface,
near the gum, and the  fulcrum covered with a piece of
linen or leather, on the  outside of the gum, opposite the 
23G
extremity of the root of the tooth.  If it be an  upper
tooth, the operator keeps the fang in place, with the
thumb of the left hand;  should it be  a lower  tooth,
he fixes the fang with the  fore finger of that hand.  He
then gives the key a half turn  from within  outwards,
and finishes by extracting the tooth in a perpendicular
direction.  If the tooth be only loosened, the extraction
is completed, by using straight or curved forceps.  When
the last molars are to be extracted, it will be better to
have the fulcrum on the inside, and turn the  tooth from
without inwards.  When there are adhesions, they should
be destroyed with a  cutting instrument.
  The mode of holding the  key varies according to the
teeth to  be  extracted.   Thus  we supinate the hand in
extracting the lower molars, on the right side  of the jaw,
and pronate it, when removing one on the left side. To
extract an upper tooth on  tlie right side, we move the
hand in  the same manner as for the lower teeth  of the
left side, and vice versa on the opposite side.
  When the grinders are  loose, and their roots appear
neither very large nor divergent, we extract  them with
curved  forceps.  For this purpose, we  lay hold of the
tooth, bearing with the thumb or fore finger  of the left
hand, on the back of the jaws of the  forceps; we care-
fully loosen the tooth, and finish by extracting it perpen-
dicularly. To operate on the left side, we should stand
in front of the patient—to operate on the right side,
stand on that side.   This instrument  has the triple ad-
vantage of being less painful, not breaking the alveoles,
nor wounding the gums.
  3d. Extraction of the roots of the Teeth.  According
to their length and degree of adhesion, we extract them
with a  key, whose fang is sharper than that used when
the tooth is entire.  We use the  grooved punch to raise
the root, and then extract it with the pullikins, or with
straight or crooked forceps, as  the case may require. In 
<v
257
*ome cases, we are obliged to cut through the gums, to
expose the roots of the teeth, and sometimes to remove
the external surface of the alveole.
   When  there is much hemorrhage, we check it, by
plugging with lint or agaric, soaked in some astringent
fluid; or  better still, with a ball of  softened wax,  or
even with the actual cautery, should other means fail.
   As dentists are generally consulted for other opera-
tions, such as filing, plugging, setting artificial teeth, &c.
and  moreover, as what we  could say on the subject
would be necessarily too concise, we must refer to books,
professedly on dentistry, for farther information on the
subject.

             Removal of the Nails,  <§fc.

   Different methods have been proposed to remedy the
affection,  known  as the nail growing into the flesh.
We shall  present the modes most commonly employed.
   Dupuytren"s method.  The patient  being seated  on a
chair or upon the edge of a  bed, the surgeon,  sits in
front of him, and takes the patient's foot upon his knee;
he then takes a pair of straight strong scissors, introdu-
ces the pointed blade underneath the nail, and passes it
rapidly, from  the outer edge to the middle of the base
of^the nail, dividing it from before backwards, in two
equal parts.  Then taking hold, with the dissecting for-
ceps, of the interior edge of the diseased portion, he raises
it, turns it over, and  pulls it entirely away, after having
destroyed  its adhesions:  he  then applies the actual
cautery, at a white heat, to consume  the fungous flesh*
which surrounds the ulcer, when the quantity is great.
   Another mode  of removing the  Nails.  When we
wish to remove the whole nail, it may be done in two
ways; by raising it all at once, or by dividing it into two
equal parts, which are to be successively removed. Which- 
238
ever method be preferred,  an incision  should be made
behind the root of the nail, to destroy its matrix, which
without this precaution, may give origin to a new nail,
after the first has fallen off.  To make this incision, we
lay hold of the extremity of the great, or another toe,
between the thumb and fore finger of the  left hand:
holding a  bistoury in the third  position with the right,
we make a semi-lunar incision with a posterior convexity*,
upon the  dorsal  suiface of  the great toe, about a line
behind the loose edge  of the skin covering the base of
the nail.  We then take  hold of this by its  anterior
edge, with dissecting  forceps,  and  turn  it over on its
base.  If  we prefer to divide the nail into  two equal
parts,  after Dupuytren's mode, we  remove  the  two
pieces  sucessively, after having  acted as in  the  first
instance.
   Ambrose Fares' method, commonly attributed to more
modern practitioners.  This consists in  cutting off, on
the level  of the  nail,  the soft parts which cover it, by
thrusting a straight bistoury through, near their base, and
cutting from  before backwards,  we turn the  blade to
the opposite side, and  finish by cutting off the flap. We
then use  the  actual cautery.  This method has  been
often successful  in the hands of Messrs.  Brachet and
Lisfranc
   Mr.  Faye's method.   This consits in thinning as much
 as possible, the back of the nail, in the direction  of  its
 length, by scraping it with  the edge  of  a keen instru-
 ment.  We then  make with the scissors  a V shaped
 incision,  to remove a part of the free edge of the nail; in
 the middle, if the disease  exist on  both sides, and
 nearest the diseased side, if but on one.   When this is
 done, we pierce the nail  on each side of the incision,
 near its  anterior extremity, and pass through each of
 the small holes, a small wire, the two ends  of  which
 are united, to twist them  together,  in order to approxi 
239
mate the two edges of the incision, and by this, to with-
draw the side of the nail growing into the  flesh.   The
twisting is daily increased a little, and the desired effect
is gradually obtained.  Mr. Faye, a naval surgeon, em-
ploys this method with great  success; when it is  practi-
cable,  it  has the  additional advantage  of saving the
patient from the horrible pain, inseparable from tearing
oft'the nail.*.
   At  the same  time that  we employ this method, we
may apply  a small  bandage, whose fiist turn  passes
over the free edge of the nail, and with which we make
several light turns around the end  of the toe,  to  com-
press the  soft  parts which raise up at  the side of the
nail,  after  having placed over  the  projecting portions,
 small rolls of lint. When the disease is not very far ad-
 vanced, and is on the outside,  it often  suffices, to cure
 the affection, if the toe be kept apart by a  small roll of
 lint, or a piece of linen folded  up several times, which
 may  be  secured  by some turns of a bandage passed
 around the great toe.
   Desault's mode.  This consists in passing under the
 nail, a thin plate of tin, or rather of lead, as Professor
 Richerand advises, and to  bend it lengthwise  towards
 the lower part of  the  toe, to depress the  soft  parts

   * In all cases, the " horrible  pain" of dragging off the nail
 mav be avoided,  by the following  method, which I have used
 with  the most satisfactory results.   With  a very keen knife,
 cut perpendicularly through the middle of the whole length of
 the nail, by removing small  sbavings at each stroke.  When
 the nail is entirely divided in the  middle, take a very  Darrow
 bladed knife (such a* the iris  knife of the ocular case) and
 gradually cut under the segment  of the nail, so as to  detach
  it from the soft parts, letting the edge of the knife  always be
  directed upwards, or towards the nail.  In this way, by a little
  patience, the whole  nail ma\ be removed,  if necessary, with-
  out giving the patient very perceptible pain.—J. D. G. 
240
 placed below it.  A small bandage serves to keep it in
 place, and the dressing is renewed every two or three
 days.  This method has fallen into disuse.


 Extraction of the Eyelashes, and operation for Tri-
                       chiasis.

   In the affection called trichiasis, the eyelashes grow-
 ing towards the globe  of  the eye,  irritate it, and may
 produce a dangerous opthalmia.   The indication is to
 remove such  eyelashes with a pair of tweezers.   But
 they will  soon sprout out  again,  if the bulb be not  de-
 stroyed at the same time:  this may be done by means of
 the  cautery.   To do  this, we employ a cautery made
 for the purpose, terminating in a blunt point, but havin»
 at five or six lines from the point,  an orbicular enlarge-
 ment, about as large as a hazle nut.  This  little ball,
 which is heated at the same  time  as the point  is des-
 tined to keep up the necessary quantity of heat, to eft'ect
 the cauterization; hitherto,  this was the greatest diffi-
 culty.  The cautery being  properly heated, the surgeon,
 taking its  handle in the right hand, with his left sepa-
rates the lid from the globe of the eye, by pinching up
its loose edge, and  applying the  heated point to the
holes left by the hairs pulled  out.


                  Of Bloodletting.

 '"However simple this operation may appear, it is some-
times accompanied by formidable accidents, which may
result from the inexperience of the operator, or circum-
stances peculiar to the state of the  patient.
  We draw blood from the veins  or the  arteries,  but
 most frequently from the veins. 
241
   The  veins  most commonly opened, are those of the
arm or foot; of the neck and tongue, as for the arteries,
none but the temporal is chosen.
   To perform  this operation, we require, if the chamber
be obscure, a candle, a ligature  of ribbon or flannel, two
compresses, a smaller and a larger one, a roller bandage,
and a bowl to  receive the blood; also some warm water,
cold water, and Cologne water or vinegar, or a bottle of
hartshorn, in case the patient faints—a fine  lancet—a
small pair of dissecting forceps,  to lay hold of the fat,
which  may be pressed  over the opening in the vein, or
a probe to push it out of the way.*
   Bloodletting from the Arm.  Mr. Lisfranc has pub-
lished an excellent memoir on bleeding from the arm,
by which we shall profit on the present occasion.
   The  upper part of the median cephalic vein is the
most advantageous point for the  performance of blood-
letting.   To eft'ect this, the arm  should  be in a state of
semi-flexion,  and  slightly pronated,  to  cover the mus-
culo cataneous nerve and the tendon of the biceps, and

  * In many cases,  we fear that the lives of patients would be
in danger, were we to wait until this paraphernalia should be
arranged.  To perform the operation efficiently  and safely,
the only instruments necessary, are a good luncet  and a liga-
ture of any material, to compress the arm above the elbow, and
make the vein swell, and a vessel of some sort, to receive the
blood. "To avoid any obstruction from the fat, let the incision
through the textures, superjacent to  the vein, be made freely,
and the  arm be kept in the position it  was in,  when the cut was
first made.  After the bleeding ia ended, and the compress re-
moved from the arm, two  slips of court plaster (made with fish
glue) placed so as  to cross the cut at right angles, will keep
the edges in contact with more certainty and advantage than
the common compress and figure of 8 bandage, round the arm.
When the patient faints, the recumbent posture, and sprinkling
the face with cold water,  will, under ordinary circumstances.
soon revive him.—J. D. G. 
24'2
 the opening be made in  the vein above the middle part
 of the insertion of the tendon of this muscle.  By fol-
 lowing this method, we may always avoid wounding the
 nerve or tendon.  When we cannot open the median
 cephalic,  we next prefer; 1st. its continuation; 2d. the
 superficial radial; and 3d. the median basilic.
   When the latter vein  runs along the  muscular inter-
 stice, formed by the long supinator and  round pronator,
 it has always  over it some nervous filaments, which  it
 becomes almost impossible to  avoid  cutting.  In thin
 subjects, the radial artery, situated immediately  under
 the antibrachial fascia may be wounded;  in such cases,
 we avoid the last two named veins.
   If we cannot bleed, except from the  ulnar or median
 basilic veins, the latter should be preferred, because all
 the ulnar  veins are accompanied by so large a number
 of  nervous filaments, coming from the  median nerve,
 that it is almost impossible to avoid them.  The median
 basilic vein ought to be  opened  on the outside of the
 artery, and never immediately over the point where the
 latter is crossed by the vein,  as is done by the greatest
 number of bleeders, because the vein projects most at
 that place. With these precautions, the  following is the
 mode of performing the operation.
  The patient being seated,  or most commonly reclin-
ing on the edge of his bed, presents  to the surgeon,  the
 arm to be operated on.   The surgeon  places his liga-
 ture, with which he makes several turns around the arm,
 at about an inch and a half above the  point where he
 wishes to  open  the  vein; he secures this ligature by  a
 bow knot, in order to be able to loosen or tighten it at
 pleasure.   He keeps it on for a length of time, varying
 according to circumstances, even for half an hour,  or an
 hour, if necessary, and causes the patient to contract the
 muscles of his fore-arm  frequently.  By taking  these
 precautions, he  will less seldom fail in drawing  blood 
243
from the arm, than commonly happens, when it is diffi-
cult to perceive the  presence  of the vessels.  Should
this be unsuccessful, in causing the veins to swell, we
place the limb  in warm water,  for a short time;  other-
wise the cellular tissue  swells, the skin  reddens, and
the vessels are much more concealed than before.
  The surgeon then opens  his  lancet  at  right angles,
with  the handle, the end of which he  puts  into his
mouth, having the heel towards the hand with which he
is to use it. The patient's arm remains extended over one
of the surgeon's hands,  while with the other, he seeks
by  slight friction,  from below  upwards, to bring the
blood from the extremities, towards the nervous trunks.
When the vessel  is sufficiently  visible,  the  surgeon
steadies it with his left thumb; seizing then the heel of
the lancet  between  the  thumb, fore and middle finger
of the right hand; if he be  about to bleed from the left
arm, the ring and  little fingers being destined to serve
as a point of support, he flexes the fingers, holding the
lancet, whose point he presents towards the vessels, and
by a slow and moderate extension of  the same fingers,
he penetrates the  vein,  and raises up the point  of the
instrument, which enlarges the incision.  The direction
of the incision is commonly oblique.
   If  the operator make a first cut without opening the
vein, he  examines whether the wound corresponds with
the situation  of the vein  he wishes to open: in this case,
he  introduces his  instrument into the wound,  to open
the vessel .more deeply, quieting the patient by  saying
something  prevents the blood  from flowing.*   Should


  * In the original, the surgeon is advised to tranquillize the pa-
tient, by  saying he is going to remove a pieco of fat which
prevents the flow of blood.  He who can utter an untruth as a
matter of convenience, is not fit to  be trusted even with a lan-
cet.—J. D. G. 
244
the wound noi correspond to the vein,  we may draw it
aside, so as to bring the wound over the vein, and then
proceed as above stated.   When the fat closes the ori-
fice, and prevents  the flowing  of blood, it should be
pressed ;;side with  the forceps or a probe.  Should  the
ligature be too tight and compress the artery too much,
the blood  cannot even reach the veins: in this case, we
relax the ligature a little. We tighten it on the contrary,
when the bleeding  is  stopped,  because the superficial
veins are not sufficiently compressed.
  When enough blood has flowed, the surgeon loosens
the ligature, places the left thumb over the opening, and
cleanses the arm with a rag dipped in warm water.   A
small square compress is applied  over the wound, then
a larger one, and  the whole is kept on by a bandage
passed round the arm, which forms a figure  of 8.
  It may happen  when the arm is thick  and  round,
that we  cannot discover  a vein even on the hand. It
may, nevertheless,  be requisite that blood be forthwith
drawn.  In this case, Mr. Lisfranc proposes to open
the cephalic  vein  at the intermuscular space  of  the
deltoid and great pectoral, near the point of their junc-
tion; there this vein  is most constantly found without
anomaly.  We  make an incision along  this interstice
about an inch long, parallel to the axis of the humerus,
with a  convex  bistoury, and after having divided  the
skin and  cellular  texture, the  vessel  is exposed, and
opened  with a lancet.
  Bloodletting from the handy— After applying the liga-
ture as heretofore  directed, an inch or two  above the
point where we wish to open the vein, we dip the hand
for some  minutes  into tepid water to render the veins
apparent. The cephalic vein of the thumb is commonly
the one which is of the largest size, which is tobe open-
ed according to the directions heretofore given.
   Bloodletting from the foot.—This  is  performed from 
2Aj
the internal  or external saphena vein, but almost con-
stantly from the former. We first apply a ligature a lit-
tle above the ancle, place the foot in warm water, and
then open the vein. The foot should be kept in the water
While the blood is flowing; when we perceive by the dis-
colouration of the water that enough blood has flowed,
we remove the ligature, and apply first a small and then
a large compress over the wound, sustaining the whole
by aid of a roller bandage.
   Bloodletting from  the external jugular.—To render
the jugular veinapparent, we apply a graduated compress
on the inferior part of the trunk below the point where
the opening is to be made; we place over this compress
the middle of a bandage, whose extremities are given to
an assistant, who tightens them  to the necessary de-
gree, or  else they  are carried under the arm pit of the
opposite side.   The surgeon being seated, or standing
alongside  of the patient, and holding the  lancet as has
been pointed out, opens the vein above the point of com-
pression, by giving the incision a direction perpendicu-
lar to the fibres of the platysma myoides.  The blood is
received in a cup, which  is pressed against the neck to
prevent the blood from  flowing over the body.  The
bloodletting being finished, we remove the ligature, and
place over the wound a small, and then a large compress,
 which is kept on by  a moderately tight roller, passed
 alternately under the arm pit, and round the neck.*
   Bloodletting  from  the  lingual veins.—This is per-
 formed  from the raninal veins.   The patient, seated fa-
 cing a window, opens the mouth, and raises the tongue,
 the point of which should touch the roof of the mouth.
 If we fear that he may lower it, we may retain it by

   * Slips of strong court plaster, extending to some distance
 on each  side of the wound, and crossing each other at right
 angles, would be preferable.—J. D. G.
                           x 2 
24b
pressing it with the handle of a directoi, alter placing
a piece of cork between the teeth at the angles of the
jaw. We then  open the vein with  very sharp-pointed
-cissors, or better still, with a lancet. The patient spits
out the blood as fast  as  it flows; it almost uniformly
ceases to flow spontaneously,  when the head is raised
and the breathing is free.  Should it  not  stop, we apply
a compress of lint.
  Opening the temporal artery.—The surgeon takes a
straight bistoury in  his right hand, pla -es the extremity
of his fore finger over the course" of  the artery, to mark
with precision the  place where he purposes to cut, and
then introduces  the point of the bistoury alongside of
tiie artery, and lowers his hand horizontallv  to cut the
vessel  across.   When a sufficient quantity of blood is
discharged,  he compresses the  artery,  by placing his
finger over it, between the heart and the wound.  After
Avashing the  blood  off, he substitutes a graduated com-
press, which should not be applied over th- wound. He
then applies a second compress on the other side of the
sound, because the blood may escape from that side, ow-
ing to the anastomosis of the arteries.  A larger com-
press is applied  over both  the others, and  the whole is
retained by a moderately tight bandage.  In case this is
not sufficient, a harder compress and a tighter bandage
should be used.
  Bloodletting being so frequently performed, we may
here speak of an accident  which is  often  produced by
it; this  is phlebitis, or inflammation  of  the vein.  It is
enough to say, that this operation >ometimes produces tho
death of the patient, in order to keep the operator on his
u,uard. The most certain mode of preventing it from be-
coming dangerous,  is positively  to  forbid  the patient
from usiug the arm for the first  twenty-four hours suc-
ceeding the bleeding. 
247
              Application of Leeches.

  The most simple and expeditious mode of applying
leeches is the following:  We place in a fine cloth the
number of leeches we propose to employ, and we gath-
er them into a sort of  lamp by rolling them in the linen.
This mass is  placed over the part we desire to have the
blood drawn from, under a tumbler intended to prevent
the leeches  from crawling oft'.   We  then  pull by the
edges of the cloth to place the  leeches on the skin; by
this  means they  cannot attach themselves to the sides
of the glass, and if they be well-chosen and disposed to
bite, they can only do so on the skin.
  When the leeches have fallen  oft*, we keep up the
flow of blood by  washing the bites  with warm  water.
Should theyinot let go spontaneously, it is sufficient to
sprinkle them with a little salt, vinegar, &c. to prevent
the flow of blood, it is commonly enough to apply over
them a dry and rather tight compress.  When this does
not succeed, we have recourse to cold lotionsand astrin-
gents, or the  application of a morsel of agaric over the
wounds. Should the bleeding continue notwithstanding
these applications, we cauterise the  bites with the ni-
trate of silver, the sulphate of copper, or even the actual
cautery.  It  has been proposed to employ the following
method, which never fails: It consists in placing over
the opening a piece of linen doubled several times,over
this we apply the extremity of a spatula or other con-
\ eniently shaped  piece  of iron, heated so as not  to
cause burning.   The heat evaporates  the  more fluid
parts of the blood, and  the remainder forms acoaguloro
which prevents the continuance of the hemorrhage. 
248
                       Cupping.

   Alter having exposed the part which it is proposed to
 cup, and shaved, if it be covered with hair, we foment it
 with a sponge, or a piece of rag soaked in warm water.
 Alongside the sugeon are arranged several cups, towels,
 a lancet, a bistoury, or a scarificator, several little balls
 of cotton as large as a hazlenut, a lamp, or a lighted can-
 dle, a pair of forceps, and a vial of alcohol. Every thing
 being ready,  the surgeon holds a cup in his right hand;
 with the left he takes one of the little balls of cotton, in
 the  forceps, dips it in alcohol, and sets it on fire by the
 lamp, he then drops it into the cup. The air is soon rare-
 fied and driven out of this instrument, which is then ap-
 plied with quickness and exactness over the skin, where
 prepared for the purpose, so as to prevent the access of
 the atmospheric air. The cotton ceases to burn almost in-
 stantaneously; the  rarefied air  condenses; a vacuum is
 formed; the pressure of the atmosphere drives the blood
 into the cutaneous tissue, which raises up within the cup,
 which remains strongly applied without the aid of the
 hand.  We  may  also make the vacuum by holding the
 mouth of the  cup over the blaze of a spirit lamp. The
 surgeon repeats the same manoeuvre in relation to the
 other cups; he may even repeat the operation on the same
 spot until he judges the rubefaction sufficient. He then
 removes the cup,  unless it fall of itself; then applying
 the scarificator over the turgid part; he lets go the spr'm"
 and  cuts  the little incisions through the skin, and  over
 these the cup is applied, and in the same way as many
 as are desired, may be applied.
   If we have no scarificator, we use the common bis-
 toury, or a lancet simply. To do this, we make slightly,
 several  longitudinal  and parallel incisions, a quarter or
half a line deep; while the right hand directs the lancet, 
249
we tighten the skin in the opposite  direction, with  the
left thumb and fore finger.  We may, if it be preferred,
make punctures through the skin,  perpendicularly with
the point of the lancet; these should not be more than a
line deep.
  Instead of  balls of cotton dipped in alcohol, we may
on  occasion,  use dry cotton  or lint. But  this  is  too
readily extinguished, and being more tedious and incon-
venient, we never use it where it can be avoided.
  When enough blood has  been  drawn, we wipe the
parts with a rag or  sponge,  soaked in  warm water; we
then cover the little wounds with a piece of  diachylon
plaster, to prevent suppuration.  Some practitioners are
in the habit  of pouring oil on the scarified skin, cover-
ing it with a bandage of fine linen, and  retaining it by
a roller.
   Dry Cupping.   The operation is precisely the same
with that described, except  that after producing the ru-
befaction, we do not scarify the skin.  After removing
the cups, we apply a hot towel on the reddened parts,
and cover up the patient.*


   * The next article' in the original, relates to the use of Sar-
 lANDIere's Bdellometre, which  is not used at all in this coun-
 try, neither does it deserve to be, since we have a vastly supe-
 rior contrivance in
           SFXLERS'S CUPPING INSTRUMENTS.
   The  cups of the ordinary shape have a small brass nut,;witb
 a hole through the centre, projecting from the  bottom of the
 CUp.  This hole is closed by a very simple, fasting, and easily
 replaced  valve.  A small syringe or exhausting pump, having
 an extremity corresponding in figure to the bottom of the cup,
 and  having this extremity covered by a soft piece of buck-
 skin, which is retained by a screw.  When we wish to apply
  an* number of cups with this apparatus, it is only necessary to
  have the end  of  the brass syringe dipped in  warm water, and
  after making  the scarifications in the ordinary way, to apply 
250
                Plugging the Nostril*

   When epistaxis  cannot be  otherwise arrested,  we
 have recourse to plugging the nostrils.
   We  introduce Bellocq's  director,  containing  its
 spring stylet along the floor of  the nostrils, till  its ex-
 tremity  passes  beyond the palate: the spring is then
 pressed,and the button projects towards the anterior part
 of the mouth. To this we  attach a doubled thread,in the
 middle  of which  a little bundle of lint is tied.  The
 stylet is then drawn within  the canula,  and the latter
 withdrawn  from  the nostrils.   We  then  detach the
 thread, and fix between the two strands a second mass
 of lint, which closes the anterior opening of the nostrils
 exactly,  as the first  does the posterior.   The other nos-
 tril may  be plugged  in the same manner, if necessary.
  In case BELLocq's. instrument be not at hand,  we
 may employ a piece of flexible whalebone, or other flexi-
ble substance, introducing it through the nostrils, and
bringing  forward the thread and lint  nearly  in the
 same manner as above directed.


                      Blisters.

  The part being prepared and the plaster ready, the
 latter is slightly warmed,  and  applied,  pressing   it

the bottom of the cups to the end of the syringe, place its
mouth against the scarified part, and give one or two pulls, to
exhaust the syringe and cup.   In this way, as many cups may
be applied as desirable, without the least inconvenience.  The
 great advantages of this instrument are, its simplicity, cheap-
ness, and the ease with which it may be used, and kept in  re-
 pair. It is the invention of Mr. Colman Sellers, a very inge-
 nious mechanician of Philadelphia. 
251
 lightly with the palm of the hand.  When  the  blister
 is applied upon the arm, thigh, or leg, after coverng it
 with a soft compress, we retain  it  by aid of a roller;
 but  when it is applied upon the trunk, or any other part
 where the roller bandage would be inconvenient or in-
 adequate, we fix the blister, by applying  two adhesive
 straps, which cross at right angles  over the middle of
 the  plaster,  having their extremities to pass beyond it,
 and  be attached for five or six inches to the adjoining
 skin.
   When  the blistering ointment is good, the vesication
 occurs in about  twelve hours, and it would  be useless
 to allow it to remain longer.
  We then remove the bandages, detach the plaster care-
 fully; and should any of  the ointment adhere to the skin,
 we wipe it off with a warm wet  cloth. We then cut the
 vesicle at several points, in order to discharge the water,
 but do not allow the cuticle to be removed, which would
 expose the sensible surface of the skin, and cause a great
 deal  of pain. By leaving it in  place, we scarely occa-
 sion perceptible uneasiness.  We then  apply a piece of
 soft  old linen, spread with simple cerate,  such as bees-
 wax and sweet oil, &c. &c. or with fregh cabbage leaves,
 wilted or softened,  by holding them before the fire, and
 squeezing them  in the hand.  The whole blistered sur-
 face should be thus covered,  and the dressing be retained
 by a suitable bandage.  The dressing, if with cerate, is
 repeated once a  day; if with leaves,  according to cir-
cumstances,  as  they  sometimes  soon  grow dry  and
 unpleasant.
   When  we wish  to keep up  an irritation  for  some
 time, we  must not apply the dressing of simple cerate,
as the surface will be healed in two  or three days, but
 we apply  a salve, containing some of the blistering oint-
 ment, at  every daily dressing.   When  we wish to heal
 the surface, we again  substitute the simple cerate,  in-
 stead of tho irritating ointment. 
252
   It often happen-, that the fluid produced by the irri-
tation of the blister flows on the adjoining surfaces, and
excoriates them.   We obviate  this inconvenience,  by
applying  lint around the lower edge of the  blistered
surface,  after having applied a piece of bibulous  paper
over it; the  lint is kept in  place,  by covering  it with
a large piece of linen, and a roller, or by means of two
adhesive straps, placed parallel  to  the axis of the body;
a third strap crosses the two former on  the outside  of
the compress, and all of them extend for some inches on
the adjoining skin.
  We never wash a blistered surface, but dry it at each
dressing,  with a fine linen  cloth,  frequently applied,
slightly pressing it against the surface, holding it tightly
at each end.
  Small blisters applied behind the  ears or other parts,
may be kept in place by adhesive straps; if we wish  to
make them  suppurate,  we  use the blistering ointment
repeatedly.  Otherwise, we  dress them with  simple ce-
rate,  or rather leave  them uncovered or exposed to the
air, if not liable to  be irritated  by the  friction of the
hair, or the dress of  the patient*

  * Blisters, when applied on delicate or irritable subjects,
sometimes cause a very severe wound, which is sometimes fol-
lowed by a disposition to gangrene, or by an erysipelatous  in-
flammation, which terminates fatally.  In such cases, the most
effectual  remedy is the application of a decoction of cantha-
rides in spirits of turpentine, which almost in)mediately affords
relief from the intense  irritation, and stops the progress of the
disease.   For the use of this excellent remedy in  this state of
inflammation, the profession is indebted  to John Rhea Barton,
M. D. of Philadelphia.  Dr. Samuel L. Howell, of Wood-
berry, N.  J. has published in (the second volume, new series,
of) the Philadelphia Journal, a very interesting account of  his
experience of the good effects of this prescription.—J. D.  C» 
253
                       Seton.

  When we have  chosen the place for this operation,
we take hold of the skin with the left hand, to make a
fold perpendicular to the axis of the body or limb. We
pass a seton needle carrying a proper quantity of thread
through this fold, not forgetting to give it a slightly ob-
lique direction  in  order  to facilitate the flow of pus.
Should we not use  the seton needle,  we  may perforate
the  fold with  a straight bistoury, and  pass the seton
needle through, by introducing it alongside of the point
of the  bistoury, which is withdrawn  after the needle is
introduced.  It often happens that  patients object to
having the seton through the skin of the neck, on ac-
count of the cicatrix,  which  it leaves visible.   As we
 frequently have  no other means of conquering  violent
 opthalmia, it is of importance that the above objection
 should be  overcome, and the seton be placed so as to
 cause no deformity. To effect this, it is only necessary
 to choose  the upper part of the neck, which is covered
 by the hair.  This is  shaved where the needle is to be
 passed through, and we perform the  operation as before
 directed.
    If we cannot pinch up the skin into a fold, we do not
 hesitate to perform the operation. In this case,  we pass
 the  needle through the skin, push it  along underneath
 it, to the  point where it is to come out, without injuring
  the subjacent parts.


                    Permanent Issues.

     When  an  issue is established on the thigh  or leg, it
  may be inconvenient; but should the leg  be chosen, we
  place it  three or four fingers breadths below the knee,
  between  the internal gastrocnemius, and the tendon of
                           Y 
2 5 4
 the sartorius.   On the thigh, we choose the depression
 near the knee on the inside; if on the arm, the space be-
 tween the biceps and deltoid muscles.
   When the place is decided on, the  surgeon makes a
 longitudinal fold with the  skin  pinched up, and then
 makes a transverse incision through the integuments. A
 small tent of lint  is kept in the wound for a few days,
 in  order to irritate  it.  We then place  a  pea in the
 wound to prevent  the healing, and keep up a continual
 irritation.  To retain the pea or peas in place, it is best
 to stick them  against a  strip of  adhesive plaster, and
 then apply them; they will then be sufficiently within
 the  wound.
   When  the  patient objects to the cutting instrument,
 we employ  caustic potash to establish the issue, which,
 however, is  more-oainful, and less expeditious. We  ap-
 ply  a piece  of adhesive  plaster,  having a hole in  the
 middle over the point where the  issue is to be estab-
 lished,  to receive  a morsel  of potash  of the size of a
 large pea, and  to  retain this we place over it another
 piece of adhesive plaster.  A roller bandage is applied
 over the  whole, and in five or six hours the eschar is
 formed.   We then remove the dressing,  and make a
 crucial  incision through the eschar, and to facilitate, its
 falling off, we apply an emollient cataplasm.   The  es-
 char commonly comes  oft' in four or five days, when  we
 apply the pea, as has been already described.

     Application of Potash to open an Abscess.

  To open an abscess, profoundly, or even superficially
 -eated,  it is directed  that  a piece  of  potash, propor-
 tioned to the opening to be made, should be applied over
the point, as for the purpose  of establishing an issue.
 When the abscess is very deeply seated, we repeat the 
■£55
potash several times,  until the purulent cavity is laid
open.

         Application of the Actual Cautery.

  The actual cautery may take precedence of all others,
and  is one  of the most powerful assistants to surgery.
When we have chosen the cauterising iron, which is
adapted to the form  of the part to which it is to be ap-
plied, we  heat it in a chafing dish of glowing coals at a
short distance from the patient.  The  degree of heat
imparted  to the instrument is marked by the colour it
acquires,  and  which  varies from gray to white.
  The less the cautery is heated, the more pain it cau-
ses,  and the less it destroys the parts to which it is ap-
plied:  thus the  cautery heated  only to a gray heat, is
very irritating, and causes acute suffering, while the cau-
tery at a  white  heat is more active, but much less felt.
  The cautery being properly  heated, an assistant pre-
sents its handle to the surgeon, the latter applies it im-
mediately to  the  proper point for some seconds.  He
should always have several cauteries at the same time
in the chafing-dish, so  that if the first does not produce
the desired effect, he may use a second without keep-
ing the patient in suspense.

                Application of Moxa.

   To prepare inoxas,  carded cotton is commonly used,
which is  twisted  so as to make a sort  of  cord, (of a
thickness  proportioned to  the eschar we wish  to ob-
tain:) around  this we sew a piece of linen very tightly
drawn. The latter precaution is unnecessary if the cot-
ton  be properly prepared  and covered externally by a
solution   of gum arabic, which in drying keeps the fila- 
■:5ti
ments of cotton united.  When  it is  prepared,  nc set
tire to one of the extremities, and place the other on the
part to be cauterised.  We hold it in  this position with
the dressing forceps, and we accelerate the combustion
by blowing it with a pair of bellows, or with the mouth.
W e  should  blow so that the  moxa may burn as slowly
as possible, without allowing  it to be extinguished.


    Cauterizing by  the application of an acid Fluid.

   rhe sulphuric, nitric,  and hydro-chloric acids, are
those most frequently employed,  when we do not wish to
use the actual cautery nor potash.  To use these acids,
we dip in the fluid,  a small pledget of lint, fixed on the
end  of a wooden handle.  The hydro-chloric acid is
very often employed by Dubois, after the bite of rabid
animals.   To use this, he excisea with  a bistoury the
bitten part,  and  touches the wound with the acid, by
means of the wooden handle, &c. above mentioned.

                    Vaccination.

   After having received  on the  point  of a lancet or  a
needle, a portion of the vaccine fluid,  the surgeon takes
hold of the left arm of the patient, by its posterior sur-
face, tightens the skin, and makes with his right hand,
a longitudinal or horizontal incision on the anterior sur-
face of the superior part of the arm, and of such a depth
as that the point of the instrument is scarcely coloured
with blood.   He then  passes the extremity of  the lan-
cet flatwise, over the point where  he has broken  the
skin, to deposit there a part of the vaccine fluid, which
is still adherent.   The  same operation is done upon
the other arm. A common needle, dipped in the vaci ine
fluid, and with which  a simple  puncture is made,  be- 
257
tween the epidermis  and skin, (giving it a slight rota-
tory motion, to deposit the fluid) may on occasion, serve
to effect the vaccination.
  The vaccine fluid is fresh or dried: it  is  fresh when
we take it immediately  from a patient's  arm; dried
when it has been preserved between two pieces of glass
or in capillary tubes.  The scab is also employed for the
same purpose.  When we wish to use the dried matter,
we wet the point of the lancet, and scrape a small por-
tion of the matter,  until it is sufficiently fluid to  be
used.  When much water is added, the success of the
operation will be very doubtful.

                  Artificial Nipple.

   It is not uncommon to find the nipples of nurses
.hopped, and  60 very irritable, that they cannot suckle
their infants  without dreadful  pain.  The following
mode of obviating this  inconvenience is described  by
Lisfranc,  in his lectuies,tas the invention of another
practitioner.
   A sort of funnel of wood or ivory is turned nearly of
the form of a large cupping  glass,  except  that  its ori-
fice is much  deeper; at tl e basis  of this,  a small rim
made on the  same piece stands up, which has a small
groove about two lines from its extremity.   The skin of
a young cow's teat  is fixed  over  this,  and tied by a
string, which  presses into the circular groove.  The
cow's  teat may be kept in alcohol  for this purpose,
during several years; when it is to be used, all smell of
the spirit  of  wine may be dissipated by  boiling it in
milk.
   The instrument being prepared,  it is  only necessary
lo  applv the orifice in the ivory on the  breast, so that
the nipple shall  correspond to the  central opening;
the child will soon lay hold of the false nipple, and suck
                         Y 2 
25b
with neat 1> ;:s much ease as from the true one, and
without pain to the mother.

          Perforation of the lobe of the Ear.

  After pressing the lobe of the ear for some time,  to
deaden its sensibility, we support  it against a piece  of
cork, and  pierce it with a conical needle of gold or pla-
tina.   When the needle is withdrawn, we introduce a
piece of leaden wire, and after a time, the opening be-
comes  permanent.
THE  END. 
INDEX.
Introduction       ••••...     5
Of Incisions in general       .....        9
Rules for holding the Bistoury       ...         fo
Simple  puncture for opening an Abscess     •     .    •  10
Puncture and straight Incision       .         .    .    \ 1
Crucial Incision       .     .     .     .     .     .    .12
T Incision    .    .    •    .    .     .     .     . -    jg
V Incision       .     .     .    .     .     •     .    .   ib.
Elliptic Incision    .     .     .    .          .           jb
Incision to correct Deformities, &c.        .     .    ."14
Incision to avoid penetrating a Cyst, &c.      .     .       ib.
Opening of Abscesses among parts supplied with nume-
  rous Nerves and Blood-vessels                        15
Counter opening       ......       jb.
Dilatation  of an opening on the grooved Director    .    16
LIGATURE OF ARTERIES IN GENERAL   .       ib.
-----------of Arteries in the superior extremities       20
-----------of the radial Artery near the Wrist     .     ib.
---------:—ulnar Artery near the Wrist    .     .       ib.
----•-------radial Artery, at the upper part of the fore-arm 21
-----------ulnar Artery at the upper part of the fore-arm  ib.
             brachial artery near the articulation of the
  arm antl fore-arm         ....      22
Ligature of  the posterior tibial artery near the middle third
  of the leg      •       ...                23
——-----•-------------------near the  upper
  third of the leg       ......ib.
-----------of the anterior tibial Artery near the middle
  of the leg.......''    ib. 
;bu
 Ligature of the peroneal or fibular Artery somewhat be-
   low the middle of the leg        ....       24
 Ligature of the subclavian artery above the Clavicle       2.s
 ----------of the common Carotid                      ib.

 LIGATURES OF TIIE ARTERIES  IN TIIE INFE-
   RIOR EXTREMITIES.....       '2*
 Ligature of the A rteria Dorsalis Pedis                    ib.
 Ligature of the posterior tibial Artery  behind the  inner
   Ancle      ........       2"
 ---------------■        --------near the middle third
   of the I.op   ........       ib.
 -------------------------------near the  upper third
   of the Leg       ....        2Q
 ■      ----the anterior tibial artery near the middle of the
  Leg      ......       ib.
 ---------the peroneal or fibular artery somewhat below
   the middle of the Leg       ....      29
 ---------of the popliteal Artery towards its inferior
   portion       .     .     .    .    .    .     .    .    ib.
 ----------of the popliteal Artery     .'"'".            30
 -----------of the crural  Artery near the middle of the
   Thigh.........31
 ----------------------------near the fold of the Groin ib.
 ----------of the external iliac Artery      .            ib.
 -----------of the internal iliac Artery                  :;j
 -----------of the Aorta    .    .    .    •            33

 OF AMPUTATIONS IN  GENERAL, &c.             M

Amputations of  the sopeiiior extremities    .       40
 Amputation of the 1st. and 2d. phalanges of the Fingers  ib.
----------of the Fingcis at  the metacarpophalangeal
  Articulation       .     .    .    .    .         ,    4 ;
---------- of the Thumb at its carpo metacarpal Arti-
  culation    ......         .       4-
---------of the little Finger at its carpo metacarpal
  Articulation      •••...     46
----------of all the Fingers at the mriacnrpo-phalangeal
  Articulation    .... 
261
Amputation  of the Wrist at  its Articulation with the ra-
  dius and ulna           ......49
Amputation  of the Fore-arm  towards its lower third with
  two flaps   ........      51
----------at the middle of the Fore-arm      .     .    53
----------of the Fore-arm at the Elbow Joint   .      54
----------of the Arm at some point below the Shoulder
  Joint    .........    55
Circular amputation of the Arm at the Shoulder Joint     56
Partial Amputation of tbe  lower Jaw     ...    62
Partial Amputation of the Toes at their metatarsophalan-
  geal Articulation      ......       63
Amputation  of all the Toes     .     .    . .   .     .    64
----------of the 1st. and 5th metatarsal Bones  .      ib.
Partial Amputation of tbe Foot, at the tarso metatarsal Joint 66
________________of the  Foot, at the Articulation of the
|i astragalus and os calcis, with the os cuboides       .    69
Amputation of the Leg with a single flap .               70
Circular Amputation of the  Leg, four inches below the
  Articulation of the Knee   .....      71
Amputation  of the Leg at the Knee Joint      .     •    72
----------of the Thigh with two flaps ...      73
Circular Amputation of the Thigh      ...    74
Amputation of the Hip Joint      .                     75
AMPUTATION, EXCISION, SECTION, EXTIRPA-
  TION, &c. OF SOFT PARTS     .                79
Amputation of the Breast      .....    ib.
Extirpation  of the Eyeball    .    .    •    •    •      ^
Artificial Eye........     84
Excision of a Pterygium
-------of the Lips
_______of the Tonsils
85
86
ib.
_______of the Uvula.....         87
_______of cancerous Tumours and of the Tongue      89
Division of the Frosnum Linguae      ...      91
Amputation of the Penis      .
Circumcision      •     •          •
Excision of the Prepuce in Phymosis      .     .     .    ib.
Reduction ofParaphymosis   ...     -      94 
262
Extirpation of the Testicle      ...»         ^
Excision of the Neck of the Uterus     .                98
------- of Venereal excrescences, &c.   .          •    99
-------of the Clitoris.....       100
------of the Nymphae       .....     101
Excision of part of the sterno-mastoid Muscle, &c   .    101
Incisions for the removal of imperforations, &c           103

OPERATIONS  FOR THE EXTRACTION OF  FO-
  REIGN BODIES......       105
Polypi    .........    ib.
Extirpation of Polypi from the Nasal Fossa       .       106
Ligature of  Nasal  Polypi      .....     107
Extraction of Polypi from  the Maxillary Sinus    .       110
Extirpation of Uterine Polypi      .    .     .     .     112
Ligature of Uterine Polypi  .     ,    .     .     .       113
Laryngotomy       .     .     .     .    .     .     .     114
(Esophagotomy     .......       116
Gastrotomy    •    .     .   -'.     .    .     .     .     118
Operation for the evacuation  of  Pus from a Tumour,
  caused  by ./Edematous Angina     ...       120
Catheterism   .......121

LITHOTOMY.......       124
Lateral operation with the Lithotome Cache'    .   .    ib.
■---------------with the Knife   ....       127
---------------with the Gorget      .     .           128
High Operation     .......      129
Recto vesical operation               t                 130
Lithotomy in Women     •    •    .     .     .          131
Extraction of Foreign  Bodies from the Joints     .       133
Trephining    ........    ib.
Operation for Cataract     .....       136
---------by Depression     .....     137
---------by Extraction                   ,            140
Artificial Pupil    .         .....142

PARACENTESIS    .....       f44
Paracentesis Abdominis                  4              ib
Operation for Empyema.....       J47 
263
Puncture of the Pericardium   ...         .     149
--------of the Bladder.....151
Operation for Hydrocele      .                        153
Paracentesis  Oculi     ......       154
Puncture  of  the Tympanum      ....     155
Perforation of the Maxillary  Sinus      .      .         156

FISTULjE      .......       157
Operation for Fistula Lacrymalis                       ib.
Fistula of tbe Parotid Gland      ....      161
Operation for Ranula     ...•••     163
Fistula in Ano.......       164
Recto vaginal Fistula......!66
Vesicovaginal and  Urethrovaginal Fistula  .     .       ib.
Urinary Fistula     .......    ib.
Ducamp's treatment for Strictures of the Urethra       168

OF HERNIA.......l76
 Reduction of inguinal Hernia        .     .    .     .    ib.
 Operation for inguinal Hernia     ....       m
 Reduction of Crural Hernia  .•    ...    181
 Operation for Crural Hernia      .             .       '82
 Reduction and operation for other abdominal Herniae      183
 Prolapsus Ani             .       .      •       .      ib.
 __________Vaginae......184
       ----Uteri......ib-
Retroversio Uteri.......183
Procidentia Iridis......      186
Fall of the upper Eyelid or Ptosis    .    .     .     .    ib.
Inversion of the Eyelids.....      lb-
Eversion of the Ejelids  .     .     •         •    •    187

OPERATIONS TO FACILITATE THE REUNION
  OF  DIVIDED  SOFT PARTS    ...      187
Interrupted Suture    ......
Looped    -----      .....
Glover's   -----......
Quilled-----•
Twisted   -----    •     - •    •    \    '
188
189
190
191
 ib. 
264
Other modes of procuring Union                  .191
Harelip operation      ...-••       19*
Stapbyloraphia      ....•••    l''7
OF FRACTURES  IN GENERAL       .    •       199
FrACTL RES OF THE SUPERIOR PARTS     .    •    .     204
Fractures of the Nasal Bones, &c.     ...       204
____________Vomer  ......     ib.
Fracture of the lower Jaw.....204
_______.-----Oshyoides.....206
____________Sternum      .....     ib.
____________Ribs  ......       ib.
____________Spine......207
------.-----Scapula     ....       ib.
____________Clavicle.....208
_____.------Humerus              .               209
.___________surgical neck of the Humerus          210
______.-----■ Fore-arm.....       211
____________Carpal Bones     .                  213
______.-----Metacarpal Bones       .       .        ib.
____________Phalanges       ....       214
FRACTURES OF THE LOWER  LIMBS      .     215
Fracture of  the Pelvic  Bones   ....        ib.
____________Thigh Bone        .     .       .     216
____________Neck of Thigh Bone      .       ,     217
------------Patella.....218
.------------Leg      ....         ib.
------------Os Calcis                       .     220
OFLUXVTIONS......       220
Luxations of the superior Limbs  .       ...    221
Luxation of the  lower Jaw      ....       jb
_----------oblique processes of the Vertebrae      ib.
_____■      — Ribs    ......    222
------------ Clavicle   .....       ib.
___--------Humerus,      .       .              223
.------------Fore-arm     ...     .       jj,
--------—— Wrist        .                       225
------------Os Magnum   «...       jb
------------Metacarpal bones       .     .     .    226
—---------— Phalanges of the Fingers  .      .       jb. 
265
LUXATIONS OF THE INFERIOR EXTREMITIES  227
---------the femur      .            .        .    ib.
---------patella       ....       229
-----------upper end of  the tibia   .      •      .     ib-
.----------of the fibula       .                      230
-----------of the foot      .       .      .       .230
Removal of part of the ribs, &c.                       231

APPENDIX, &c.         ....      235
Extraction of Teeth   .       .       •      •            #•
Removal of the Nails     •                          237
Extraction of the Eyelashes  .      .       •          240
Bloodletting     .      »      •       •       •       ib*
Leeching                        ...  247
Cupping    .                                      ^4^
Plugging the Nostrils      ...            250
Blisters                           *                 lb-
Setons           .              ...      253
Issues       •      •      •       •      •       .ib.
Application  of Potash, &c.             •      .254
Actual Cautery      •      •      •   .              2'5u
Moxa      .                   •                     ib-
Cauterizing by an Acid      .      .                 256
Vaccination                                         l°-
Artificial Nipple      •             .             .   257
Piercing the lobe of the Ear                  •        258 
 
SYNOPTIC   TABLE
CONTAINING  THE PRINCIPLES OF NATURAL  LABOURS,

             AND THOSE REQUIRING MANUAL ASSISTANCE.
   Dimensions  of the female  pelvis
and foetal  head.
  Dimensions of the female
pelvis.
  To understand tbe principles contained  in these two tables, it is necessary to remember {the dimensions of the pelvis, and of the head of
foetus.  Moreover the mechanism of natural labour should be well known, of which the others should only be an imitation.

                                                                        The pelvis in the superior and inferior strait,  and the  hol-
                                                                      low comprised  between them.   Axis of the superior strait: a
                                                                      line drawn Irani the umbilicus, to the inferior extremity of the
                                                                      sacrum.  Axis of the  inferiqj strait,  a line passing from the
                                                                      sacro-vertebtal angle to the centre of the vulva. Length of the
                                                                      four diameters  of the superior strait in the living subject:
                                                                    .  antero-posteTior or sacro-pubic four inches: transverse four; the
                                                                      oblique from one acetabulum to the opposite sacro-iliac sym-
                                                                      physis four and a half. Length of the four diameters of the in-
                                                                      ferior strait,leach four inches; the antero-posterior may acquire
                                                                      half or three-fourths of an inch, by the motion of the coccyx back-
                                                                      wards.  Extent of the cavity of the pelvis; from the  symphysis
                                                                      pubis to the hollow of the sacrum fivelnches; this is the greatest
                                                                     .. diameter.
                                                                        We distinguish five diameters: occipito mental five inches and
                                                                      evenfiveandfiquarter; occipito-frontal fourandone-fourth: trans-
                                                                      versely from one parietal protuberance to the other  three and
                                                                      one half:  perpendicular diameter from the vertex to the base of
                                                                      the cranium (three or three and a half.
                                                                    if  Mechanism.  Flexion of the chin on the breast.  The head
                                                                       clears  the superior strait. Movement of rotation producedby
                                                                      the inclined planes of the pelvis; the occipital protuberance is
                                                                      carried behind the symphisis pubis, the face towsffd the hollow
                                                                      of tbe sacruni.
                                                                        The head (arrived at the interior strait; clears it; the occiput
                                                                      is first disengaged as in all head presentations: then the face by
                                                                      passing successively over  the whole concavity of the sacrum;
                                                                       the shoulders enter  the superior strait diagonally; perform a
                                                                      movement ofl rotation: the one  which is to the back  part hrst
                                                                      escapes from! the inferior strait.  The same mechanism for the
                                                                      nates.  ,
Head presentations.
Four positions.
  Dimensions  of  the foetal
head.
  First, occiput towards the
left acetabulum.
  Second,  occiput towards
the right acetabulum.
  Third, the occiput towards
the right sacro-iliac junction.
  Fourth,  the occiput  to-
wards  the left sacro-iliac
junction.
   Breech presentations.
   Four positions of the feet, knees .
and thighs.
               f   The same; mechanism, except that after the rotatory move-
                ment, the face comes behind the symphysis pubis and the vertex
                into the  concavity of the sacrum;  the occiput  is first disen-
                gaged and the face follows.
                  When the pbin first presents and is in front, the delivery may
                lake place; then the face is first disengaged; this position is ex-
                tremely rare. The head is thrown backwards. Should the chin
                present and the head be thrown backwards, nai iral delivery is
                impossible.                                *
                  Mechanism. The thighs enter the superior strait diagonally;
                movement  of rotation; one arrives behind the symphisis pubis;
                and the other  in the concavity of the sacrum: the posterior
                one is first delivered.  The same mechanism for the shoulders-
                The  chin  is bent on the breast to clear the superior strait.
                Movement of rotation; the occiput arrives behind the symphy
                sis pubis, and the face in the cavity of the sacrum.   The face
                is first delivered from the  inferior strait,  as in all cases of
               ' breech presentation, and the occiput last.

to the right sa- (  The same mechanism except that after the movement of re
              \ tatioh the fac? is carried behind the pubis and the occiput to-
              ( wards the sacrum; the face is also first delivered.
  First, the heel or tibia to
the left acetabulum.
  Second,-----to the right.
  Third,
pro-iliac.
  Fourth,-----the left sacro-
iliac junction.
   Labours requiring manual assist
ance.
r   Presentation of the head
  or some part of the trunk.
J    Presentation of lower ex-
i  tremities  of the feet, knees
I  or nates.
    Two Indications First, When the labour is without accident,
  and the head is near the superior strait, but badhjsituated,  to
  place it in the  natural situation.  To do this we introduce the
  hand opposite the side of the pubis, to where the head is placed;
  press the fingers of this hand on the vertex if possible; bring i*
  into the superior strait, diagonally; then abandon the rest to na-
  ture: the lever may be advantageously substituted for tbe hand.
    Second,  When there is syncope, convulsions, daBgerous be.
  morrhage,  want of uterine action;  lay hold of  the  feet and
  turn the chilli.  Whatever is the position, introduce the hand
  which  corresponds to the side of tbe child which is backwards:
  the right, if it be the right side; the left, if it be the left; pass the
  hand over th« lateral parts of the trunk, which arc found back'
  wards; lay hold of the feet together, if possible, or separately and
  bring them out of the vulva. Apply at tbe same time the other
  band over the  uterus to incline  its fundus toward the opposite
  side.  When we cannot get but one foot at a time, disengage ir.
  in the direction of  adduction, pass a fillet round it, to secure it
  and search again, with the same hand, for the other foot: change
  the third and fourth positions, to the fiiwt and third, if possible)
  by giving the trunk in  proportion  as it  is disengaged, slight
  movements of rotation from without inwards; disengage the ami
  in the direction of adduction by commencing with the one which
  is behind, first depressing the shoulder; then  by passing  tbe
  hand over the  different parts of the face and chest, give  the
  head its  movement of flexion, by applying the ends of  the fin-
  gers of one hand upon the occiput which is raised, and the otbef
  upon  the sides of  the nose,  to  depress  the head; give it  the
  movement of rotation, by placing the fingers of one hand neat
  one of the mastoid  processes, and the other upon the opposite
  side of the chin; support the perineum,  deliver the face first,
  as in natural labour, with a breech presentation.
    Diagonal  Positions.  Lay hdld of the feet with the hand
  opposite to the side of the  pelvis, towards which  they  are di-
  rected, with the right hand if they are to the left;  with the left)
  if they are towards the right; bring them down together, if pos-
  sible,  or separately after securing the one which is brouglit
  out; finish the labour as after tbe turning; change, if possible, th«
  third  and fourth position to  the first and second sacro-pubic
I positions; employ either hand as may be  most convenient. 
SYNOPf IC  TABLE  OF  INSTRUMENTAL  LABOURS.
Instrumental la-
      bours.
                      In every c
   Presentation   head should
of   the   head .  hold of in thejdirec
at the  superior j  tion of its  oclcipito
strait.            J  mental or meijto-oc-
                  tripital diameter.
      Presentation of  the knee$.
Application  of fillets if manual  aid<
            be insufficient.     „a.
  Complicated  la-
)ours requiring  the
ase  of cutting  in-
struments.
                                              In the direct positions in which Hie occiput or forehead is
                                            found behind the symphysis pubis;, the two blades are alter-
                                            nately applied with each of the hjfflds; the left blade or the
                                            jointed one with the right hand, anq  the right  blade with the
                                            left hand'-  One of the  hands is pWced  in the vagina on the
                                            sides of the head to direct the forces.  In the diagonal posi-
                                            tions both blades are introduced m\h the same hand.   First
                                            apply the blade of the side opposite  to the one on which the
                                            occiput, forehead or chin is found, w ien they are directed for-
                                            wards;  if the occipital protuberance, the forehead or chin  is in
                                            front and to left, the left blade; and vice versa, if one or the
                                            other be  in front and to the  right Sde.*  The other  blade is
                                            applied with  the same  hand; the oyier hand remains in the
                                            vagina to direct tbe blades upon the  sides of the. head.   This
                                            being secured, disengage the  occifratj  first if it be a head  pre-
                                            sentation; support the perineum: disengage the fsce first, if it
                                            should  be a breech presentation: should tbe head be still in the
                                            superior strait, give it some movements of flexion and then of
                                            rotation, by moving it in imitation of  the natural ones.  When
                                            the trunk of the body is not freed from the pelvis, and the head
                                            is still  within the superior strait, the  forceps should always be
                                            applied on the anterior surface of toe foetus;  however, if we
                                            fear to injure the chest, apply the forceps on the posterior sur-
                                            face, bring the head into the inferior!  strait by moving itfin the
                                            direction of flexion and rotation; to«jn disengage the blades of
                                            the forceps to pass them upon the anterior surface of the foetus*
                                            join them together again, support the perineum, and finish by
                                            disengaging the face first.          .
                                               We  apply it always upon the knee which is directed forward
                                            with the  hand opposite to the side of the pelvi3 lo which this
                                            knee corresponds.   Carry the forefinger of the hand used into
                                            the hollow of the knee to puss the fillet; tighten it at the same
                                            time the fore finger of the other hand is carried into the hollow
                                            of the  knee which is behind; finish the delivery as in the ma-
                                            nual labour, with a breeeh presentation.
                                           f   It is always applied  on whichever of the nates is  directed
 Presentation of the breech or IfcneeS.   forwards.   Place one hand in the vagina to direct the blunt
 A    ,•   ,-     c .,   ,,    , ,    ■   .f.       book first introduced flatn ise, tben torn  it, in order to engage
Application of the blunUiook, if ma-<! it  from without inwards in the fold of  tb'e groin. appl¥8tgc
                                            fore finger of the other hand  in the fold of the opposite groin,
                                           c and finish the delivery as in the breech presentation.
                                               First Indication.   The infant is  dead.   Empty tbe skull,
                                            Should a fontanelle present, open it with a bistoury, whose blade
                                            is conducted on the fore finger of the/left band: if a solid part
                                            of the skull present, pierce it with a perforator; the serum then
                                            escapes; if there be none,  break dofq the brain with the in-
                                            strument, and use injections to wash  away the remains.  Then
                                            apply the forceps.   If  the forceps cannot be  applied, use the
                                            crotchet  upon the base  of the cranium or occiput, taking care
                                            not to  injure the  mother; use methodic force in drawing the
                                            head into a favourable  position.
                                               Second Indication. The narrowness of the pelvis is less than
                                            two inches and a  half.   The Caesarian operation  must be
                                            performed. The patient reclines on the bed; cut upon the  linea
                                            alba with a convex bistoury for the extent of about four inches;
                                            terminate the incision with a  probe  pointed  bistoury  directed
                                            from above downwards to avoid the intestine: cut the womb for
                                            the same extent, and in the same direction:  extract  the  child
                                            and placenta, wash  out the womb, and free the peritoneum of
                                            blood and other matters; apply a light bandage.
                                               Third  Indication. The narrowness of the pelvis is somewhat
                                            more than two inches and a  half.  Perform Symphyseotomy,
                                            or section of the symphisis pubis.f The patient lies on her back,
                                            as for  the operation of lithotomy; shave the pubis;  introduce a
                                            sound  into the bladder and press its neck to one side; draw the
                                            skin of the pubis upwards; cut the skin gradually, tbe cellular
                                            texture and interarticular cartilage; separate the thighs with
                                            caution to enlarge the pelvis; extractjtbe foetus through the na-
                                            tural passages by aid of the forceps;  then apply a proper ban-
                                            dage round the body.
                                               If the  foetus has been decollated, and the head alone remain
nual aid.be insufficient.
Disproportion between the size of the
      fcetal head and the pelvis.
Or decollation of the foetus.
Extraction of the placenta.
 in the womb, it must be brought into a proper position with the
 hand; seize it then with the forceps, sharp crotchet, and empty
 tbe skull if it be of a size disproportioned, and terminate the
 labour as in other cases.           •*
    If the trunk remain within and the shoulders still in the su-
 perior strait, we must  turn the foetus, as heretofore directed;
 otherwise bring down the arms and  draw by them; to extract
 the rest of the trunk, apply the blunl hook in the axilla, ano\
|^ draw thereby in the usual manner.

    Two Indications.  First. Merely*;assist nature; draw  by
 the umbilical cord, first in the direction of tbe superior strait
 by making a pulley of the fingers placed  near the perineum,
 roll the  placenta  upon itself without using force, in order to
 bring away all the remains.  Second| Introduce the hand into
 the womb, separate  the placenta cautiously,  if it be slightly
 adherent, and  remove it: should it be strongly adherent to tbe
 walls of the womb, it may be dangerous to detach it. Leave it
(.for some time longer.

    * Dr. Columbus.
    + The operation here recommended, is attended by no  advantage, and
 many dangers.  It has never been performed in this country, and  nevet
 should be.—J. D. G. 
•*.* 
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Scott, being the first part of the Cabinet History of the Bri-
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and Thomas Moore, to be completed in 6 vols.

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graceful facility of style and picturesqueness of descnption of his other charming
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Hume and other professed historians. Such is  the magic charm of Sir Walter
Scott's pen, it has only to touch the simplest incident of every day life, and it
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fidelity to the  text of nature, that the knights, and serfs, and collared fools
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    III.  The PRACTICE of PHYSIC, by W. P.  De-

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„,,*• and having also availed himself of his long experience, he  trusts Uiat
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Published by Carey §• Lea.             3
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   XVI.  A  CHRONICLE  of  the  CONQUEST  of

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  XX.  A  REPLY  to SIR WALTER  SCOTT'S
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Published by Carey 4* Lea.           7
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  XLIV. A JOURNEY ROUND MY ROOM, from
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Levasseur, Secretary to the  General during his journey, Z
vols. 12mo. Translated by John D. Godman,  M. D.




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               /Ar THE PRESS,

  I. A HISTORY  of MARITIME DISCOVERY,
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To be completed in 6 vols. 18mo.

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  VI. BELL on the ANATOMY, PHYSIOLOGY,
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  VII.   MACCULLOCH on  REMITTENT  and
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  VIII.  The PRINCIPLES  and  PRACTICE  of
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                              Philadelphia, February, 1830.

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          CONVERSATIONS-LEXICON.
             Edited by Dr. FRANCIS LIEBER,
       Assisted by EDWARD WIGGLESWORTH, Esa


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2
ENCYCLOPEDIA AMERICANA.
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sand copies,  have been printed in  less than fifteen years.   It
has been translated into the Swedish, Danish and Dutch lan-
guages, and a French translation is now preparing in Paris.
  A great advantage of this work  is its liberal and impartial
character; and there can be no doubt that a book like the En-
cyclopedia. Americana will  be found peculiarly useful in this
country,  where the wide diffusion of the  blessings of education
and the  constant intercourse of all classes, create a great de-
mand for general  information.
  In the  preparation of the work  thus  far, the Editors have
been aided by many gentlemen of distinguished ability; and for
the continuation, no efforts shall be spared to secure the aid of
all who can, in any way, contribute to render it  worthy of
patronage.
  The American Biography,  which  is very extensive, will  be
furnished by  Mr. Walsh, who has long  paid particular atten-
tion to that branch of our literature,  and from materials in the
collection of which he has been engaged for some years. For
obvious reasons, the notices of distinguished Americans will bo
confined to deceased individuals: the European biography con-
tains notices of all distinguished living  characters,  as well aa
tho«e of past times.
  The articles on Zoology have been written expressly for the
present edition  by Dr. John D.  Godman ;  those on Chemistry
and Mineralogy, by a  gentleman  deeply  versed in those de-
partments of  science.
  In relation to the Fine Arts, the work will be exceedingly
rich.  Great  attention was given to this in the  German work,
and the Editors have been anxious to render it, by the necessary
additions, as perfect as possible.
  To gentlemen of the Bar, the work will be peculiarly valua-
ble, as in cases  where legal subjects are treated, an account ia 
ENCYCLOPAEDIA AMERICANA.
3
given of the provisions of American, English, French, Prussian,
Austrian, and Civil  Law.
   The Publishers believe it will be admitted, that this work is
one of the cheapest  ever published in this country.  They have
been desirous to render  it worthy of a place in the best libraries,
while at the  same time they have fixed the price so low as to
put it within the  reach of all  who read.
  Those who can, by any honest modes of economy, reserve the sum of two
dollars and fifty cents quarterly, from their family expenses, may pay for this
work as fast as it is published; and wo confidently believe that they will find
at the end that they never purchased so much general, practical, useful infor-
mation at so cheap a rate.—Journal of Education.
  If the encouragement to the publishers should correspond with the testimony
in favor of their enterprise, and the beautiful and faithful style of its execu-
tion, the hazard of the undertaking, bold as it was, will be well compensated;
and our libraries will be enriched by the most generally useful encyclopedic
dictionary that has been offered to the readers of the English language.  Full
enough fur the general  scholar, and plain enough for every capacity, it  is far
more convenient, in every view and form, than its more expensive and ponder-
ous predecessors—American Farmer.
  The high reputation of the contributors to this work, will not fail to insure
it a favorable reception, and its own merits will do the rest.—Silliman's Journ.
  The work will  be a valuable possession  to every family or individual that
can afford to purchase it; and we take pleasure, therefore, in extending the
knowledge of its merits.—National Intelligencer.
  The Kncycloptedia Americana is a  prodigious improvement upon all that
has gone before it; a thing for our country, as well as the country that gave
it birth, to be proud of; an inexhaustible treasury of useful, pleasant and fa-
miliar learning on every possible subject, so arranged as  to be speedily and
safely referred to en emergency, as well as on deliberate inquiry; and better
still, adapted to the understanding, and put within the reach of the multitude.
*  *  * The Encyclopaedia Americana is a work without which  no library
worthy of the name can hereafter be made up.—Yankee.
  The copious information which, if a just idea of the whole may be formed
from the first volume, this work affords on American subjects, fully justifies
its title of an American Dictionary; while at the same time the extent, varie-
ty, and felicitous disposition of its topics, make it the most convenient and
satisfactory Encyclopaedia that we have ever seen.—National Journal.
  If the succeeding volumes shall equal in merit the one before us, we may
confidently anticipate for the work a  reputation and usefulness which ought
to secure  for it the  most flattering encouragement and patronage.—Federal
Gazette.
  The variety of topics is of course vast, and they are  treated in a manner
which is at once so full of information and  so interesting, that the work, in
stead  of being merely referred to, might be regularly perused with as much
pleasure as profit.—Baltimore American.
  We view it as a publication worthy of the age and of the country, and can-
not but believe the discrimination of our countrymen will sustain the publish
ers, and well reward them for this contribution to American Literature.—
Baltimore  Patriot.
  We cannot doubt that tbe succeeding volumes will equal the first, and we
hence warmly recommend the work to tbe patronage of the public, as being by
far the best work of the kind ever offered for sale in this country.— V. S. Oa:.
  It reflects the greatest credit on those who  have been concerned in its pro-
duction, and promises, in a variety of respects, to be the best as well as the
most compendious dictionary of the arts, sciences, history, politics, biography,
&c. which  has yet been compiled.  The style of the portion we have read
is terse and perspicuous;  and it is really curious how so  much scientific and
other information could have been so satisfactorily communicated in sueh brief
limits.—JV. Y. Evening  Post.
  A compendious library, and invaluable book of reference.—JV*. Y. American. 
4
ENCYCLOPEDIA  AMERICANA.
  This cannot but prove a valuable addition to the literature of the "age.—Mtr.
Advertiser.
  The appearance of the first volume of this valuable work in this country, 11
an event not  less creditable to its enterprising publishers, than it is likely lo
prove lastingly  beneficial to the public.  When completed, according to the
model presented by the first volume, it will  deserve to be regarded as the spirit
of all the best Encyclopedias, since it  comprises whatever is really desirable
and necessary in them,  and in addition, a large proportion of articles entirely
original, or expressly written for  its pages.  This  is the condition of all the
articles of American Biography, by Mr. Walsh; those on Zoology, by Dr. God-
man; and those on Mineralogy and Chemistry, by a gentleman of  Boston,
distinguished for his successful devotion to those studies.   The work abounds
with interesting and useful matter, presented in a condensed and perspicuous
style; nor is  it  one of  its  least commendations that it is to be comprised in
twelve octavo volumes, which may be placed on an office table, or occupy a
shelf in the parlor, ever ready for immediate reference, instead of reciiimng
almost a room to itself, like its ponderous predecessors, the Britunnica, lldin
burgensis, &c.
  The vast circulation this work has had in Europe, where it has already been
reprinted in four or five languages, not to speak of the numerous German edi-
tions, of which  seven have been published, speaks  loudly in  favor of its in-
trinsic merit, without which such a celebrity  could never have been attained.
To every man engaged  in public business, who needs a correct and ample book
of reference on various  topics of science and letters, the Encyclopaedia Ameri-
cana will  be  almost invaluable.  To individuals obliged to goto  situations
where books are neither numerous nor easily procured, the rich contents of
these twelve volumes will prove a mine which will amply repay its  purchaser,
and be with difficulty exhausted, and we  recommend it to their patronage in
the full conviction of its worth.  Indeed  it is difficult to say to what  class of
readers such a book would not prove useful, nay, almost  indispensable, since
it combines a great amount of valuable matter in small compass, and ut mode-
rate expense, and is in every respect well suited to augment the reader's stock
of ideas, and powers of conversation, without severely taxing time or fatiguing
attention.  These,  at least, are our  conclusions after a close and  candid ex-
amination of the first volume.—3m. Daily Advertiser.
  We have seen and carefully examined the first volume of the Encyclopaedia
Americana, just published by Carey,  Lea and  Carey, and think our readers may
be congratulated upon the opportunity of making such a valuable accession to
their libraries.—Aurora.
  The department  of American Biography,  a subject  of which it should lie
disgraceful to be ignorant, to the degree that many are, is,  in this work, a
prominent feature, and has received  the attention of one of the most indefati-
gable writers in this department of literature, which tbe  present age can  fur-
nish.—Boston Courier.
  According to the plan of Dr. Lieber, a desideratum will be supplied; the sub-
stance of contemporary knowledge will be  brought within a small compass;—
and the character and uses of a manual will be imparted to a kind  of publica-
tion heretofore  reserved, on strong shelves, for occasional reference. By those
who understand the German language, the Conversation  Lerkon is consulted
ten times  for one application to any English  Encyclopaedia.—National Gaz.
  The volume now published is not only highly honorable to the taste, ability
and industry of its editors  and publishers, but furnishe* a proud sample of tiie
accuracy and elegance,  with which the most elaborate and important literary
enterprises may now be accomplished in our country.  Of the manner in which
the editors have thus far completed their task, it is impossible, in the course of
a brief newspaper article, to speak with adequate justice.—Boston Bulletin.
  We have  looked  at  the  contents, generally, of the  second volume of this
work, and think it merits the encomiums which have been bestowed on it in
the northern papers.  It continues to lie particularly rich in  the departments
of Biography and Natural History.  When we look at the large mass of mis-
cellaneous knowledge spread before the reader, in a form which has  never been
equalled for its condensation, and conveyed in a style that cannot be surpassed
for propriety and perspicuity, we cannot but think  that the American Ency-
clopedia deserves a place in every collection,  in which works of reference form
a portion."—Southern Patriot.
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