lillllilll Wti':.!!iiillMUN] ■fell; jfo'liiiiiiii.iiii'iiiiil'iiiiiiiiiili'i'inN.........<'..... — ' ■" '......*"•'------""* ,I,JI-::;;;M By" \:', I lllllll iliijirtnllin.. ».- ■■«'■—• ~*w~~**»*.i>l-*« ^ ..^' •Mh^aaiMaain ■ 'i4I!I || Niliii"illiiir l! mm- ^itil,,.: Hffljifil?-ll:''''N!t|ilii'i"iij!: iH^wnjhiiMii.mi.," •^^;ii?!iii^ll|j|rr 73 £>. fRti* <$#A&r- S ETC. ETC. PHILADELPHIA: PUBLISHED BY A. HART, late CAREY AND HART, 126 CHESTNUT STREET. 1852. Vv'O - J\8Qt | 1&S2. Entered according to the Act of Congress, in the year 1844, by JOSEPH PANCOAST, M. D., in the Office of the District Court of the United States in and for the Eastern District of Pennsylvania. T. K. Sc P. G. COLLINS, PRINTER!*. ADVERTISEMENT TO THE SECOND EDITION. In issuing a new edition of the Operative Surgery, the publishers are desirous of offering their acknowledgments to the medical public for the unexampled favour with which the work has been received—an edition of two thousand copies having been exhausted in less than eighteen months from the time of publication. In the former advertisement the author expressly disavowed his intention to do more than give the operative surgery of the day as he best understood it, with the surgical anatomy of the parts concerned, and such brief details in reference to the pathology and therapeutical management of surgical affections as seemed absolutely necessary— a condensed, comprehensive, and purely practical treatise like this not being the place for discussing at large prin- ciples in surgery or settling controverted claims to the earliest performances of particular processes, which local prejudices and national rivalry must ever render an ungracious task. On the grounds thus assumed in preparing his work, he alone deems himself amenable to criticism; and, on carefully revising and enlarging it for a second edition, he has found no reason to change his plan. All descriptions of operative processes, like those of mathe- matical problems, must, if correct, be to a certain extent analogous, and while the author has been earnestly desirous of doing no one injustice, he believes that the question, who has given them most clearly and intelligibly, is the one which mainly interests the profession at large. The plan of describing fully and systematically the operations of surgery apart from lengthened therapeutical details, is new to the science; not an instance of it, prior to the appearance of this work, being found in the whole range of English literature: for while British surgeons have borrowed freely from the French, both as regards processes and illustrations, they have not taken from them at the same time their scientific order and arrangement. But three works have previously appeared on this plan— those of MM. Velpeau, Malgaigne, and Bourgery, from the last of which, as well as from the numbers of Froriep, as duly acknowledged in the advertisement to the first edition, the author has been most indebted in the preparation of his work. The text of the three French surgeons above mentioned, as it has been drawn from the same sources, must of necessity have close analogy in language and arrangement. M. Bourgery has followed closely the systematic classification of operations adopted by M. Malgaigne, and as this is the natural classification, the author of this work did not deem it best to vary greatly from the same plan. Since the publication of the first edition, the sheets of M. Bourgery, from the subject of Hernia to the conclusion of his splendidly illustrated work, have reached the author, and he has availed himself of them to a certain extent in preparing the present edition. ADVERTISEMENT TO THE FIRST EDITION. The necessity of thoroughly illustrating the operations of Surgery, has been felt from the earliest periods of the art, as a means of rendering the processes for their performance intelligible to the student. Almost every modern surgeon of distinction, and especially Camper, Scarpa, Cooper, Hesselbach, Bell, and Dupuytren, have, in par- ticular departments of the science, contributed much to the attainment of this most desirable end. The attempt to collect the newest and completest modes of illustration into a continuous whole, has been made but in two instances—by M. Froriep of Berlin, who has issued them in numbers, without any other regard to order than the time of their appearance, and by M. Bourgery of Paris. The voluminous and expensive character of these works, and especially of the latter, which is as yet but little more than half completed, as well as their being clothed in a foreign language, renders them in a great degree inaccessible to the American surgeon. With these admirable treatises before him as a guide, and having at hand the greater portion of the surgical works which have recently appeared in various languages, and with the advantage which nine years' continuous service in one of the largest hospitals of North America has given him, not only in comparing to a certain extent the value of the different methods, but in enabling him to obtain a large number of accurate drawings of operations which have been done by his own hand, the author has endeavoured to furnish a work that shall represent, so far as its limits will allow, the operative surgery of the day. In pursuance of this desire to portray the actual state of the science, many processes of operation have been given for which the author cannot hold himself any further responsible than of having made of them a clear and impartial statement, drawn from the most authentic sources. The description of processes, too often given obscurely by their inventors, is confessedly difficult, and the author has not hesitated, when he believed he could thereby render their details more plain, to risk occasional repetition. The drawings, in almost every instance, have been represented in such a point of view that the examiner may, in the sta^e of the process immediately shown, consider himself as the operator. In order to render the work still more useful to the practitioner, a brief but comprehensive description of the surgical anatomy of the parts immediately concerned has been added, as well also as some account of the patholo- gical changes, when this was deemed necessary to the comprehension of the operation in question. It has not, however, been possible to enter into a discussion of the claims of different surgeons to particular processes, or to detail in full the therapeutical management of surgical affections, which would have expanded the work to an immoderate size. Some brief observations have, however, in the latter respect, been given, in order to assist those in forming opinions who have not other means at hand for consultation, but without invalidating the claims of this work to be especially considered as a Practical Treatise on Operative Surgery. In the prospectus, the work was announced as consisting only of seventy plates, containing two hundred and fifty separate figures, with from two hundred to two hundred and fifty pages of illustrative text. But as these limits were found too restricted for so copious a subject, the publishers, with a liberality that does them honour, have consented, without increasing the price to subscribers at the time of publication, to its extension to its present dimensions, which will be found to consist of eighty quarto plates, comprising four hundred and eighty-six separate illustrations, and three hundred and eighty quarto pages,of description. CONTENTS. PAKT FIRST. ELEMENTARY AND MINOR OPERATIONS. I. Division of parts with the bistoury and scissors, Of the bistoury, ...--. Straight incisions, Compound incisions, ..... Incisions from within outwards and from right to left, Incisions with the bistoury upon a director, Incision with the scissors, ----- Punctures, ------- II- Division of parts by ligature, - - - - III. Phlebotomy or blood-letting in general, - Venesection at the bend of the arm, ----------------foot, - neck, near the part affected, Bleeding by incisions from the cephalic vein, IV. Arteriotomy, ------- Cauterization, .----- V. Cauterization with potential cauteries, - - - - .-----------with the metallic or actual cautery, or surgical pyrotechnics, ------ VI. Reunion by suture, - - - - Rules for the application of sutures in general, Individual sutures, ------ VII. Of the seton, ------- VIII. On the formation of an issue or fontanel, - - IX. Moxa, ------- X. Acupuncturation, - - - - - Electro or Galvano-puncture, - XI. Means of preventing hemorrhage or surgical hemostatics, 1. Of the mode of compression in general. With the hand, - Mechanical compression, - Compression of the individual arteries, - - - 2. Means of arresting hemorrhage during operation, - Arterial and venous hemorrhage, - - 3. Means of arresting arterial hemorrhage after operations, - 4. Means which have been applied to the arteries of small and medium size only, - PAGE 9 9 11 11 12 12 13 13 14 15 15 18 18 19 19 19 20 20 23 25 25 26 27 27 28 28 28 29 29 29 32 33 33 33 34 PART SECOND. GENERAL OPERATIONS, OR THOSE PRACTISED WITH REFERENCE TO ONE OR MORE PARTICULAR TISSUES. I. Operations upon the Veins, For transfusion of blood, Varicose veins, by compression, by section, by ligature, by cauterization, 2 36 36 37 37 38 38 39 II. Operations upon the Arteries, - Ligature of the arteries in their course, To expose the sheath of the vessels, - The isolation of the artery, . . - - Application of the ligature, - Ligature of the different arteries, - -------------arteria innominata, - - - - common carotid, - --------place of election or upper third, - --------place of necessity or lower third, of the external carotid, Ligature of the superior thyroid, - -------------lingual artery, - —------------facial, ----- -------------occipital, ----- -------------posterior auris, ... - -------------temporal, - - - Ligature of the arteries of the upper extremity, - - - Ligature of the subclavian artery, - - - - -------------outer portion of the artery or over the first rib, -------------between the scaleni, ... -------------within the scaleni, - - - - --------of the branches of the subclavian, axillary artery, 1. above the pectoralis minor, called the high operation upon the axillary, and sometimes spoken of as ligature of the subclavian below the clavicle, - - - 2. behind the pectoralis minor, - - - - Ligature of the brachial artery, .... -------at the middle part of the os humeri, ——— immediately above the elbow joint, -------at the bend of the elbow, - -------of the arteries of the forearm, -------------radial artery, ... - -----------------------at the upper third of the forearm, middle or lower third, on the back of the wrist, of the ulnar artery, - ----------------- near the termination of its upper third, -----------------either at the middle or inferior third, -------------— below the pisiform bone, -------of the anterior interosseal in the lower half of its course, ------ Ligature of the arteries of the trunk, - - - - Ligature of the abdominal aorta, - - - - -------------iliac arteries, .... -------------internal iliac, - -------------primitive or common iliac, -------------external iliac, .... -------------epigastric artery, - -------------gluteal artery, ... - -------------ischiatic artery, ... - -------------internal pudic, Ligature of the femoral artery, - - - - - 1. above the profunda or at the crural arch, page 39 39 40 41 41 42 42 44 46 47 48 48 49 49 51 51 51 52 52 53 54 55 55 56 57 59 60 62 62 63 63 63 63 64 64 65 67 67 67 67 68 68 69 70 71 71 72 72 73 73 73 76 6 CONTENTS. 2. at the uppeT fourth of the thigh below the profunda, - 3. in the middle third or under the sartorius, 4. at the inferior third as the artery passes through the Bheath of the adductor magnus, - - - Ligature of the popliteal artery, - 1. usual process for the upper part of the popliteal, 2. by incision upon the inner side of the ham, - Lipature of the arteries of the leg, - Ligature of the anterior tibial upon the leg, -------------------------in the middle or upper third, -------------------------on the dorsum of the foot, - posterior tibial, in the upper third of the leg, — at the middle third of the leg, -------------posterior tibial behind the malleolus internus, -------------peroneal artery, - III. Operations for Diseases or the Bones and Joints, - Hydrarthrosis—articular dropsy, - - - - Foreign bodies or movable cartilages in the joints, Foreign bodies or movable cartilages in the bursal sheaths of the tendons, - Ganglions or synovial cysts—hydatiform cysts, Hygroma—enlarged bursa mucosae, - Dropsy of the bursa?, - Anchylosis, ------- Rupture of the anchylosis, - - - - Anchylosis of the hip, .... Removing a wedge-shaped portion of bone for straight- ening an anchylosed knee, ... Complicated fractures and luxations, ... Pseudo-Arthrosis—False joint—Ununited Fracture, Friction of the ends of the bones. Compression—Seton, Cauterization of the bones. Acupuncturation. Excision of ends, ------ Deformities from the irregular union of fractured bones—Vi- cious or deformed callus, .... Resection, ------- Use of the seton—Rupture and section of callus, - Exostosis, ------- Cysts in the bones, ------ Caries and necrosis, - Spontaneous and artificial cure of necrosis, Extraction of the sequestrum, .... Operation for caries, ----- Trepanning or Trephining of the bones of the cranium, Instruments required, - - - - - Resection of the bones, ...... General rules for resection, - - - . Resection of the bones of the trunk, ... -------------------------face in general, upper jaw, lower jaw, Partial resection of the sternum, .... --------------of the ribs, .... --------------of the pelvic bones, Resection of the clavicle, - ----------------------entire, - Partial resection of the scapula, .... Resection of the shoulder joint, - --------of the elbow joint, - - - . --------of the end of the humerus only, --------of the radius, ... --------of the wrist joint, - --------of the inferior extremity of the radius and ulna, --------of the metacarpal bones, ... --------of the metacarpophalangeal joints, Extraction of the first phalanx, - Resection of the head of the os femoris, - --------of the knee-joint, .... --------of the fibula, - page 76 76 77 77 78 78 79 79 79 80 81 81 81 83 83 84 84 85 86 86 87 87 89 91 92 92 93 94 95 95 96 97 97 99 100 100 101 101 104 107 108 109 109 109 113 117 117 118 118 119 119 120 122 125 127 127 128 128 128 128 129 129 131 Resection of the ankle joint, .--------of the tarsal bones, - --------■ of the first metatarsal bone, --------of the metatarso-phalangeal articulation, --------of the metatarsal bones entire, - IV. Amputations, - - - - Amputations in general, - - - Place of election, - - - - Instruments, . - - The position of the patient, the surgeon and his assistants, Method of operation, - Circular, flap and oval methods, - - - - Ligature of the vessels and dressing of the stump, Special amputations—Upper extremity, 1. Of the hand, - . . . Amputation of the phalanges, - ----------at the two phalangeal joints, - ----------of the fingers in continuity or through the pha- langes, ----- ----------in the metacarpophalangeal articulations, ----------of the four fingers together, -------------------------— in the continuity of the me- tacarpal bones, - ----------of the metacarpal bones separately, - ----------at the metacarpo-carpal joints, ----------at the metacarpo-carpal joint of the thumb, ----------of the metacarpal bone of the little finger, ----------of the metacarpal bones of the 2d, 3d, and 4th fingers at their junction with the oarpus, - ----------of the four metacarpal bones of the fingers toge- ther at their metacarpo-carpal joints, ----------in the radio-carpal articulation. 2. Of the Forearm, - - - - - Amputation in the continuity of the forearm, ----------at the elbow joint, - ----------single and double flap methods, 3. Of the Arm, ----- ^ - Amputation in the continuity of the arm, ... ----------■ in the lower two-thirds of the arm, ----------at the upper third of the arm, - - - ----------af the shoulder joint, - ----------circular method, - ----------flap method, ----- ----------oval method, - ----------of the shoulder blade with the arm, - Or THE LOWER EXTREMITIES, - 1. Amputations of the foot, ----- Amputation at the metatarso-tarsal joints, - - - ----------at the middle tarsal joint, (Chopart,) - ----------at the ankle joint, - 2. Of the Leg........ Amputation in the continuity of the leg, ----------at the first place of election, - - - ----------circular method modified, ----------position of the operator, - ----------• flap method, - ---------- at the place of election, - ----------at the place of necessity or through the condyles of the tibia, .... ----------at the knee-joint, - ~" '-------------flap method, 3. Of the Thigh, --..... Amputation in the continuity of the thigh, - --------— flap method, - —--------■ anterior and posterior flaps, ----------at the hip joint, .... ----------■ single and double flap methods, ----------circular and oval methods, - - . PAGE 131 132 132 133 133 133 133 134 134 135 135 136 137 137 138 138 139 140 140 141 141 143 143 143 144 145 145 147 148 148 149 149 151 151 152 153 153 155 156 157 158 158 159 159 162 164 164 164 165 165 166 167 168 168 168 169 172 172 173 173 174 175 178 CONTENTS. PART THIRD. SPECIAL OPERATIONS, OR THOSE WHICH ARE PRACTISED UPON COMPLEX ORGANS IN PARTICULAR REGIONS OF THE BODY. PAGE 1. Operations practised upon the eyeball and its accessory organs. 180 180 181 182 183 185 186 187 188 189 189 189 Operations practised on the accessary organs of the eye, Lachrymal apparatus, ------ Treatment of lachrymal tumour and lachrymal fistula, Injections through the puncta. Catheterism, Catheterism of the nasal duct through the nostril, - Dilatation by the puncta and by the nasal duct, Dilatation through an orifice in the sac, - - - Introduction of a nail-headed stile, - - - - Permanent dilatation with a tube, - - - - Cauterization after puncture from below upwards, - Obliteration of the lachrymal puncta and canals, - Formation of an artificial canal, - - - - Perforation through the os unguis—Through the maxillary bone,.......189 Operations for various diseases of the eyelids, - - - 190 Operation for Ectropion, - - - - - 190 Of ectropion caused by tumefaction of the conjunctiva, - 191 Operation for shortening of the skin of the lid, - - 192 -----------Ectropion from caries of the orbit and from tumours, - - - - 194 ------------Entropion or inversion of the eyelid, - 194 ---------------------from relaxation of the integument, 194 ------------Inversion from a detracted and deformed state of the cartilage, - •■ - 195 ------------Trichiasis and distichiasis, - - - 196 ------------Blepharoptosis, - - - - 196 ------------Adhesion of the lids. Ankyloblepharon. Syn- blepharon, - - - - 197 ------------Tumours of the lids, - - - 197 -----------> ColobomapalpebrtE, - - - - 198 ------------Epicanthis, - - - - - 198 Operations practised through the conjunctiva, - - - 198 Operation for Excrescences—Encanthis—Pinguecula, - 198 ------------Pterygium, - - - - - 198 ------------Pannus—Varicose condition of the conjunc- tiva—Vascular cornea, - - - 199 Operations on the ball of the eye, - - - - - 199 Cataract, ------- 199 Operations for the removal of cataract, - - 201 1. Depression. Couching or displacement, including Re- version and Reclination, - - - - 201 2. Division, ------ 205 3. Extraction, - - - - - - 205 For secondary cataract, - - - - - 212 Operations for artificial pupil, - - - - -213 1. Incision—corectomia—iridotomia, - - - 213 2. Excision—iridectomia, - - - - 214 3. Detachment of the iris at its outer margin, - 214 4. Extension of the natural pupil, - - - 215 Staphyloma corneasp, - - - - -219 ----------sclerotica?, ----- 220 Strabismus, ...... 220 II. Operations on the ear, ..... 225 1. Foreign bodies in the auditory passage, - - 225 2. Polypous tumours, fungous excrescences, etc. - 226 3. Closure of the auditory passage, - - - 226 4. Catheterism of the Eustachian tube, - - - 226 5. Perforation of the membrana tympani, - - 230 6. ---------of the mastoid cells, ... 230 HI. Operations upon the nose and nasal cavities, - 230 Tumours of the nose, .... 232 Extraction of foreign bodies, - Plugging or tamponing in nasal hemorrhage, Polypous tumours, ------ Extraction of polypous tumours—with forceps, ,----------------------------by excision, -----------------------------by strangulation with liga- ture, - - - Catheterism and perforation of the frontal and maxillary si- nuses, ------- ----------------------— by the mouth, ------------------------by the cheek, - IV. Operations upon the mouth and its dependent structures, - Of the lips and cheeks, - Hypertrophy of the lips, - - Atresia oris—contraction of the orifice of the mouth, Hare-lip, ------- Simple hare-lip, - Double and complicated hare-lip, - Cancer of the lips, ------ Anchylosis of the lower jaw, - Salivary fistula, ...... Fistulas of the parotid gland, .... Cicatrization of the fistulous orifice, - Dilatation of the natural passage when this is found contracted, - Formation of an artificial passage in case of the obli- teration of the anterior or internal part of the canal, Extirpation of the parotid gland, .... Obliteration of the natural duct for the purpose of suppressing the salivary secretion, by producing atrophy of the parotid gland, - - Extirpation of the submaxillary gland, ... Ranula, ....... Operations on the tongue, - Ankyloglossum—adhesion of the tongue—tongue-tie, Stammering, ...... Removal of diseased portions of the tongue with cutting in- struments, - - Removal and atrophy by ligature, - - - - Excision of the uvula, ----- Extirpation of the tonsils, - Staphyloraphy, ------ Application of ligatures, .... Excision of the edges—knotting the ligatures, Process employed by the Author, Excision. Introduction of the ligatures, Knotting the ligatures, - - - - - Modification of the operation rendered necessary when there is deficiency of structure or the fissure is unusually large, - - - - - V. Operations upon the neck, ----- Bronchotomy, --.... 1. Tracheotomy, ------ 2. Laryngo-tracheotomy, - - - - - 3. Laryngotomy, ------ Catheterism of the oesophagus, - Stricture of the oesophagus, .... Removal of foreign bodies from the oesophagus, - CEsophagotomy, ...... VI. Operations upon the thorax, .... Extirpation of the mammary gland, ... Empyema—paracentesis thoracis, - - - - Wound of the intercostal artery, - Paracentesis of the pericardium, - VII. Operations upon the abdomen, .... Operations for the cure of ascites, - - - . Penetrating wounds of the abdomen, Wounds of the intestine, - - - - . Operations for hernial tumours of the abdomen, Treatment of hernia, ..... page 233 233 234 237 238 239 240 241 242 242 242 242 243 244 244 245 246 247 248 249 249 249 249 251 251 253 254 255 255 255 256 257 258 258 259 260 261 262 262 262 262 263 263 264 265 265 266 267 267 268 269 269 271 274 274 275 275 276 277 281 284 s CONTENTS. Radical cure of hernia, .... Of particular forms of hemia, Inguinal hernia, - Strangulated inguinal hernia, Operation for inguinal hernia, ... Crural or femoral hernia, - - - - Treatment of crural hernia, ... Operation for strangulated crural hernia, Umbilical hemia, --.--. Operation for strangulated umbilical hernia, VIII. Operations upon the anus and rectum, For imperforate anus, - Formation of an artificial anus, Polypous tumours of the rectum, Prolapsus ani, - Prolapsus of the mucous membrane, - Prolapsus of the rectum with invagination, Cancer of the rectum—extirpation, Hemorrhoidal tumours or piles, - Abscess by the side of the anus, - Fistula in ano—complete anal fistula, - - - -------------incomplete external and internal fistula, Fissure of the anus, - Stricture of the anus, - . . . . IX. Operations upon the genito-urinary organs—(in the male,) Operations upon the scrotum, - - - . . For Hydrocele, ---... Hydrocele of the tunica vaginalis testis, Hydrocele of the spermatic cord, ... Encysted Hydrocele, - Hydrocele in the child, - Sarcocele, ------ Castration, -----. Varicocele and Cirsocele, - 1. By division or excision, - 2. By ligature, - 3. By compression, - 4. Shortening of the scrotum, Operations upon the penis, - - . . For Phimosis, --.-... Paraphimosis, - Cancer of the penis—amputation of the penis, Hypospadias, --..._ Epispadias, ..... Operations on tlie urethra and bladder, - For Stricture of the urethra, - Dilatation, - Cauterization, - Incision and scarification, .... Puncture of the bladder, - Operations for stone—(lithotomy in the male,) - Operation through the perineum, - Lateral operation, ... The division of the prostate with the knife, the lithotome, :-----the gorget, Bilateral operation, Recto-vesical or median operation Super-pubic, hypogastric or high operation, Lithotrity, --._'_ Lithotripsy, ... Lithectasy. ... Operations upon the genital organs in the female, Lithotomy in the female, - --------through the vestibulum, - ■------------urethra, - Suture of the perineum, Recto-vaginal fistula, Vesico-vaginal fistula, page 285 287 287 289 290 293 295 295 297 298 298 298 300 301 302 302 303 303 305 308 308 310 310 310 311 311 311 311 314 314 314 314 315 315 315 316 317 317 318 318 320 320 321 322 322 323 324 325 325 327 329 329 331 331 332 333 335 335 336 337 337 340 341 341 341 342 342 343 345 PART FOURTH. PLASTIC AND SUBCUTANEOUS OPERATIONS. PAGE I. Plastic operations, various modes of, - - - 348 Rhinoplasty, ------ 350 Blepharoplasty, - - - - - -359 Cheiloplasty, ....-- 360 Stomatoplasty, ------ 363 Genoplasty—meloplasty, ----- 363 Otoplasty, ------- 365 Staphyloplasty, - - - - - -365 Uranoplasty—palatoplasty, - - - - 365 Bronchoplasty, ------ 367 Posthioplasty, - - - - - -367 Chalinoplasty, ...... 367 Oscheoplasty, ...... 367 Urethroplasty, ...... 367 For the cure of deformities resulting from burns, - - 368 II. Subcutaneous Operations, - - - - -371 Surgical pathology of the retracted muscular and fibrous tissues, - - - - - - 372 Mechanical distension, ----- 372 General rules for subcutaneous section, - - - 372 Myotomy on the head and trunk, - 373 Section of the muscles of the back, - 373 Torticollis—caput obstipum—(wry-neck,) - - 373 Subcutaneous section of the temporal and masseter muscles in cases of permanent spasmodic closure of the jaws, 376 Subcutaneous section of the masseter, - - . 37$ Section of the various muscles of the face for the cure of spasmodic contraction, - - - . . 375 Section of the tendons of the armpit in old dislocations of the os humeri, - - , - Subcutaneous operation for the cure of empyema Puncture of abscesses or other deep-seated collections of fluids by the subcutaneous method, - Subcutaneous section of muscles, tendons, and fascia, for the cure of deformities of the lower extremities - Talipes or club-foot, - - . ------• varus—pes varus, - ------■ equinus—pes equinus, .... ------valgus—pes valgus, ------■ calcaneus—pes calcaneus, - 1 plantaris, - Section of the tendo-Achillis, ■--------adductor muscle of the great toe --------tendon of the anterior tibial muscle ---------------posterior tibial muscle, ■ - common flexor muscle of the toes, — plantar aponeurosis and short flexor of the toes, — long flexor of the great toe, "——— tendons of the two larger peronei muscles " -----------extensor muscles of the toes, . '. tendons and fibrous structures for false an chylosis of the knee joint - D Subctitaneous section for deformities ofthe upper extremities' ~^- for curvatures of the hand and fingers, (club-' t77 ~ ?{ the flexor tendons above the wrist" Deformities of the elbow joint ' Section of the tendon of the biceps muscle, Q„r . " triceps muscle, Subcutaneous section of the stricture in hernia, - ) • sphincter ani, ■ inferior oblique muscles of the eye; • proposed in various other affections 377 378 378 379 379 379 380 380 381 381 381 382 382 382 383 383 383 384 384 384 387 387 388 388 388 388 388 389 389 389 LIST OF PLATES PLATE I. Position of the bistoury. Incisions, II. Position of the bistoury and scissors, III. Phlebotomy. Bleeding from the arm and foot, - IV. Arteriotomy. Bleeding from jugular and cephalic veins, V. Operations upon the blood-vessels, varicose veins, &c. - VI. Seton, Moxa, Acupuncture Needles, Sutures, and Cau- teries, - - - ■ VII. Compression of the arteries, - - - - VHI. Ligature of the arteries in general, IX. Ligature of the arteria innominata. Subclavian, - X. Ligature of the arteries of the head and neck, XL Ligature of the arteries of the head and neck, XII. Ligature of the humeral and ulnar arteries, XIII. Ligature of the arteries of the arm, XIV. Ligature of the arteries of the forearm, - XV. Ligature of the arteries of the trunk, XVI. Ligature of the external iliac and femoral arteries, XVII. Ligature of the femoral artery, XVIII. Ligature of the popliteal artery, - XIX. Ligature of the anterior tibial artery, XX. Ligature of the posterior tibial and perineal arteries, XXL Operations on the bones. Ununited fracture. Anchylosis of knee, etc., - - " XXII. Operations on the bones. Exostosis. Anchylosis of hip, XXIII. Operations on the bones for necrosis, XXIV. Trepanning or trephining the cranium, XXV. Resection of the upper jaw, • - XXVI. Resection of the lower jaw, - - XXVII. Resection of the ribs, scapula, and clavicle, XXVIII. Resection of the shoulder joint, - XXIX. Resection of the elbow joint, XXX. Resection of the bones of the forearm, - XXXI. Resection of the bones of the leg and foot, XXXII. Resection of the bones of the ankle and foot, XXXIII. Amputation of the phalanges of the hand, XXXIV. Amputation of the metacarpus, - XXXV. Amputation of the metacarpo-carpal joints, XXXVI. Amputation of the wrist and fifth metacarpal bone, XXXVII. Amputation of the forearm, XXXVIII. Amputation of the arm, - - ' _ ' XXXIX. Amputation of the shoulder joint and upper third oi arm, XL. Amputation of the shoulder joint, 3 PAGE I 10 12 I 16 20 22 26 30 40 44 46 50 58 64 66 70 72 74 78 80 82 90 94 98 102 110 112 116 120 122 124 126 136 138 142 144 146 148 150 154 156 PLATE XLI. Amputation of the foot, - - - - XLII. Amputation of the foot, - XLIII. Amputation of the leg and thigh, XLIV. Amputation of the hip joint, . - - - XLV. Operations upon the eye, XLVI. Operations for Ectropion and Blepharoptosis, XLVII. Operations for cataract, - - - - XLVIII. Operations for cataract, - - - - XL1X. Entropion. Pterygium. Artificial pupil. Staphyloma, - L. Strabismus, - " LI. Operations on the cavities of the face and throat, LII. Nasal Polypi. Hare-lip, - - - - - LIII. Salivary fistula, - LIV. Operations for cancer of the tongue, LV. Staphyloraphy. Bronchotomy, - - - - LVI. Extirpation of the mammary gland, LVII. Wounds of the abdomen, - LVIII. Radical cure of hemia, - - - - - LIX. Surgical anatomy of hernia, LX. Operations for strangulated hernia, LXI. Operations upon the rectum, .... LXII. Hydrocele. Sarcocele, - - - - - LXIII. Operation upon the penis and scrotum, LXIV. Operation upon the urethral canal, LXV. Puncture of the bladder, - - - - - LXVI. Lithotomy. Lateral operation, - - - - LXVII. Lithotomy. Bilateral. Recto-vesical or median operation, LXVIII. Lithotripsy, ------ LXIX. Lithotripsy, - - - - - LXX. Lithotomy in the female, - - - - - LXXI. Suture of the perineum. Vaginal fistula, LXXII. Plastic operations. Rhinoplasty, - - - - LXXI II. Plastic operations. Rhinoplasty, - LXXIV. Blepharoplasty, ------ LXXV. Cheiloplasty,...... LXXVI. Plastic operations,—removal of deformities arismg from burns, - - - - LXXVII. Subcutaneous operations for torticollis, and deformity of the elbow joint, . - - - - LXXVIII. Subcutaneous operations for club-foot, LXXIX. Subcutaneous operations for club-foot, LXXX. Retraction of the hamstring muscles, PAGE 160 162 170 176 184 191 202 208 213 222 228 236 250 256 260 270 278 284 286 292 300 302 318 324 328 332 334 336 338 340 344 350 352 358 362 366 374 380 384 386 PART FIRST. ELEMENTARY AND MINOR OPERATIONS. UNDER THIS GENERAL HEAD ARE CONSIDERED, 1. THE DIVISION OF PARTS WITH THE BISTOURY AND SCISSORS; 2. DIVISION BY LIGATURE; 3. PHLEBOTOMY; 4. ARTERIOTOMY; 5. CAUTERIZATION; 6. REUNION BY SUTURE; 7. SETONS; 8. ISSUES; 9. MOXA; 10. ACUPUNCTURATION; AND 11. THE MEANS OF ARRESTING HEMORRHAGE, BEFORE, DURING, AND AFTER OPERATIONS. I. DIVISION OF PARTS WITH THE BISTOURY AND SCISSORS. (PLATES I. & II.) OF THE BISTOURY. The term bistoury is but a name for a knife, and was derived, according to Huet, from a town called Pistori, once celebrated for the manufacture of this kind of instrument. The term is frequently employed synonymously with that of scalpel, or the ordinary knife for dissection. Though differently shaped instru- ments, and for this reason especially suited to particular manoeu- vres, the one is frequently substituted for the other in a great number of operations; the proper bistoury being the greater favourite with the French, the scalpel with most of the English and American surgeons. The form of the common scalpel is well known and is subjected to little alteration. That of the bistoury is more varied ; it may be either curved or straight, and at the same time either sharp or probe-pointed. The sharp-pointed bistoury, which is the most generally useful of all surgical instru- ments, may be curved upon both the edge and back with the concavity upon the cutting surface; or it may be similarly curved with the concavity upon the back, so as to give it a sabre-like appearance. It may be curved on the back only, and straight upon the edge, or it may be straight upon both edge and back, so as to give it a long narrow point, as in the needle-shaped bistoury of the French. The positions below described, apply in the main to the ordinary English scalpel, as well as to the common opera- ting bistoury of the French, which is curved on the back and straight on the edge, as seen in the accompanying drawings. The different positions in which this instrument is held in sur- gical operations, are distinguished by numerical names. Authors vary in regard to the number of these positions, as well as to the order in which they are described, and have dwelt with unne- 3 cessary minuteness on the subject. M. Bourgery, one of the latest surgical writers, has made eight, and classed them as fol- lows, according to the frequency with which they are employed. In each of the positions described below, the instrument is consi- dered as held in the right hand. 1st Position, PL 1, fig. 1. The bistoury held somewhat as a knife with the cutting edge turned dowmuards upon the surface upon which it is to cut.—The ends of the thumb and middle finger, the former extended and the latter flexed, are applied upon the two sides of the handle, near the heel of the blade. The fore finger is car- ried forward upon the back so as to rest at some place between the heel and the point, in order to augment the pressure down- wards, when resisting tissues are to be cut; or applied upon one of the sides, when we wish to give additional firmness to the position of the knife, to prevent its slipping laterally. The ring and little finger flexed like the middle, rest upon the handle, the free end of which is pressed against the metacarpo-phalangeal articulation of the last finger. This position is of all others the one that puts the bistoury most completely under the control of the hand, and is commonly pre- ferred by the French and German surgeons, in incisions from without inwards. The facility with which the cutting edge is presented parallel to the surface, causes it to cut like a common knife in whittling along the whole extent of the blade, so as to render the division of parts more neat, more free and prompt, and at the same time less painful. The movements of the knife are effected principally by motion at the wrist and shoulder joints; they are thus rendered free and sweeping, but are not so well suited for light and delicate incisions, or when the cut is to be made directly towards the operator. For these reasons a large 10 ELEMENTARY AND MINOR OPERATIONS. majority of the English and American surgeons prefer commonly the third position in all incisions from without inwards; but when an extensive superficial cut is to be made, as in the amputation of a breast, the first position will be found decidedly preferable. 2d Position, PL 2, fig. 2. Bistoury held as a knife, the cutting edge upwards.—The instrument is held precisely as in the first position, with the exception that its cutting edge is upwards ; the hand is in this, as in the first position, slightly pronated. It suits especially for incisions from within outwards, and from right to left. 3d Position, PL 1, fig. 5, 6. Bistoury held as a writing pen. —It is unnecessary to describe minutely this familiar mode of holding an instrument. The middle finger, which is extended upon the side of the blade, may be made to approach at will, more or less near to the point, so as to limit the depth of the inci- sion, or by pressing on the side, turn the instrument as upon a pivot, between the thumb and fore finger; while the two smaller fingers, extended upon the surrounding parts, give a point of sup- port to the hand. When held vertically, the point of the instru- ment may be readily applied for the purpose of making punctures as directed in some forms of erysipelas. The bistoury may be inclined more or less forward or backward in this position so as to facilitate the section of parts, but cannot be brought to the horizontal direction for the purpose of giving a sweeping cut; the section is, therefore, chiefly made by pressure, but is well suited to operations in which it is necessary to make deep but short inci- sisions, as in the external cut for stone, or the laying bare of a deep-seated artery for the purpose of surrounding it with a liga- ture. Uh Position, PL 1, fig. 7. The cutting edge turned towards the palm of the hand.—The bistoury held as has just been de- scribed, may be turned between the thumb and fore finger, so as to present obliquely backwards, and come into the fourth position, ready to cut in a direction opposite to that in which it is com- monly employed; that is, with the back turned towards the parts to be incised, and the edge towards the palm of the operator. This position of the bistoury is convenient for cutting from within outwards and to the left, or from within outwards and backwards. bth Position, PL 2, fig. 3. Bistoury held like tlie bow of a violin. The situation of the fingers in this, is in all respects the same as in the 1st position, with the exception of the last finger, which is elevated and free. The light hold which is taken of the instrument in the fifth position, suits for the delicate and superficial section of parts which have been previously exposed by a bolder cut; when we intend, as it were, to graze the surface of some impor- tant structure, and retract the instrument upon the least intimation of danger, as in opening the sheath of an artery, or in exposing an encysted tumour which we wish to remove entire. The division of the tissues in this case is made by slight pronating movements of the wrist. 6th Position, PL 1, fig. 8. The bistoury held as a bow, with the little finger lowered.—This position varies chiefly from the fifth, in not having the handle of the instrument supported against the ulnar margin of the hand, but resting Upon the radial side of the little finger, which should be flexed. If the bistoury be held flatwise in this position, the surgeon may act with great rapidity and precision, over a large extent of surface, so as to abridge the time of operation, when the part to be removed is of considerable volume, as in the detaching of a mammary gland from over the surface of the great pectoral muscle. 1th Position, PL 1, fig. 10. The bistoury held balanced by the margins of its handle, the cutting edge of the blade turned towards the operator.—The blade is presented more or less obliquely, or entirely flat upon the parts to be divided. The thumb and middle finger half flexed, are placed upon the opposite sides of the instru- ment, at the junction of the blade with the handle; the index finger is carried forwards on the back of the blade. The ring and little fingers are lightly closed so as to sustain the handle more firmly. This position is commonly resorted to, when it is found necessary to make a horizontal section of a part previously raised with the forceps, in order to uncover the structure below without risk of injury, as in opening the sheath of a deep-seated vessel or the coats of a hernial tumour; the back of the instrument being kept applied against the part, which it is important to avoid. 8th Position, PL 1, fig. 9. The bistoury puncturing like a trocar.—The instrument is laid flat, upon the palmar face of the articulation of the second and third phalanges of the last three fingers. The thumb and middle finger are opposed upon its upper Fig, Fig Fig Fis. Fig Fig Fig. Fig. Fig. Fig. PLATE I.-POSITIONS OF THE BISTOURY. INCISIONS. 1.—Bistoury held in the first position; back of the instrument to the palm of the hand 2.—Incisions from without inwards, and from left to right ■ vertical nnsifinn „fti,.i ■/ •,,,, 3—Hand brought down so as to continue the incision; the knife in the same position J^c^X" £^tt£ SandW !thd ^V^ ^ bought out after the complete, and without a LtL^ at dief "d ^""^the b.toury, the surgeon renders the incision 5—Bistoury in the third position, held as about to make the puncture at tfc* ™ r • 6.-Act of cutting with the bistoury in the third position commencement of an incision. ^^^:^:z^:x:::^ a r,Qre wia ,h< w* -■ stoury, m the act of sllcing off a portion of tissue raised with the forceps. Vial? / Fig. 4 (■■ -it-on.- In C.Kuchel Thiladdphui, TviUsTied by Carey &-Ea,rt PS.Duval, Litfv.PhU* DIVISION OF PARTS WITH THE BISTOURY AND SCISSORS. 11 and lower faces, and the fore finger carried a little in advance upon the blade. The last three fingers are flexed so as to secure the free end of the handle against the palm. The direction of the cutting edge of the bistoury may be varied. This position with the blade presented flat, is convenient for the purpose of making punctures, as in the opening of a lumbar abscess ; or if the edge be held vertical, in making a crucial or X incision, cutting from within outwards after the knife has penetrated sufficiently far. STRAIGHT INCISIONS. (PL. II.) These may be very briefly noticed; they are made either from without inwards, by pressing downwards with the knife, or from within outwards, by raising the parts, and running the knife through the base of the fold. The incisions from without inwards and from left to right, are divided into the simple and compound. Simple incisions.—Previous to every incision, the skin should be made tense either by the left hand of the operator, or, as in some cases will be necessary, by the aid of assistants. This may be done by the surgeon placing the thumb and fore finger of his left hand upon either side of the knife; by sinking in the ends of the fingers in the direction of the incision, as in cutting down upon an artery; by applying the ulnar border of the hand behind the track of the knife, and making the cross tension by the thumb and little finger; or by raising a fold of the skin with the aid of an assistant, as shown at fig. 6. 1st Process. Oblique incision with puncture, as in opening an abscess, or dividing a deep-seated fascia.—The bistoury is to be held in the first position. Tension having been made with the thumb and fore-finger, the point of the instrument is applied ver- tically between them, so as to be entered by puncture in the direc- tion proper to the particular' case till it has reached a sufficient depth. If it be abscess for which the puncture is made, the want of resistance to the point, the freedom with which it may be moved from side to side, and the appearance of pus on the side of the blade, indicate its arrival in the cavity. The bistoury is then to be brought more or less parallel with the surface, and by a move- ment of the hand from left to right, the puncture is enlarged so as to make a free exit for the pus. The incision completed, the bistoury is to be raised and removed in the perpendicular position in which it was first entered. Where important parts are con- cerned, it is not, however, always safe to make a bold incision in this way, at a single cut; and it will be found better to resort to one of the following processes instead. 2d Process. Incision on the flat surface of the s/cin without puncture.—This differs from the preceding in employing the cut- ting edge, for the purpose of dividing the different layers of the part from above downwards, more slowly and by successive strokes with the knife. This process is much longer and more painful, but is more safe, and is, therefore, under many circumstances to be preferred. 3d Process. Incision on a fold of sldn, (fig. 6). The integu- ments are to be raised in a fold, in a direction transverse to that in which the parts are to be divided with the knife. The section may be made at the will of the surgeon from above downwards, by holding the bistoury in the first position and drawing it from heel to point; or, by passing it by puncture in the second position with the edge upwards through the base of the fold, and cutting from within outwards. The skin is then relaxed, and we have a cutaneous incision rapidly made, twice as long as the height of the fold of the skin. If it requires to be further lengthened, the surgeon may raise with his thumb and finger one of the lips of the incision, and prolong it by cutting from above downward, with rapidity, safety, and with comparatively little pain to the patient. Incisionin the 1thposition.—This mode of incision is peculiarly appropriate for the removal of excrescences from the skin, for the opening of the layers covering the arteries, as well as hernial and various other tumours. The convex bistoury or scalpel, is well suited to this incision. It forms a part of the proceeding in most of the great operations, and requires light and delicate manipulation on the part of the surgeon. The portion to be incised requires to be raised with the forceps, hook, or the thumb and finger; the first cut of the knife is to be made obliquely downwards, then horizontally under the end of the hook or forceps; the knife is finally brought out obliquely on the opposite side, having moved in a sort of irregular crescentic line. Slight rotatory movements of the knife between the thumb and finger of the right hand suffice to place it in the position proper for these separate steps. In re- moving cancroid excrescences from the face, with the object of completing the cure ulteriorly with the arsenical paste, we may in this way, by first raising the tumours, extirpate them below the level of the surrounding skin. For the removal of large tumours, or even of smaller ones situated below an aponeurosis, or when we wish to remove a part at some distance from the surface, straight incisions will not afford sufficient space. Under these circumstances it becomes necessary to resort to the compound incisions. These may be either crucial, T, V, or star-shaped, and consist merely in a combination of the simple straight incisions. COMPOUND INCISIONS. (PL. II.) Crucial incision, fig. 5.—The first incision from left to right is made, as has already been mentioned, with the bistoury in the first position, or, if the surgeon should prefer it, in the third. The two other limbs of the cross cannot be neatly formed at a single cut, as the skin would slide before the knife on the right hand side of the wound. For this side, therefore, the skin having been pre- viously made tense, the cut should be commenced from the bottom of the first incision ; that of the other side is made in the opposite direction, or towards the first wound. The two smaller incisons may, however, if it be preferred, be made in another direction— from within outwards—by entering the knife under each lip of the first incision, passing it for the requisite distance parallel with and below the skin, through which the point is to be passed by low- ering the handle, and the division effected by a cut from the point to the heel: the bistoury for the right half being changed to the left hand. The right hand may, however, be used for this latter purpose if the surgeon shift his position to one side, or which will be found more convenient, enter the point through the skin and bring it out at the centre of the first incision. The crucial incision being made, the four angular flaps of in- 12 ELEMENTARY AND MINOR OPERATIONS. topurnent are to be raised by the point, dissected up, and turned back. The sixth position of the bistoury will be found most convenient for the dissection, as the loosening of the four flaps may be completed quickly, merelv by varying the movements at the wrist joint. This crucial incision is well suited to a variety of cases where we wish to expose clearly the parts below, as is necessary in the use of the trephine or the operation for hernia, and has moreover this advantage, that the flaps come afterwards readily together, and are well disposed to unite by the first in- tention. Incision in the form of al, fig. 4.—This incision differs only from the crucial in having but one branch made upon the first line of division, and is practised according to the same rules. It is employed also under similar circumstances, and can in a mo- ment, when not found during the operation to expose the parts below sufficiently well, be transformed into the crucial. Incision in the form of a V.—This is formed by two straight incisions, of which the second terminates by an acute angle upon one of the extremities of the first. It is employed occasionally under the same circumstances as the two just described; but as the angle should never exceed forty-five degrees, it does not in general serve so good a purpose in uncovering deep-seated parts. It is found particularly advantageous in its application upon free margins, as the lips and eyelids, for the removal of diseased por- tions, or for the purpose of freshening the edges in a cicatrized wound or congenital fissure. Incision in the form of a star.—This is composed of three or four straight incisions crossing at a common centre, so as to form six or eight V shaped flaps, adherent to the surrounding parts by their bases. It is employed only in cases where it is necessary to divide the parts freely in order to remove inflammatory strangula- tion, or give free issue to the morbid products collected in separate cells, as in severe forms of carbuncle. Elliptical o and crescentic y incisions.—The latter are only occasionally employed. The elliptical are in much more com- mon use, and serve for the purpose of removing a portion of the integument, when it is redundant, as is often observed over the upper eyelid; or when it is deformed by cicatrices in parts like the neck or face exposed to view. They are employed for the removal of large tumours, as those of the testicle or mamma, in which the skin, either from its being too abundant or from its having suffered by the disease, requires also to be in part taken away. The lower limb of the ellipse in this incision should be made first, in order to avoid the embarrassment that arises from the flow of blood, when the upper has been previously formed. In many instances, and especially when the surgeon has not had sufficient practice to make him sure of his hand, it may be well to have the lines previously traced with ink or lunar caustic, to insure that the incision shall have its proper shape. Before using the knife the parts must be made tense according to the directions given for the preceding operations. The crescentic incision is sometimes preferred to the elliptical for the removal of superficial parts, as the edges of the wound it leaves come afterwards very neatly together. It is formed by two lines curved in the same direction, but belonging to circles of different diameter that en- close between them a piece of skin thus y, which with the parts subjacent is to be removed. Incisions shaped in the form of an L, or a l-j, are also occasionally employed, as will be hereafter mentioned. INCISIONS FROM WITHIN OUTWARDS, AND FROM RIGHT TO LEFT. (PL. II. Fig. 20 In these incisions the skin is to be made tense with the palm of the left hand applied flat, transversely to the direction in which the incision is to be made, and behind the place for entering the bistoury. This instrument should be held in the fourth position, and when the point has entered to a sufficient depth, the handle is to be depressed more or less toward the ulnar margin of the left hand, so as to elevate the parts with the cutting edge, and push them as it were before it, while it advances and cuts. This incision, though not of so general use as that from with- out inwards, is found very convenient in the opening of large abscesses, when the skin is detached and loosened to a consider- able extent. INCISIONS WITH THE BISTOURY UPON A DIRECTOR. (PL. I. Fig. 7.) The use of a director is very frequently required to guide the action of the knife when it has to penetrate deeply and in the neighbourhood of parts that it is all important to protect from injury. The finger, when it can be employed, is, as has been observed by Dupuytren, a sentient instrument, and the best of all directors; but it is only in some rare instances, where the opening FU Fig. 2 Fig. Fig. Fig. Fig. Fiff. PLATE IL—POSITIONS OF THE BISTOURY AND SCISSORS. 1.—Position of both hands, one of which makes the integuments tense, while the other, holding the bistoury in the first position, and nearly horizontal, makes an incision on the surface. 2.—Incision with the bistoury held in the second position, the cutting edge directed upwards, the left hand of the operator giving a point of support to the instrument, and at the same time making the skin tense. 3.—Fifth position of the bistoury; the little finger raised. 4.—Incision in the shape of the letter T. 5.—Crucial incision, the bistoury in the fifth position in the act of separating one of the flaps. 6.—Incision from above downwards upon a fold of skin; bistoury held in the first position. 1 .-Thirdposition of the scissors; this enables the operator to act with most power in dividing resisting parts with this instrument. 8.—Secondposition of the scissors; employed in making horizontal cuts. Plate Z \ Fig 6 /-¥ l On Stone b,rj''@uren ThUadtlphia. PuJ>li.i/ieJ ir Carey a.- Hart PJ.Du.val, Litk PhW- DIVISION OF PARTS WITH THE BISTOURY AND SCISSORS. 13 is sufficiently large to admit its introduction, as in the operation for hernia, that we can employ it for this purpose. Under such circumstances we glide flatwise the probe-pointed bistoury along the palmar, and at times even along the dorsal face of the fore- finger of the left hand. After the probe point has passed beyond the part to be cut, the edge of the blade is turned upwards, and the division is made partly by pressure with the end of the directing finger, and partly by a sawing motion made with the right hand. Commonly, however, we have to resort to the use of the grooved director, which is to be introduced through an existing opening, or one made with the knife, and carried below the skin, fascia, or whatever tissue is to be cut. It should be held between the thumb and middle finger of the left hand. The fore finger should be extended upon its back to direct it in its introduction, and after it has entered to the extent required, to serve by being flexed below it, to aid by pressure upward conjoined with a down- ward pressure of the thumb upon the outer end, in elevating the part under which the instrument is passed. The cut is then made by running a probe or sharp-pointed bistoury along the groove, in such a direction as to form with the instrument an angle of about thirty degrees. When the knife is arrested at the end of the director, it is to be brought to the vertical position so as to make the division complete. Both instruments are then removed together, so as to render it certain that all the parts raised on the director have been divided. The direction of the incision has been described as made from behind forward ; but it may be varied at will. In Plate 2, fig. 7, it is shown as made in the opposite direction from before back- ward, and which, as will be seen, necessitates a change in the relative position of the fore and middle fingers. One important consideration in regard to the use of the director, when we are operating in the vicinity of important vessels and nerves, and which will be hereafter more fully noticed, is that of raising and carefully inspecting the parts which cover it, before applying the bistoury, so as to assure ourselves that it is covered by nothing but what it is proper to divide. INCISION WITH THE SCISSORS. (PL. II. Fib. 7, 8.) There are three forms of this instrument in common use; the straight, curved, and angular; all of which are to be alike held, with the thumb in the upper ring, the third finger in the lower ring, and the middle placed in front and below to render the direction steady. The little finger is to be free. The use of the fore finger varies according to the kind of section desired. If a longitudinal cut is to be made, it should be placed below the instrument and immediately in front of the middle finger, so that the two may act in opposition to the thumb. If an incision is to be made flatwise, the fore finger should rest upon the side of the joint, so as to pre- vent vacillation, as shown at fig. 7. If the parts to be cut are firm and resisting, and the use of the left hand cannot be brought in to the aid of the right, it will be found advantageous to throw the fore finger across the upper branch of the handles, and make it act in opposition with the middle, which is placed on the lowTer branch as shown at fig. 8. Finally, if we act upon tissues out of view and through a narrow orifice, and when there is a risk of injuring important parts, the fore finger may be introduced as a 4 guide between the blades, to press out of the way the parts that are to be spared, and to facilitate the section of those which are to be cut. The scissors, as they are ordinarily constructed, cannot be employed well except with the right hand, as the attempt to close them with the left has a tendency to separate the cutting edges from each other. PUNCTURES. A puncture is sometimes, as has already been shown, but the first step of an incision. With this exception, and apart from some particular operations, such as bleeding and vaccination, the object of a puncture is either that of exploring the nature of a tumour, or giving issue to liquid or gaseous matters. Punctures are made with three separate instruments; the bistoury, the lancet, and the trocar: these however, in a great majority of cases, may supply reciprocally the place of each other. Puncture with the bistoury.—This may be made either verti- cally or in an oblique direction. For the direct or vertical puncture, the bistoury should be held in the first or third position, and the blade entered by a sudden motion of the fingers to the requisite depth, which should be pre- viously determined by the fore finger extended upon the back for the first position, and the middle finger upon the side for the third. Direct puncture is frequently employed in the opening of small abscesses, and for drawing blood in some forms of superficial in- flammation. Oblique puncture.—In this the bistoury is held and introduced with more or less obliquity, like a trocar. It is employed espe- cially for the evacuation of fluids which have accumulated to a considerable amount, as in empyema, and congestive or chronic abscesses. The object of making the puncture obliquely is that of preventing the introduction of air into the cavity after the eva- cuation of the fluid; an object which is accomplished by giving the knife the oblique direction, so as to prevent the internal opening and that of the skin from becoming parallel. The bistoury is to be withdrawn as soon as the matter appears upon its side, and the left hand should be pressed gently over the walls of the abscess so as to keep up a steady flow, and leave no room for the introduc- tion of air. When the contents are sufficiently discharged, the external orifice is to be covered with a compress, and this secured by adhesive straps or a roller bandage. If any shreds of cellular tissue or coagulated lymph block up the passage, they are to be extracted with the forceps or put aside with the probe, without any interruption of the pressure with the left hand. Puncture with the lancet may be made precisely in the same manner as it is made with the bistoury, and it suits in many cases of superficial abscess equally as well. It is to be held for this purpose nearly in the same manner as directed for phlebotomy. Puncture with the trocar.—It is important before using this in- strument, to see that the stilet slides freely in the canula. It is to be held so that the handle shall be embraced by the last three fingers, and the end rest against the palm, with the thumb applied at the union of the canula and handle, and the fore finger carried forwards on the instrument so as to limit the depth to which it penetrates. In operating, it should be held at first nearly vertical till the point enters the skin, and then be gradually brought to an 14 ELEMENTARY AND oblique position, while it is at the same time pressed forwards by the palm. By this simple manoeuvre I find the instrument may be carried in without shock, and with less pain than by the or- dinary method of a direct push. When we discover, from the want of resistance and the mobility of the point that it has entered the cavity, the stilet is to be withdrawn. After the fluid is dis- charged, the canula is also to be removed. This is effected best by direct traction, while with the fingers of the other hand pres- sure is made upon the surrounding integument to prevent the sides of the puncture being drawn out and irritated by the friction of the instrument. II. DIVISION OF PARTS BY LIGATURE. This, which is an ancient process, consists, 1st, in the complete strangulation of parts by a ligature applied round their base, so as to arrest the circulation and produce separation by gangrene; or, 2d, a ligature less tightly applied so as to effect a division by moderate pressure, which occasions the progressive absorption of the part enclosed in the loop. The former is employed commonly in the removal of tumours; the latter method, when we wish the ligature to act both as a means of division and as a seton, so as to excite granulation behind it in order to close up the passage that it cuts. As the ligature in the latter case becomes loose from the absorption of the part within its grasp, it will require to be tight- ened from time to time. Various materials have at different periods been employed for ligatures. Those in most common use consist of well waxed silken or hempen threads of various sizes, or leaden, or annealed iron, silver or platina wire. There are three general rules for the application of ligatures. 1st. To choose a ligature sufficiently strong for the parts to be embraced. 2d. To enclose within a single loop but a moderate thickness of tissue, as the strangulation will be better effected, when the part is large, by the consentaneous employment of two or more ligatures introduced with the needle. 3d. To divide the skin previously with the knife, so as to avoid the pain and irrita- tion which would arise from including it in the loop, except in cases where the part embraced is small or the skin itself is ulce- rated or in a state of degeneration. But in tumours springing from mucous membranes, no previous section of the covering is either allowable or required. There are three processes for the application of the ligature. 1st Process.—When there is but a slight thickness of tissue to divide, we surround it with a thread which is simply to be tied. If it be a conoid tumour, with a broad base, it must be grasped with the fingers, forceps or hook, to prevent the ligature from slip- ping. If there is but little prominence, or it is necessary to stran- gulate the part below the level of the skin, as in cases of small subcutaneous aneurismal tumour, it is necessary to elevate it pre- viously by a pair of needles or pins placed crosswise under its base. 2d Process.—If the pedicle of the tumour be too thick to be effectually strangulated by a single ligature, or we wish to remove the tumour after tying it, without a risk of the ligature slipping off, a double thread should be drawn through the pedicle, and MINOR OPERATIONS. divided so as to make two ligatures, which arc to be tied sepa- rately on either side. 3d Process; that of the compound ligature of Mayor.—This is applied in cases of tumours having a broad base and which it is necessary to remove in separate portions. Large needles of steel, unterapered so as to admit of being bent to any curve required, slightly dulled at the point, and with an eye either near the point or heel, are employed to pass the ligature. As many of these as will be required are, according to the directions of Mayor, to be threaded with the same ligature, and placed at equal distances upon it. If we wish to strangulate a tumour in three parts, three needles only will be required. The needles are then to be care- fully passed through the base of the tumour, entering them upon the side nearest any neighbouring part that it is important to avoid, and facilitating their exit at the opposite side by pressure with the left fore finger. If the eye is at the heel, the needle must be car- ried completely through ; if near the point it is only necessary to push it so far through that the thread may be seized with the hook or forceps, and drawn out so as to form a loop. The needle is then to be withdrawn. The loops when thus passed are to be cut, and we have as many double ligatures, for the purpose of strangulating separately each portion into which the tumour has been divided, as there have been needles used. The same results, however, may be arrived at by a more simple process—either by carrying a single needle threaded with a double thread the requisite number of times through the base of the tumour, or by employing several se- parate needles, each threaded with a double ligature. In cases where the operation is performed for the removal of vascular tumours, there is not usually much hemorrhage, as ves- sels of much dimension fly before the dulled points of the needles without being penetrated by them. In case, however, hemorrhage should follow, the needles maybe kept temporarily in the wound, and after the tying of the separate ligatures another may be ap- plied below the ends of the needles to embrace the mass at its base. If, however, there is at the base of the tumour any large vessel or other important part that it is necessary to avoid, instead of passing below it, the needles should be made to traverse the tumour itself. Various processes are employed to tighten the ligatures for the strangulation of parts.—If the wire or metallic thread is employed, it is at first usually thrown round the tumour as a free loop. If a leaden wire be used, which is suited to some soft tumours found within the mucous cavities, the strangulation may be effected to the requisite extent by merely twisting the two ends of the wire together. The silver, iron, or platina wire, should be applied through a canula; the double canula of Levret being the one com- monly used. The two ends of the wire doubled so as to form a loop at the middle, are to be passed through the two tubes. One end is to be secured by a few turns to the left arm of the instru- ment, while the other is left long to be grasped by a pair of for- ceps and drawn as tight as possible after the ligature is applied, and subsequently secured by a few turns round the other arm. The canula and wire loop are usually left to remain for twenty- four hours, when the life of the part embraced, if the strangulation has been complete, is found so completely destroyed that the tumour will fall off' subsequently by sphacelation. In cases of DIVISION OF PARTS BY LIGATURE. 15 tumour -With large base, it may become necessary to leave the instru- ment for a longer period, and tighten the loop from time to time as it becomes loosened, by unwinding the end from the arm and draw- ing upon it with the forceps. Vegetable and animal ligatures may also be applied in the same manner through a double tube; and occasionally, as where a large tumour is to be embraced within a narrow cavity, as that of a uterine polypus, it is convenient, as recommended by Gooch, to have each of the canulae separate, in order to facilitate the application of the ligature, subsequently fastening them together by means of a short sliding double tube. When the latter class of ligatures are employed, and the tumour is so situated as to be readily reached with the fingers, it suffices to tie them firmly with a common knot. If the pedicle be of much size and very resisting, it will be necessary to tighten anew or reapply the ligature after three or four days, when its hold will be found loosened by the diminution of the part embraced. In some instances the operator may be compelled to renew the liga- ture three or four times. In order to keep up the progressive con- striction of the pedicle without the necessity of changing the liga- ture, which it is sometimes difficult to do when the tumour is situated within a cavity, different serre-nceuds or knot-tiers have been invented. That of Graefe, which has been most used, consists of a stalk of steel pierced at its extremity with a hole, through which are passed the two ends of the ligature after the loop has been applied. At the other end is a screw, which can be turned so as to move upward or downwards a mobile slide, upon which the two ends of the ligature are firmly attached. The serre-nceud of Rodrigue consists of a number of small balls of wood, bone, horn or ivory, two or three lines in diameter, pierced in the centre and strung like a chaplet of beads on the two tails of the ligature, so as to form a flexible tube. The two terminal balls are, however, pierced with two holes through which go separately the ends of the ligature, so that the loop maybe preserved at one extremity and the ends knotted without the knot slipping into the orifices at the other. This would seem to be a convenient means of strangulating a tumour in an irregular or sinuous passage, as the chaplet will conform itself to the existing curves of the part. The apparatus, however, is apt to prove too flexible, and take a spiral form when we wish to render the constriction very firm. To obviate this inconvenience, it has been modified in the follow- ing manner by M. Mayor. This surgeon employs the balls only for one-half the length necessary to the instrument, and replaces them for the other and outer half, wTith an inflexible metallic tube, provided at its free extremity with a sort of windlass or tourniquet, upon which are rolled the free ends of the thread, so as to render the constriction tight. The first ball, that which comes in contact with the tumour, is also modified in shape, so as to present an acute angle in order to render the cutting action of the ligature pgrfect over the whole part embraced in the loop. The applica- tion of this serre-nceud may be seen in the plate displaying the operations upon the tongue. Effects of the ligatures—If the pedicle of the tumour is not above eight or ten lines in diameter, it is easy to close the loop so tight as to immediately intercept all circulation. The tumour should be covered with charpie or lint to absorb the fluids that are discharged while its separation is going on. When the constriction is complete, all sensibility ceases in the part enclosed. The tumour, which is at first swollen after strangu- lation, shrivels after a time, takes a livid gangrenous hue, and comes away at length in a state of putrefaction in a period varying according to the size and firmness of the pedicle, from a few days to several weeks, leaving a wound with a raw surface. If vessels of considerable size enter through the pedicle, they are sometimes found to resist the strangulation, and require to be snipped with the scissors after the other Constituents of the pedicle are detached. Their cavity is usually found obliterated under such circumstances; if such should not be the case, it would be necessary to tie before dividing them. When in the constriction of a resisting pedicle the ligature is not drawn sufficiently tight to obstruct the circula- tion in the artery, though it may occlude the veins, the tumour will swell from the accumulation of arterial blood, and be the source of severe local pain and great sympathetic disturbance. If we cannot, by drawing on the ligature, effect complete strangula- tion, it may become necessary to relax or even remove the liga- ture for a time. If a nervous trunk be included, or the irritation be so great as to excite spasm, or involve a risk of tetanus, the removal of the ligature becomes still more obligatory. In many instances, Avhere the point of operation could be readily reached, I have been enabled to remove these symptoms by puncturing or even excising a portion of the tumour, so as to allow some of the fluids to escape, and subsequently drawing the ligature tight. Conjoined with these local measures of relief, great advantage will be derived under such circumstances from the administration of opiates and diaphoretics. III. PHLEBOTOMY, OR BLOOD-LETTING IN GENERAL. The opening of the superficial vessels for the purpose of extract- ing blood, constitutes one of the most common operations of the practitioner. The principal results, which we effect by it, are 1st. The diminution of the mass of the blood, by which the over- loaded capillary or larger vessels of some affected part may be relieved; 2. The modification of the force and frequency of the heart's action; 3. A change in the composition of the blood, rendering it less stimulating; the proportion of serum becoming increased after bleeding, in consequence of its being reproduced with greater facility than the other elements of the blood ; 4. The production of syncope, for the purpose of effecting a sudden gene- ral relaxation of the system ; and, 5. The derivation, or drawing as it is alleged, of the force of the circulation from some of the internal organs, towards the open outlet of the superficial vessel. These indications may be fulfilled by opening either a vein or an artery. To the former system of vessels it is, however, except in cases of emergency, usually restricted. Formerly it was the custom to bleed from a great number of veins, as those on the back of the hand, the temporal, the frontal, the angularis oculi, the ranina, dorsalis penis, etc.; as well as from those of the bend of the arm, the ankle, and the neck, which are the only veins that are now usually opened. VENESECTION AT THE BEND OF THE ARM. Surgical anatomy.—The veins at the bend of the arm are situ- ated between the skin and the deep-seated brachial aponeurosis, lfi ELEMENTARY AND MINOR OPERATIONS. in the midst of the fatty cellular tissue which separates these parts. In children, females and obese adults of the male sex, the accu- mulation of adipose matter is, mainly, in front of the veins, render- ing in many cases their location obscure, and but faintly indicated to the touch, as soft elastic rolling cords. But in a majority of subjects they are obvious to the eye, and stand out in relief on the arm. There is such great variation in regard to the size, number and course of the superficial veins of this region, that we scarcely find two individuals in whom they are exactly the same. Even in the arms of the same person they are very commonly found to vary. The veins as they come up from the forearm may, however, be arranged into three classes. 1. Those from the outer side of the forearm and hand, which usually form a trunk, passing over the outer side of the elbow joint, called the superficial radial. 2. Those from the inner and back part of the forearm and hand, forming on the same side of the elbow the superficial ulnar vein. 3. Those which come up on the middle and front part of the fore- arm, and form, by their union near the middle of the bend of the arm, the superficial median, which shortly after its formation di- vides into two branches like the letter Y.* One of these branches, called the median cephalic, runs obliquely outward across the bend of the arm, to join the superficial radial, and forms with it the common trunk called the cephalic vein, which runs up along the outer side of the arm, and passing between the deltoid and great pectoral muscle, opens into the axillary vein, just below the cla- vicle. The other branch, called median basilic, crosses to the inner side of the arm and joins with the superficial ulnar, to form the proper basilic vein, which empties into the brachial at a varia- * Very frequently this median vein does not branch but runs inwards as a single trunk to join the ulnar. Occasionally it will be observed running out- wards, in the same manner to join with the radial. ble distance above the elbow. From the deep-seated radial vein which accompanies the artery of that name, there is an anasto- mosing branch (vena communicans) which traverses an opening in the deep fascia at the outer side of the tendon of the biceps muscle, and discharges into the median vein just before its bifurcation, thus increasing the amount of blood that flows through this vein. Occasionally it opens into the median basilic. There are, therefore, five superficial veins at the bend of the arm, either of which may be opened in venesection; the radial, the ulnar, the median and the two branches of the latter—the median cephalic, and median basilic. The superficial radial and ulnar, are usually the smallest of the whole, and are so surrounded with branches of the cutaneous nerves, especially the ulnar, (see Plate 3,) that they should not be selected for the operation, except in cases where the other veins are either wanting, or cannot be felt. The radial under equal circumstances, though it does not bleed so freely, is to be pre- ferred to the ulnar, as the latter cannot be opened without risk of injury to the nervous filaments that cover it in front, which though not so serious an accident as formerly supposed, it is desirable to avoid. As the nerves run nearly parallel with these veins, the risk of injuring the former will be diminished by making the opening with the lancet, parallel with the course of the vessel. A slightly oblique cut is, however, usually preferred even here, as it is found to give blood in a larger stream than one exactly parallel. The median vein is occasionally opened below its place of division: while yet deeply situated in the interstice be- tween the mass of muscles of the two sides of the forearm, it is surrounded with nervous filaments, and has the brachial artery placed below it, and so near, especially in thin subjects, that there is some risk of wounding that vessel. But when it lies on either PLATE ffl.-PHLEB0T0MY—BLEEDING FROM THE ARM AND FOOT. Fig. 1.—The right arm is here represented, prepared for the operation at the bend of the elbow. The circular ]i«m ture (a), knotted upon the anterior and outer face of the limb, has caused a distension of the superficial veins below, which are here shown as they are found existing in the greater number of cases: (1), the median basilic- (2), the median cephalic; (3), the anterior radial or common median; (4), the posterior radial and (5) the anterior ulnar The thumb (b) of the left hand of the operator is applied on the common median'vein, so as to keep its branches lull, while the lancet is introduced as seen at (/); the incisions (d, e, g, h,) represent the other Client ^ " " ' direCti°nS in which the °PeninS maJ be nia^, with least risk to the Fig. 2 and 3, exhibit the surgical anatomy of the elbow, in reference to the operation. In fi«. 2 the veins ahsnrh ents, nerves, and the superficial fascia with its adipose layer, are exposed by the careful removal of the skin" br.ng.ng into view the aponeurosis of the arm. In fig. 3, a portion of the aponeurosis is removed in addition' all the superficial veins with the exception of the median basilic being preserved The bicinital a„n„ ' seen projecting a little above the lower line of section. In regard toll vein and the dff2 o Z"" Ihtat-fi^^ cutaneous filament of the ulnar nerve; (10), the brachial u^^^^Xr^^^ BLEEDING FROM THE INTERNAL SAPHENA. Fig. 4, shows the manner of bleedinc in the intpmal ™l,ono ™- /i\ a saphena, which is a continuation of the ^L^Z£ (2)!^ ST^Jt^^ '^ he vein on he malleolus to prevent its rolling, while with the right hand the surgeon opens he vessel n Z figure (d) below, the lancet is held in the proper position for making the puncture for bloodJettinT Plate >3 Ftp 3 On Stone di l.t'V t'hi/u-Urti.titn Hiiltshed 6y i <.rey £ Bart f>Sl>n>... I.i'h fhil' • fc* PHLEBOTOMY. 17 side of this interstice or can be carried there by pronation of the hand, or pressure with the thumb, it may be bled in with im- punity.* The two branches of the median are those commonly punctured in venesection. The median basilic is generally the largest, most superficial and most constant, and the one which we are very often compelled to open, in the absence of others of sufficient size. It is the only one, however, which requires great precaution on the part of the operator. In its oblique course to join the ulnar, it rests on the aponeurosis of the biceps tendon, which alone with some thin layers of fatty cellular tissue separates it from the bra- chial artery. The vein sometimes exactly covers the artery, sometimes is placed at the margin but parallel with it, but more usually it varies a little from the same direction so as to cross it obliquely. It is surrounded with some filaments of the internal cutaneous nerve, one or two of which pass diagonally over it, in the inner half of its course. When we bleed in this vessel, it is best to select the first or lower part of its course, since the artery, as it descends, separates from the vein to get under the muscles of the forearm. When the vein runs parallel with the artery, the hand should be strongly pronated, so as to sink the tendon and aponeurosis of the biceps by partially winding the former round the radius, and thus increase the distance between the artery and the vein while at the same time the supinator longus muscle is brought in front of the tendon, and pushes the vein upon the inner edge of the pronator teres. If the muscles are thin, a slight flexion of the forearm will aid in producing the same effect. Across the middle of the median basilic the greater part of the absorbent vessels of this region pass. These in certain subjects are prone to inflammation, and present another objection to those already mentioned, against bleeding in the middle part of the course of this vein. At its place of junction with the ulnar vein the median basilic covers the great median nerve. The median cephalic may be opened with safety in any portion of its course, as there is not, except in cases of anomalous distri- bution of the arteries, any part of importance near it except the external cutaneous nerve, which crosses somewhere in the infe- rior half of the vein but at some little distance behind it. This vein, when of good size, is to be preferred in all cases for the operation. But it is often small or imperceptible, and sometimes deficient, and notwithstanding the objections urged, we are often compelled, as before observed, to resort to the median basilic, as the only vein at the bend of the arm, in which we can succeed in drawing blood in a full current. Operation.—The points at which the veins may be opened are seen at Plate 3, fig. 1. If at the most favourable spot for the ope- ration, the scars of several previous bleedings are observed, it has been recommended by Dionis and Boyer to make the puncture just below, lest the vein should be found narrowed or obliterated. But this is not a result met with, except there have been twelve or fifteen or twenty punctures near the same place; and except this obliteration has taken place so as to transform the vein into a fibrous cord, it answers perfectly well to make the incision over the old cicatrix. The apparatus required for vene- section consists of a bandage for compression an inch and a half * In case of need, even, the cephalic vein may be opened just above the bend of (he arm. 5 wide and a yard long, a thumb or Spring lancet, a vessel to re- ceive the blood, and a separate bandage and compress to secure the wound. The operator should first examine on the inner side of the tendon of the biceps, for the pulsations of the brachial artery, so as to form an opinion of its direction and depth. He should also feel in the neighbourhood of the different veins, whether or not there be any anormal and superficial distribution of the ulnar or radial arteries, which sometimes occurs where the division of the main trunk has taken place high up in the arm. This should be done previous to the application of the ligature, which would stop the pulsation in the superficial artery, and ren- der it readily mistaken for a turgid vein. This caution is not use- less. In two instances I have been called to operate for false aneurism, caused in a superficial artery, by careless venesec- tion. The ligature should be placed as seen in fig. 1, suffi- ciently tight to cause the veins to fill, but not check the circula- tion of the artery. The arm is then to be allowed to hang down for a few moments till the veins are sufficiently distended. If they do not quickly fill, the fingers are to be worked, friction made upwards along the arm, or the hand immersed in hot water. Bleeding with the thumb lancet.—If the right arm is the one selected, the operator places the hand of the patient under his left arm-pit, and secures it firmly against his chest. With the palm of the hand of the same side he embraces the elbow; the thumb and the fingers appearing on the opposite sides of the joint. Some slight friction being made upwards with the little finger of the right hand, so as to distend the vein, the left thumb is to be suddenly depressed, in order to retain it in the distended state. The spear-pointed lancet held as seen at fig. d, is then passed with firmness and precision obliquely on into the vein, until we see the blood beginning to ooze by its side. The smaller the vein, the larger is the opening to be made. If the vessel be deep, it is necessary to enter the lancet more or less perpendicularly for fear of missing it altogether. By elevating the point of the lancet before drawing it out, we may enlarge the opening, as will be re- quired if we intend to bleed freely. The compression made by the left thumb is to be relaxed, and the blood allowed to flow when the bowl is properly disposed for its reception. Care is also to be observed during the flow of the blood, that the arm does not much ehange its position, so as to produce a want of-corre- spondence between the opening in the skin and vein, causing a subcutaneous effusion of blood known as thrombus or ecchymosis, which often becomes subsequently painful when the tumour form- ed by it is large. Sufficient blood having been drawn, the ligature is to be removed, the arm partly flexed, and the- orifiee earefully closed and secured with the compress, and figure of 8 bandage. If adipose matter protrude between the lips of the ineision, it is to be pressed backwards, or if that wilt not suffice clipped away, so as to allow the edges of the skin to come together, in order to insure union by the first intention. If the vein has been many times bled in, and has become thinned in its walls and varicose-,. there is sometimes a difficulty in arresting the blood. But a mare methodical compression, effected by the aid of some small gradu- ated compresses, secured with a nodose bandage reversed over the wound, will be found to answer. The arm should be worn in a sling for twenty-four hours, by which time the puncture is usually closed:: the compress may be removed on the third day. 18 ELEMENTARY AND MINOR OPERATIONS. Bleeding with the spring lancet.—The thumb lancet, if in pro- per order, is by far the surest, safest and neatest instrument for venesection. But in this country, and the north of Germany, the spring lancet, or phleme, is more commonly employed, in conse- quence of the greater facility with which it is kept in order, and because bleeding with it is found so easy that little skill or expe- rience, in ordinary cases, suffices for its use. In using this instru- ment the blade is to be fixed, so as to strike at such a depth, as l>y calculation will divide the skin, cellular tissue, and anterior wall of the vein. As there is a chance, however, that the blade may penetrate the posterior wall of the vein, and wound the parts beneath, it never should be held in the direction of the artery, or the aponeurotic expansion of the biceps; the mere puncture of the latter being apt to give rise to the inflammatory swelling of the cellular tissue below it, which, when it occurs, prevents for a time the complete extension of the arm, and in cases tending to suppuration requires an operation for the division of the resisting fascia, so as to take away the painful pressure on the swollen part. The cautions above given in reference to bleeding in the median basilic are especially to be observed in the use of this instrument. VENESECTION AT THE FOOT. Next in order of frequency, is the practice of bleeding from the vena} saphenae. This is resorted to in cases where it is impracti- cable to open a vein at the bend of the arm; or, in accordance with the opinion entertained by some practitioners, for the purpose of producing a revulsion in affections of the head and chest, especially when these have followed a suppression of menstrual or haemorrhoidal discharges. We may bleed either from the in- ternal or external saphena. The walls of these veins are thick in proportion to their calibre, and seldom bleed freely. They are accompanied by nerves of the same name. The internal saphena consists usually of a single trunk, formed by veins from the same side of the foot, runs over the middle front portion of the internal malleolus, ascends on the inner side of the knee joint, and discharges into the •femoral vein near the groin. The internal saphenus nerve runs on the inner margin of this vein, and sends branches across it below the malleolus. It is therefore at the upper or middle part of the ankle bone, and on the posterior part of the vein, that wre make the puncture. The foot should be immersed for a sufficient time in wrarm water, to cause a distension of the veins. A ligature is then to be placed two inches above the ankle, and knotted on the outer side of the leg. The foot, well dried and inclined on its outer side, is to be taken on the knee of the operator or rested on a chair, and the puncture made with the thumb lancet, the vein being well secured with the thumb of the left hand to prevent its rolling under the instrument. If the spring lancet be used, great care should be taken that the blade does not come in contact with the bone, as it might be broken, and a fragment left in the wound. When the blood ceases to flow, or a sufficient quantity is taken, the vein is to be secured in the ordinary manner. The external saphena vein is usually inferior in size to the inter- nal, and is seldom opened. It runs up behind the external mal- leolus, where it has the external saphenus nerve lodged in a distinct sheath at its posterior border, and empties into the pop- liteal vein just above the knee joint. The ligature should be placed a little higher than for the preceding operation. The foot should be rested on its internal margin, and the puncture be commenced near the outer border of the vein, and carried ob- liquely across so as to avoid the nerve. VENESECTION AT THE NECK. (PL. IV.) This is practised exclusively on the external jugular vein. This vein receives blood from the exterior portion of the cranium and face, and is connected by anastomosing branches with the sinuses of the brain. It descends in the direction of a line drawn from the angle of the jaw, to the junction of the external third with the internal two-thirds of the clavicle, where it sinks under the edge of the sterno-cleido-mastoid, and opens into the subcla- vian. The vein is covered in front by the skin and platysma- myoides muscle, and lies on the outer surface of the sterno- cleido-mastoid. At several points, but especially near its middle, it is crossed by some nervous filaments from the cervical plexus. No artery is in its neighbourhood. The place at which it is opened, is, in the adult, about three fingers' breadth above the clavicle, and over the belly of the sterno-cleido-mastoid. Operation.—The patient is to be placed in the sitting posture, with the head slightly turned backward, and to the opposite side from that in which we bleed; the shoulder should be protected with a napkin. The vein may be made to swell up and become apparent, by pressure with the thumb of an assistant upon it a little distance above the clavicle. It answers better, however, to lay a thick, hard compress on this point, and bind it firmly down upon the vein writh a broad ligature or a folded cravat, which should be knotted under the axilla of the opposite side ; or the ends of the band may be carried directly round the neck, and held tightly though at some distance apart, so as to compress only the vein, and not interfere with the circulation in the other vessels of the neck. If the vein does not fill well, it will be found, advan- tageous in this respect to cause the patient to move the jaws as in mastication, and make a few prolonged expirations. The same measures will also be found after the vein is opened to facilitate the discharge of blood. The lancet properly opened, and held as seen in PL 3, the operator, pressing with the left thumb upon the swollen vein above the compress and with the fore finger of the same hand a little distance higher in order to steady the vessel and stretch the skin, makes a puncture between these points ob- liquely upwards and outwards, in the direction of the fibres of the sterno-cleido-mastoid, conformably to the directions Figures 1, 2, 3, 4.—Application of a seton to the back of the neck. Fig. 1.—A fold of skin, through the base of which a bistoury has been passed. about to be withdrawn so as to prolong the incision. 2.—Mesh or seton tape, passed with the eyed probe—the fold of skin subsequently relaxed. 3.—Boyer's seton needle, threaded with the mesh. 4.—A convenient seton needle: less used, however, than the former. Figures 5, 6, 7, 8.—Moxas, and instruments for applying them. Fig. 5.—Common moxa in a state of combustion held upon the skin with a pair of forceps. The burning is accelerated by blowing on it through the pipe. Commonly, the mouth of a small pair of bellows are used instead of the pipe. Fig. 6.—A small moxa, of the form preferred by M. Sarlandiere. Fig. 7.—Port-moxa of Larrey. A convenient instrument, but not absolutely necessary. Fig. 8.—Blow-pipe of Larrey. Fig. 9.—Three acupuncture needles, of the size commonly used in practice, having separately a round, an annular, and a movable head. Figures 10, 11.—Sutures. a. Interrupted suture. b. Twisted or hare-lip suture. c. Glover's or continuous suture. d. Another form of continuous suture, but little used. e. Quilled suture. Figures 12 to 17.—Metallic cauteries. set in a movable handle. Fig. 12. Halbert or hatchet-shaped cautery. The thickness of the blade is shown in profile in the small figure adjoining. The handle, which is too long for the space in the plate, is broken, or a piece taken out, as it w°ere, These are formed of steel or copper, and the stem to which they are attached at a. Fi. 13.—The three-sided prism of Rust. Fig. 14.-The reed-shaped cautery, (cautere en roseau,) formed like the mouth-piece of some musical instruments. tig. 15.— lhe conical cautery. Fig. 16.—The olive-shaped or flat round. Fig. 17.-A modification of the common cylindrical cautery, devised by M. Charriere, for the cauterization of poisoned wounds. TUte 6\ Tig. 8. {hi. Stone, by S. Sehnabct Philadelphia,, Puhlished by Carey & Ha,rb PSDuval, Lvthyktifi SETON.—ISSUE. 27 when the wound is deep to bring the lips extensively in contact, and admits of stronger traction on the threads, as these are pre- vented by their mode of application, from strangulating and cutting the parts. 4. Twisted or hare-lip suture, (fig. 10, b.)—This is made by means of straight needles or pins, which may be either cylindrical or lance-headed. As they are to be left in the parts, it is ad- visable to have them made of the unoxydizable metals, silver, gold, platina or palladium. But the common sewing needles with a head of wax, the glass-headed pin of the toilet table, or the in- sect pin of the naturalist, answer very well under ordinary circum- stances. If greased at the point they will be found to pass more readily through the tissues. This form of suture is the only one, the place of which cannot at need be supplied by adhesive straps and bandages. It is employed to fasten down angular flaps in cases where there is a section involving the whole substance of a part which is free on one of its margins, as the lip, the eyelid, or the ear; it is also used in a great variety of plastic and other ope- rations. The lips of the wound being exactly brought together, the operator takes one of the needles between his thumb and fore finger, with its heel resting against the nail of the middle finger, and passes it through both sides of the wound, traversing the tissues from right to left. The point should be entered nearly perpendicularly upon the skin a line and a half to two lines from the margin of the wound; the pin is then to be inclined horizontally and brought out afterwards with the point looking upwards over the end of the left fore finger, which should be placed so as to make pressure against it; circumscribing in the case of the lip at least two-thirds of its thickness between the skin and mucous mem- brane. The first pin should be passed near the free border; over the heel of this, a loop of ligature is to be thrown by the assistant and crossed under the point, so as to keep the surfaces from sepa- rating and in a state of tension. All the pins required are to be passed in a similar manner. The ligature is then to be wound separately round each of the needles in the form of a figure 8, or in a simple ellipsis, according to the will of the surgeon; or a single long ligature, in case of hare-lip, may be employed for the whole, commencing with the upper needle and then passing down to the second or third, finishing the wrapping of each in turn. To prevent the points from irritating the skin, or catching so as to be dragged by accident, they should be snipped off with the cutting pliers; or if the cambric needle be used, snapped between a couple of pairs of forceps. A pledget of linen or a strip of ad- hesive plaster may in addition be laid between the surfaces of the skin and the free ends of the needles. No other dressing is ordi- narily required. VII. OF THE SETON. The seton is employed in nearly the same places and under the same circumstances as the caustic issue. It is not now used so much as in former times. It consists of a suppurating wound with two openings through the skin an inch or more apart, trans- mitting a skein of silk, a piece of tape or gum elastic, or a strip of linen (mesh) with some of the threads removed upon its sides, through the subcutaneous cellular tissue. There are two methods of forming the seton. 1st. As made with the seton needle. (PL 6, fig. 3, 4.)—A fold of skin is to be pinched up with the thumb and fingers, through the base of which the needle, threaded with the material to be intro- duced and previously covered with cerate, is to be passed. This is the most expeditious method and the one usually practised. 2d. With the bistoury and eyed probe. (PL 6, fig. 1, 2.)—A fold of skin is to be raised as above described, the upper part of which is to be held by an assistant. The bistoury is pushed through the base of the fold up to the heel, and as it is withdrawn, made to enlarge the orifice to the requisite dimensions. The common eyed probe of the pocket case, threaded like the seton needle, is carried through the track of the wound before the fold of skin is relaxed. The wound is to be simply dressed; on the back of the compress covering it, the tape or thread is to be folded up and secured with a bandage. By the third or fourth day suppuration is established, and the dressing should be re- moved. The tape is then to be oiled and drawn farther through the wound, and the soiled portion cut away. This process is subsequently to be repeated daily. If a strip of gum elastic or of sheet lead be used, simple washing will suffice to cleanse it, and the necessity of using a long portion, or of cutting away a part from time to time, is obviated. But to the tape or mesh, as more manageable, the author gives the preference. As the tract of the seton becomes indolent, it will be found requisite to smear the tape or mesh occasionally with some stimulating ointment in order to keep up the discharge. VIII. OF THE FORMATION OF AN ISSUE OR FONTANEL. For the purpose of effecting protracted counter-irritation at- tended by a discharge of pus, issues were frequently established in former times, and are still occasionally resorted to in chronic affections, especially for those of the bones and joints. They are small ulcers below the surface, kept artificially open by the in- troduction of some foreign bodies, as two or three garden peas, two or three pepper corns, the dried buds of the orange-flower, or a flat piece of wood with a rough surface, all of which require to be changed daily. They may be made in almost any part of the body, where the skin is not closely connected to a bone, a tendon, or a resisting fascia. The places of election, however, are the back of the neck, the inner side of the insertion of the deltoid, the inner side of the thigh just above the knee joint, the depression between the vastus internus and the sartorius, and the internal surface of the. legs between the belly of the gastrocnemius internus and the insertion of the sartorius. They are made either by in- cision or cauterization. By incision.—A fold of skin, of an extent proportioned to the size of the issue desired, is to be raised and divided through by a bistoury passed in at its base, so as to expose the subcutaneous cellular tissue. The lips of the wound are to be separated by a firm roll of lint or charpie, and this secured by a compress and roller. At the end of three or four days suppuration is established. The plug is then to be removed, and the dried peas or other foreign substances introduced and held applied by a square piece of adhe- sive plaster, or if necessary, by a compress and bandage. This me- thod is expeditious and little painful. But there is no loss of sub- 28 ELEMENTARY AND MINOR OPERATIONS. stance in the skin; and from the strong tendency to cicatrization, it is difficult to keep the ulcer open. The formation of the issue by caustic potash, as described at page 23, is, therefore, the plan moie usually followed. IX. MOXA. Any inflammable substance burnt upon the skin for the purpose of effecting its gradual disorganization to more or less extent, is called a moxa. The pain and irritation attending this process increase progressively during the combustion, are felt at greater depth in the neighbouring tissues, and are believed to effect a more powerful derivation where deep-seated parts, as the bones or joints, are affected, than any other mode of counter-irritation, except the actual cautery or heated iron. If carried so far as to completely destroy the skin, the ulcer which follows the separation of the eschar resembles that from the use of caustic potash, and is to be restricted in like manner to certain parts of the body. But when tempered, or limited to the production of an acute glow upon the skin, it is more generally applicable. A variety of substances have been employed. Those commonly used are formed of cot- ton wadding, prepared spunk, cotton, lint or tow, rolled into the form of cylinders, soaked in a solution of chlorate or nitrate of pot- ash and thoroughly dried. The chlorate is preferred to the nitrate as the latter deflagrates as it burns. The cylinders should be jfrom half an inch to an inch in diameter, and tightly sowed in a linen or silken covering, which should be coated with a thick solution of gum Arabic, so as to give them solidity. The cylin- ders are cut in sections of half an inch to three-quarters long, ac- cording to the degree of impression we wish to produce: each of these forms what is called a moxa. (PL 6, fig. 5, 6.) They are to be moistened with saliva at one extremity and applied upon the skin, lighted at the other. They may be applied through a com- mon pill box, open at both ends, or held with a pair of common dressing forceps, or with the portc-moxa of Larrey. The sur- rounding skin should be protected by a piece of wet cloth, with a hole in the centre for the moxa. If not soaked previously in one of the solutions above mentioned, the combustion will require to be accelerated by blowing upon it with a common blow pipe, or with a pair of small bellows. As the combustion reaches the skin, it becomes exquisitely painful. The skin first reddens, shrivels, becomes then dry and yellow, and is covered with serous vesi- cles, which explode at the conclusion of the operation with a slight noise. The moxa is what is called tempered, when a piece of wetted paper or cloth is interposed between it and the skin. X. ACUPUNCTURATION. This operation consists in the introduction of fine, well-tem- pered sharp-pointed needles, through the integuments and into the subjacent tissues at variable depths. The fine point of the instrument is said to separate, not divide the tissues through which it passes; it is at least well ascertained, that the puncture is not followed by any serious consequences, and but very slightly painful. Through the muscles, vessels, and even many of the nerves and viscera, the needles have been passed with impunity. It is a practice borrowed from the Chinese and Japanese. No great value is now attached to it as a remedial measure, in this country or in Europe, though its use has occasionally been at- tended with advantage in neuralgia, chronic rheumatism, indolent tumours, indurated lymphatic glands, etc. It is employed in two ways; the first consists in the simple use of the needles; the second in the application of two needles connected by an electric current, [electro-puncture.) Simple acupuncture.—This is made from needles from one to four or five inches long, with round or annular heads, (PL 6, fig. 9,) to prevent them from slipping below the skin. A handle that can be removed or fastened to the heads at pleasure, facili- tates their introduction. In the east, they are made of fine gold or silver ; but steel, finely tempered so as not to be broken by the action of the muscles, is the material invariably preferred in this country. The needle maybe introduced, as is the custom with the Japanese, by driving it forward with a small mallet; or by the following method, which is decidedly preferable. Having select- ed the point—which should be the seat of the pain or in its im- mediate vicinity—the operator stretches the skin with the fore and middle fingers of the left hand, pierces it perpendicularly with a gentle pressure, and then advances the needle to the desired depth, with a semi-rotatory motion of the head between the thumb and fore finger of the right hand. This process is to be repeated till the requisite number of needles are introduced. Their withdrawal, after they have been left in a sufficient length of time, is to be effected by the same movements, accompanied with slight traction. A drop or two of blood is occasionally seen oozing afterwards from the place of puncture. Care should be taken to have the needles, before using them, perfectly smooth and free from rust, as otherwise the introduction is more difficult and painful. For this purpose it is well, according to-the advice of Dr. Elliotson, to pass them through an emery bag, both before and after using them. The number of needles employed is varied according to the will of the operator, from one or two to twenty, and there is no general rule in regard to the length of time that they ought to remain applied. The Japanese and Chinese keep them in only while the patient makes thirty inspirations. M. Cloquet and Dr. Elliotson state that they derived most advantage from the method when the needles were kept in for several days; and Professor Bache, who has extensively employed them in chronic rheuma- tism, observes that the more chronic and long-standing the disease, the greater will be the length of time that they should be retained in the tissues. Simple acupuncturation has been made through the coats of the arteries, for the purpose of obliterating their cavities; the needle being allowed to remain three or four days, so as to excite inflam- mation and serve as a mechanical obstacle, upon which the blood may coagulate. The practice, however, is one not to be relied on. Acupuncturation has also been employed with some success by Mr. Lewis and others, for the cure of hydrocele, for the removal of the-fluid in anasarca, for oedema of the scrotum, penis, and eye- lids, and in exploring the nature of some deep-seated tumours or abscesses. Electro or galvano-puncture.— The needles for this purpose should have a small ring at the top. (PL 6, fig. 9.) Two of these MEANS OF ARRESTING HEMORRHAGE. 29 should be inserted at the limits of the region through which the electric current is to be passed, and the conducting wires of the two poles of a galvanic pile attached to the rings at their top. A horizontal galvanic pile of small dimensions, is much easier man- aged for this purpose than the vertical pile of Volta or the Ley- den jar. A few pins only should be used at first, and the number gradually augmented as the patient is found able to endure the action of the current. XL MEANS OF PREVENTING HEMORRHAGE; OR, SURGICAL HEMOSTATICS. I. ON THE MEANS OF PREVENTING HEMORRHAGE, AS APPLIED PREVIOUS TO OPERATIONS. These measures are directed solely upon the large trunks of the arteries, and consist of two kinds, compression or previous liga- ture. The latter, however, is rarely resorted to with this object, and forms of itself an operation apart, which will be treated of under the head of ligature of the vessels. Compression for the purpose of arresting the flow of blood through an artery, must be applied with sufficient force to flatten the vessel, and cause the temporary obliteration of its cavity. It is to be carefully kept up during the whole course of the opera- tion. The vessel should be compressed at some part of its course, where it may be felt with pressure of the finger, and where it is at the same time placed over a bone or some firm fibrous structure that may serve as a point of resistance. It is to be made by the direct application of the hand, or by the medium of instruments. OF THE MODE OF COMPRESSION IN GENERAL. WITH THE HAND. 1. With the thumb and fingers.—It maybe made with the point of the thumb alone, pressed downwards; with the balls of the two thumbs applied one above the other across the course of the artery; or with the ends of the fingers of one or both hands placed parallel with the track of the vessel. Either one of these modes is rendered peculiarly applicable in certain situations by the anatomical position of the vessel. Thus the subclavian, deeply situated as it crosses the first rib, and accessible only through a narrow space, can be reached best with the end of the thumb, with which it may be compressed with considerable precision. The circulation of the femoral artery may also be controlled by pressure with the end of the thumb immediately over the pubic bone ; but immediately below the pubis it is better accomplished with the balls of the two thumbs, either hand taking a firm point of support by grasping the opposite surfaces of the thigh. On the other hand, the great arteries of the arm and thigh, which are placed at some distance from the bone, and disposed to roll under compression by the two first processes, may be obliterated more securely with the ends of the fingers of one hand placed in the direction of their length, while the palm grasps the mass of neigh- bouring muscles, and the thumb gets a resisting hold upon the surface of the bone, or by sinking itself into the flesh (PL 7, fig. 3). From the difference in their length, the fingers, when they 8 act with force sufficient, as in the thigh, for instance, to overcome the resistance of the tissues, close on the artery in a curved line, so that the obliteration of the vessel is begun by the first finger, continued by the second, and completed by the third. If the fingers become fatigued during the continuance of the operation, the individual making the compression, should, without waiting till the hand begins to tremble so as to render the pressure un- certain, sustain it with the fingers of the other. One hand may even be readily substituted for the other, without interrupting the compression, by placing the ends of the fingers of the second hand along the track of the vessel, just above those of the hand first ap- plied, so that the new pressure is made before the first is relaxed; the second hand sliding gradually into the place of the first. In the same way one assistant may be substituted for another, in case the lumbar muscles of the first become greatly fatigued in the con- strained position which he is obliged to assume. In making the compression, no more force should be used than is just sufficient to completely efface the calibre of the artery; the requisite amount may be ascertained, according to the directions of Lisfranc, by placing a finger upon one of the larger branches of the main trunk. The pulsation in this will be found gradually to disappear, as the pressure with the fingers is augmented above, and as soon as it ceases to be felt, the temporary obliteration of the vessel may be considered perfect. Considerable coolness and intelligence are required on the part of the assistant in this simple manoeuvre with the hand, and it is far better, especially if the operation is likely to be protracted, to resort to the tourniquet, which answers perfectly well in all cases in which the operation is not done so high on the limb as to forbid its application. 2. The whole hand is sometimes employed in cases of emer- gency, for the compression of the abdominal aorta and iliac ves- sels. 3. With the hand pad. (PL 7, fig. 5.)—The hand pad is pressed downward upon the artery, so as to act precisely like the end of the thumb, to which, as not endowed with sensa- tion, it is very inferior. It is, therefore, rarely employed. It has been recommended in cases where the subclavian artery is unusually deep, and the separation between the scaleni very narrow. It is seldom, however, even under these circumstances, that the compression cannot be better and more safely accom- plished with the thumb or the end of the middle finger. The shape of the hand pad is to be varied according to the form of the part through which it has to act. It should be long and narrow for the subclavian, large and broad for the aorta, and attached to a short handle to render it more manageable, like that of the letter seal, a door key, or a boot hook, which, when padded at the end, are occasionally substituted for it. MECHANICAL COMPRESSION. The instruments with which mechanical compression of the vessels is made, consist of the garot, the pad with a strap and buckle, the tourniquet, and the compressor of Dupuytren. 4. The garot. (PL 7, fig. 9.)—This was devised by Morel in 1674, as a substitute for the circular bandages or ligatures em- ployed previous to that period, for the purpose of arresting hemor- rhage. As first used it consisted merely of a band or handker- 30 ELEMENTARY AND MINOR OPERATIONS. chief twisted tight with a stick. This simple contrivance, from the convenience of its application on the field of battle, received the name of the field tourniquet. The garot, as it has been latterly modified, consists of a pad to be placed on the skin above the artery, presenting on its free surface a ring for the passage of the web or strap. On the side opposite the pad is applied a compress, or what is better, a concave piece of horn or metal, upon which the strap is to be firmly twisted with a stick, and the latter given in charge of an assistant, who is to diminish or increase the pressure according to the direction of the surgeon. The compression of the garot extends to the whole substance of the limb—arteries, veins, and nerves—and cannot, therefore, be safely kept up but for a short space of time. The advantage which it offers, of being constructed of the first things at hand, and at any time or place, renders it occasionally highly useful. It cannot, however, be gradually relaxed and tightened with precision like the proper tourniquet, which is always to be preferred. 5. Detached pad, (pad of Charrilre,) with buckle teeth on its lateral margins, to which the two ends of the strap are attached. (PL 7, fig. 5.)—This has but recently been introduced into practice, and is employed for the compression of superficial arteries of medium size. The pad is attached to a plate, and resembles somewhat the lower frame of the French tourniquet, (fig. 4,) and is forced down over the artery, by fastening the two ends of the PLATE VIL—COMPRESSION OF THE ARTERIES, OF THE TEMPORAL AND SUBCLAVIAN. Fig. 1. (A). Compression of the temporal artery, with the pad of M. Charriere, (see fig. 5.) The pad is applied in front of the ear, above the zygomatic arch, and is sustained by a simple strap, the ends of which are fastened upon the two rows of buckle teeth. The double compress under the jaw protects the skin from injury. (B). Compression of the subclavian with the newly devised instrument of Bourgery. This is composed of four principal parts. 1st. A broad rectangular pad (A) screwed to a steel plate, which, though not visible in the drawing, is fastened to a second plate (B). This pad is applied across the attachment of the pectoralis major below the clavicle, which serves as a point of support to it. One end of the pad is thick, so as to fill up the depression below the coracoid process, while the other is thinner and rests on the sterno-clavicular articulation. By reversing the margins, the same pad may be applied for compression of the artery of the other side. 2d. A second plate of steel (B), of the same form as the preceding, upon which it is exactly fitted. They are fastened together by two small pivot keys (b), which enter into corresponding mortises in the plate (A) This second plate serves as a fixed point for the rest of the apparatus. At its ends are two copper pins for the attachment of the straps. 3d. A movable steel plate (C) fastened by a screw to the second plate, capable of being turned for a quarter of a circle to the right or left, so as to suit the obliquity of either clavicle. It serves as a fixed point for the lever of the movable pad (G), with which the compression is made. Above it is attached by a hinge joint (d) on each side, with another plate of an elliptical or horse-shoe shape (D), which is thus made mobile so as to adapt itself to the projection of the trapezius. This elliptical plate is padded and provided with two pins (c), for the attachment of the posterior straps. The hollow within it is occupied by the artery pad (G) 4th. The last part of the apparatus is the elbowed lever (E), which supports the artery pad. The base of the upright part of the lever is pierced with an opening, and is fastened by a screw (/) to plate (C) • at its unner part it is attached by a bullet joint (g) to the horizontal arm (F) of the lever, so as to allow the latter to be moved m every direction. The artery pad (G) is in the form of an elongated cone, to penetrate readily between horizontTleTe" ' "*' * **"* direCti°nS " COnse1uence of *. mode of attachment to the Tli^2TZitiZr^ edBvisfheld sr rely in its ,position hy the body banda^e » *** *• ***** ■»* posterior straps (I and R). By forcing it down with the screw (i) the artery pad may in all cases according to the inventor, be made to act so as to arrest safely the circulation in the vessel. ' S OF THE CAROTID AND BRACHIAL. Fig. 2.—The instrument is represented as applied, on a plan of a section nf th* n.a i • require any specific description. It is with he exceoTion f ) * \ ," S° ^ Sh°Wn ** DOt t0 compressor of Dupuytren P f ** f°rm °f the Pad and bullet Joint> «milar to the Fig. 3.— Compression of the brachial artery with the finders KpI^w ti,Q -n ™ r groove over the vessel between the triceps behind and thv , ^ '" ^ SU"k in the fL,mi, tai„. , . ^ P d the blcePs and coraco-brachialis muscles in front The thumb takes a support upon the opposite side of the limb Fig. 8_-Compression of the same artery just above the middle of the arm, is here shown as made by the common English tourniquet; the instrument to which preference is usually given in this country. A trl!^™™ MEANS OF ARRESTING HEMORRHAGE. 31 strap after they have passed round the limb, upon the rows of buckle teefh, with which its raised lateral margins are provided. The general compression of the limb may be obviated at will, by placing a thick compress under the pad, and another on the side of the limb opposite. I have in some instances employed this method with advantage; but as a general means, the pressure can- not be made sufficiently firm or certain to be relied on. 6. The common tourniquet. (PL 7, fig. 6.)—This most useful instrument was invented by Petit, and is so well known as not to need particular description. Several modifications have been made in the form of the instrument, as will be seen by reference to PL 7, but the rules for its application are much the same in all. When the instrument is applied, the frames should be put in contact, before the strap is buckled round the limb, as the tight- ening of the strap, in order to compress the vessel, is made by turning this screw, so as to separate the upper plate from the lower. The form of the tourniquet in common use in this country and Great Britain, is represented at PL 7, fig. 6, and fig. 8. In ap- plying this instrument it is not a matter of much moment, whether the operator places the frames, or the free pad attached to the strap directly over the vessel. In either case, a stout compress or roller is to be laid immediately on the surface above the artery. In general, however, it will be found preferable to buckle the pad over the vessel, and keep the frames on the upper surface of the limb, so as to prevent their position becoming deranged by their weight. In some of the recent modifications of the French instrument, the lower plate of the tourniquet is forced downward by the screw, and should, therefore, be placed immediately above the vessel. The tourniquet, though far more manageable, presents some of the disadvantages of the garot, in producing a general constriction of the limb, so as to dam up some blood in the veins, which is necessarily lost during amputation ; and produces, if too long con- tinued, engorgement and even gangrene of the parts below. It is, however, well suited to effect the temporary compression re- quired in amputation and other processes involving the large ves- roller is observed lying over the artery, upon which it has been pressed down by the tightening of the strap, caused by the separation of the plates in turning the screw. Fig. 9.— Compression with the garot or field tourniquet is seen in fig. 9. A small compress rolled tight (a), is applied over the vessel Kb). A transverse bandage is applied to hold the compress, and twisted tight with the stick (e). The stick is secured with a cord, as at (d),to prevent its turning; (e) is a plate of wood, horn, a piece of card, or some similar substance, introduced below, before the tightening of the bandage, to protect the skin. OF THE FEMORAL ARTERY. Fig. 4.—The thigh is semiflexed on a pillow, and the artery compressed both at its upper and middle part. Compression at the pubis, with the modified tourniquet of Petit. This instrument is preferred to all others by the French surgeons. Unlike the English instrument, it has an artery pad (a), sewed upon the lower plate (b). This is moved by a screw (c), and kept straight in its descent upon the artery by two conducting rods (d d), which pass through another smaller metallic plate (e), that supports the compressing strap (gg). On the opposite side of the limb is a counter pad, supported on a plate not seen in the drawing. The strap envelops the whole apparatus, by passing longitudinally over the upper plate and over that of the opposing pad. The strap is split where it passes over the first, to transmit the screw and the two conducting rods, and its two ends are fastened by a buckle (i) upon the side of the limb. At (h), a sort of staple is seen by which the pad is kept from slipping off the upper plate. The instrument is here seen applied. The pad (a) rests upon the artery over the pubis. The straps pass under the folds of the buttocks, and compresses are placed below them to protect the skin. As the pad, at its application upon this part of the limb, has a tendency to rock over upon the thigh, it is secured by a long com- press (B), which is attached to a body bandage (6). Compression is made by turning the screw, so as to force the pad towards the vessel. Fig. 7.— Compression upon the middle of the thigh with the compressor of Dupuytren. This instrument is composed of two elliptical metallic bars, which slide over each other so as to lengthen or shorten it. Near each end there is a strong hinge joint. Its anterior end sustains the screw (G), the two conducting rods (H), and the movable artery pad (I) with which the artery is compressed. Its posterior part is constructed precisely as the posterior portion of the instrument shown at fig. 2. The counter pad (F) supported on the arm (E) is applied over the muscles at the back part of the thigh. The manner in which the two sliding bars are joined together and" rendered fixed by a screw, is shown at (D D, fig. 2). Fig. 5. The artery pad of Charriere. The pad is attached to a metallic plate, upon the upper part of which is placed a small saddle of the same material. Between the two branches at either end of this saddle are the rows of buckle teeth, and a sliding roller over which the strap plays. One end of the strap is secured in the drawing to a row of these teeth, the other, having formed a loop as in embracing the limb, is passed over the roller, and is ready to be drawn tight and secured on the second range of teeth. Fig. 6. The ordinary English tourniquet. The two plates have been separated by turning the screw, in order to show the manner in which the strap is connected with them. 32 ELEMENTARY AND sels, when the operation is done sufficiently far from the trunk to leave room for its application. The French instrument is shown applied at PL 7, fig. 4, on the upper part of the thigh ; the English at PL 7, fig. 8, and at PL 43, fin-. 6, where it is made to compress the artery of the thigh in a position that will be found to answer in amputations of the leg. When we desire to daily check for some hours the circulation of the vessel above an aneurisraal tumour, for the purpose of ef- fecting the coagulation of the blood and the gradual obliteration of the sac—a process to be preferred to the ligature of the vessels when an aneurismal diathesis is known to exist—the following instrument is entitled to a decided preference over the tourniquet, as it makes positive pressure upon the limb only at two opposite points. The same instrument, though capable of serving in cases of amputation, possesses in that respect no particular advantage over the tourniquet, and is more liable to displacement. 7. Compressor of Dupuytren. (PL 7, fig. 7.)—This instrument consists of two steel plates, from one to two fingers broad, which are curved on their flat and joined at their middle, so as to slide over each other, in order to allow it to be lengthened or shortened at will. To the ends of these plates two others are attached by a joint which supports the pads, the one movable, the other fixed, the whole instrument being curved so as to form when complete the two-thirds of a circle. When the compressor is applied, the pads rest upon the opposite sides of the limb ; the movable one is placed over the artery, and is made to descend by turning a screw, so as to compress the vessel. The construction and mode of ap- plying this instrument will be best understood by reference to the plate. COMPRESSION OF THE INDIVIDUAL ARTERIES. Of those of the face and cranium.—The compression of these is seldom required except as a means of arresting traumatic hemor- rhage. When there is no urgent reason to the contrary, it is better to resort to this measure merely for the purpose of temporarily checking the hemorrhage while the bleeding orifice can be properly secured by a ligature. 1. Of the, temporal artery.—This is easily compressed against the cranial bones, in any part of its course above the zygomatic arch. For the main trunk, the detached pad to which the two ends of the strap are buckled, described at page 30, and shown in its application just in front of the ear at PL 7, fig. 1, is the most appropriate. A graduated compress secured with the nodose or knotted bandage, suits very well to arrest the hemorrhage from one of its branches, and may be made to serve in the absence of a more fitting apparatus for compression of the main trunk. 2. The frontal and infra-orbital arteries may be compressed by similar means, where they come out from the orifices in the bones to take a position under the skin. The graduated compress for the infra-orbital should be placed nearly vertically, in the direction of a line from the external canthus of the eye to the ala of the nose of the same side—and for the frontal laid just above the super- ciliary notch. 3. The facial artery may be compressed just be- low the jaw and in front of the masseter with the finger, or by a graduated compress, secured in one of the modes just mentioned. 1. In injuries of the occipital or posterior auricular arteries, it is MINOR OPERATIONS. best to apply two graduated compresses, one above and one below the lips of the wound. Arteries of the neck.—In consequence of the mobility and great sensitiveness of the parts in front of the neck, the carotid is the enly vessel of this region which it is possible to subject to com- pression. The ligature of this vessel would, however, except in cases where its temporary occlusion only was required, be a pre- ferable, as it would be a more certain, and even in the end, a less distressing or painful proceeding. The compression may be made with the fingers, or with the proper compressor devised by Bour- gery and Malapert, and shown in its application at fig. 2. The freedom of the anastomosis between the branches of the two carotids is so great as to render either the ligature or compression of the trunk of a single side of but little avail in erectile and other vascular tumours of the neck and head. When compression is resorted to, it has been advised to make it upon both trunks at the same time. For this purpose an instrument has been contrived with two pads, each of which is to be depressed with a screw between the edge of the sterno-cleido-mastoid, and the lower bor- der of the larynx. The compression should, however, be made gradually, giving time for the vertebral arteries to dilate, in order to avoid the danger that might arise from suddenly interrupting the columns of blood sent to the brain by the two great carotid trunks. Arteries of the arm.—The subclavian artery, as has been before observed during an operation involving the great branches round .the shoulder joint, may be temporarily compressed by the thumb and finger inserted endwise between the scaleni muscles, as di- rected by Camper. For the permanent compression of the artery, in the cure of axillary aneurism, various forms of the tourniquet have been devised. No instrument, however, appears so well calculated to accomplish its object as the one lately devised by M. Bourgery, and shown in position, PL 7, fig. 1. The axillary artery is only susceptible of compression, at its passage over the second and third ribs. But at this place, from the thickness of the two pectoral muscles which cross in front of the vessel, it is impossible to command the circulation completely except in very thin subjects. The compression may be made with the ends of the fingers, as shown at PL 7, with the knuckle or with the hand pad. To facilitate the compression, the pectoral muscles should be relaxed by bringing them to the side of the chest, placing the shoulder in the state of adduction. The compressor invented by Dalh for this artery, is not to be relied on. The humeral artery may be readily compressed at its upper part, just below the tendon of the pectoralis major, and between the biceps and coraco-brachialis, either with the fingers or one of the several instruments above mentioned; though from the con- tiguity of the nerves, that with the fingers is found least painful. In any other part of its course no difficulty attends the compres- sion ; the thumb or the fingers usually sufficing as well as any of the more complicated instruments. When at liberty to choose, the junction of the inferior with the middle third of the arm, is the most favourable site, as the median nerve is here found running in- wards so as to separate itself from the artery. The radial and ulnar arteries may be compressed against the corresponding bone, in any part of the inferior third of the arm, temporarily with the fingers, or permanently with the free pad and strap (described page 30;) or, if MEANS OF PREVEN at hand, the more complicated compressors of Dupuytren, of a suitable size, may be used. Arteries of the lower extremity.—The femoral artery may be temporarily obstructed, at the upper or lower surface of the os pubis, with the end of a single thumb, or the flat surfaces of both, as observed at page 29. The tourniquet may also be applied in the same location, provided it be placed as represented in plate 7, fig. 4, with the strap passed under the fold of the buttocks, and the skin protected with double compresses behind and upon the sides, so as to admit of the strap being tightly drawn, and the frames of the tourniquet raised up upon the pubis, by a compress fastened to a body bandage. In the upper or middle third of the thigh, or in the popliteal region, compression is easily effected with the ordinary tourniquet or the compressor of Dupuytren. Compression of the artery at the latter point rather than in its course along the thigh is preferred by Professor Ferguson in am- putation of the leg, as being attended by a smaller loss of venous blood, in consequence of the less capacity of the veins below the place of constriction. The posterior tibial artery is accessible to pressure at two points: at the inferior extremity of the leg, between the tendo- achilles and the flexor tendons above the ankle ; and between the internal ankle bone and the heel, in its course along the sinuosity of the os calcis. The anterior tibial artery may be readily compressed over the middle of the front surface of the ankle joint where it can be felt pulsating. The graduated compress secured with the pad and buckled strap answers well for this object. Arteries of the trunk.—The external iliac artery may be com- pressed for a brief space of time with the hand pad or the back of the fist, against the upper margin of the pelvis, provided the abdominal muscles be placed in a state of relaxation. Little advantage, however, is likely to be derived from this measure, except to gain time by the temporary control of the circulation for the application of a ligature, in cases of accidental injury of the artery or its branches, near Poupart's ligament. The aorta, as has been before observed, may be compressed in the lumbar region, provided the muscles of the abdomen be thoroughly relaxed, by a mutual flexion of the trunk and pelvis. The back of the, hand placed crosswise, and pressed down with moderate force, or a large hand pad, may suffice for the purpose. The application of the latter is occasionally made in the operation for ligature of the iliac arteries, though in the hands of a skilful surgeon it may very safely be dispensed with. When employed for the purpose of arresting uterine hemorrhage after accouchement, six or eight minutes compression, according to Trehan, Baude- locque, and others, has been sufficient to permit the uterus to assume its contracted state, and thus present the natural obstacle to the recurrence of the hemorrhage. The hand pad should be applied across the linea alba two inches above the umbilicus, and with its lower edge a little inclined downward. II. MEANS OF ARRESTING HEMORRHAGE DURING OPERATIONS. Measures for this purpose are rendered necessary, when from the situation of the part, as in operations upon the root of the neck, shoulder, or hip joint, it is difficult to compress the principal 9 [NG HEMORRHAGE. 33 trunks; or in other cases where the means of compression are liable to become temporarily displaced. The bleeding may take place either from the arteries or veins. As the peculiar applica- tion of these measures will be noted in reference to each important operation, it is not necessary to do more in this place than briefly enumerate them. Arterial hemorrhage.—There are three different processes, by which this may be arrested during the operation. The 1st process consists in a direct compression of each bleed- ing orifice with the end of a finger. This is done usually by one or more assistants, and may, according to circumstances, be main- tained to the end of the operation,—until the compression has been re-established on the main trunk if it had previously become displaced,—or until a ligature may be got ready to tie the opened vessel. The 2d process is a mediate or indirect compression of the divided vessels, and is principally used in flap amputations about the joints, where the fingers of an assistant can follow the knife so as to grasp between them and the thumb the vessels in the whole thickness of the flap. It is employed also in operations upon free margins, like the lip, nose, and ear, which are held by both sur- faces in a similar manner. The 3d process consists in a previous ligature of the main trunk, as in Larrey's method for amputation at the hip joint. Venous hemorrhage.—This arises from two causes: 1st, from the compression of the limb necessary to flatten the artery, wdiich prevents the ascent of the blood through the veins. In this case the bleeding ceases of itself, as soon as the compressing force is removed. 2. From some impediment to the circulation of the blood through the lungs, dependent upon the cries and efforts of the patient—met with commonly only in operations near the root of the neck, or the top of the chest. When it arises from this cause it suffices usually, in order to arrest the hemorrhage, to cause the patient to make several long inspirations in quick succession. It is important, however, in operations on the root of the neck, to make pressure when it is possible upon the vein before it is cut, especially if found in the midst of hardened tissues, in order to prevent the passing of air into the course of the circulation. If the bleeding should not cease, pressure may be made on the orifices for some minutes with the finger; this, by causing a co- agulation of the blood, may arrest the flow. As a last resort, each vein may be tied as an artery, though this measure is always attended with more or less risk of phlebitis. The same plans are to be pursued for the purpose of arresting the bleeding from the veins after operations. III. MEANS OF ARRESTING ARTERIAL HEMORRHAGE AFTER OPERATIONS. Direct ligature of the open mouths of the divided vessels, aided by compression of the cutaneous surfaces with adhesive straps, compresses and bandages, are the means ordinarily relied on for this purpose. Various other ingenious measures have been de- vised, some of which may occasionally be practised with advan- tage. These will be noticed in succession. By ligature.—This process is applicable to arteries of all sizes, from those of the largest calibre, to such as emit only a feeble jet 34 ELEMENTARY AND MINOR OPERATIONS. of blood. Its first effect is to close immediately the opening of the divided vessel, put an instant stop to the bleeding, and cause R stagnation of the blood between the place at which it is applied, and the first collateral branch of importance given off'by the vessel above. Subsequently the coagulum becomes absorbed, and its place is supplied by the effusion of lymph from the sides of the lining membrane, which gradually obliterates the cavity and con- verts the end of the vessel into a cord; the ligature is finally loosened by the division of the part within its grasp, and causes an effusion of lymph on the outer side of the vessel, which attaches it firmly to the surrounding parts. Material employed.—A single silk or hempen thread sufficiently large and strong, to admit merely of being drawn tight enough to compress firmly the coats of the vessels, or cut the internal and middle coats, is that commonly used, and in the author's opinion entitled to the most decided preference. A ligature too large in proportion to the size of the vessel, does not close it effectually, and is more liable to slip ; and provided it should not slip, does not cut through the parts embraced in the loop, till long after the vessel is thoroughly obliterated, when, from its presence being no longer needed, it becomes a source of useless irritation. On the other hand a ligature relatively too small, by embracing but a narrow line of the vessel, might detach itself too early so as to occasion secondary hemorrhage. For the largest class of vessels usually operated on, such as the femoral, brachial, or axillary, a single strand of the saddler's sewing silk will be found of the proper size. For the larger trunks, such as the innominata, the iliacs, or the aorta, a round cord of greater dimensions is con- sidered more appropriate. Various other kinds of material have been employed. Animal ligatures, made of various substances, but especially of kid skin rolled into small cords, were employed by Physick, Dorsey, and Jamieson, under the belief that the knot would soften, and become absorbed after it had been applied a sufficient length of time to obliterate the vessel, so as to offer no obstacle to closing of the wound by first intention. Dr. Paul Eve, Prof, of Surgery in the Medical College of Georgia, has employed with the same views, fibres from the sinews of the deer.- Experiments with the metallic ligature have also been successfully made upon the arteries of the inferior animals.* The instruments required in the application of the ligature after operations, consists of a tenaculum or hook, and a pair of dissecting or proper catch artery forceps. The tenaculum suiting best usually for the smaller branches, the orifices of which are not very obvious on the bleeding surface, and have to be taken up with some of the surrounding cellular tissue or muscular fibres. The forceps answers for the larger vessels, the mouths of which are usually conspicuous, and into each of which one point of the instrument can be introduced so as to seize the vessel firmly and draw it out from the nerves and veins that usually accompany it. In parts which are inflamed, the structure of the artery is sometimes found so soft, and occasionally even its investing sheath, as to cut across in the closing of the knot. The mediate ligature, as it is called, is then to be applied in the following manner: a thread is to be armed with a curved needle at each end; one of these needles is passed in a semicircle through the tissues at a little distance from • Vide paper, by Dr. Levert, in the Amer. Journ. Med. Sciences for 1829. the artery, and the second in a similar manner on the other side of the vessel, coming out near the point where the first entered. The thread thus passed is to be tied on the parts which it embraces, and the bleeding orifice will be found inclosed. Care should be taken, however, to avoid including any nerves in the loop. The same results I occasionally obtain in a more expeditious manner by raising the tissues on either side of the vessel with a couple of tenacula, while an assistant throws a ligature round and ties the raised part firmly below. The mediate ligature is also applicable in cases where after the arteries are tied a free capillary oozing con- tinues from a part of the surface of the wound, so as to be likely to fill it with blood after the application of the compressing bandage. One tail of each ligature is to be cut off near the knot, and the other brought on between the lips of the wound; the whole are then to be covered by a greased compress, and secured by the dress- ings so as to prevent their being unnecessarily disturbed. The ligature is to be left as a general rule till it becomes spontaneously loosened, and can be removed by a slight pull upon the free end. The length of time required for its separation will depend upon the size of the vessel. If any fibrous or other resisting tissue has been included in the loop, the time will be longer in proportion, and it becomes sometimes necessary to hasten its separation by slightly pulling or firmly twisting the thread from day to day. Jones and Travers, in their experiments upon animals, found the temporary application of a ligature sufficient to effectually close the artery. Twelve, twenty-four, or at most fifty hours, according to the latter surgeon, causes an obliteration sufficiently solid to admit of the division of the knot and the removal of the ligature. But there is no object likely to be gained by the removal of a ligature at this early period, that would counterbalance the risk of hemor- rhage, to which, to a greater or less extent, it certainly exposes the patient. Occasionally we find the large artery after amputation so ossi- fied in its structure, as not to close without crushing under the loop. Under such circumstances I have succeeded satisfactorily by plugging the orifice with a piece of linen compress and tying the vessel over it; when the ligature becomes detached it will bring away the plug. Professor Mutter has succeeded in nearly a similar way, by plugging the orifice with a portion of muscle from the detached limb. If the orifice of the bleeding artery is found in the substance of the divided bone, the hemorrhage may be effectually checked by plugging it with a piece of wax or soft wood. IV. MEANS WHICH HAVE BEEN APPLIED TO THE ARTERIES OF SMALL AND MEDIUM SIZE ONLY. 1st. Cauterization.—The eschar produced by the hot iron forms a sort of impermeable plug, adherent to the tissues, and may, as has been before observed, be eminently useful in arresting hemor- rhage from the smaller vessels. It is applied in cases of bleeding —from the surface of a bone, from the ranina artery, from the branches of the internal maxillary after operations upon the face, or in cases where bleeding follows the removal of fungous, erectile, or cancerous tumours ; or where the coats of the arteries are so softened by inflammation as to tear under the thread, and when the mediate ligature is found unavailing to check the flow. For MEANS OF PREVENTING HEMORRHAGE. 35 an artery of medium size, as the radial or anterior tibial, it is ne- cessary to repeat two or three times in succession the application of the iron, in order to form a plug sufficiently firm to arrest the blood during the period required for the obliteration of the cavity by adhesive inflammation. 2. By tearing or rupture.—It is well known that where arteries of considerable size are torn off* by mechanical force, as in the lacerated wounds produced by ma- chinery, but little bleeding follows. This is owing to the external coat being drawn out into the form of a cone, and forming when it snaps several spiral turns, which offer resistance to the passage of the blood, while the two inner coats, broken at different heights, curl inwards so as to form little septa, between which the blood forms itself into a clot. This process is occasionally imitated by surgeons in the tearing out of large tumours from their beds in the cellular and vascular spaces, after they have been exposed by a superficial incision. In this way, tumours of great size have been removed with but little hemorrhage. 3. Pinching or mashing the walls of a vessel for a little distance from its bleeding orifice with a pair of toothed forceps, causes in a similar manner the laceration and shriveling of the two inner coats. This process is found of useful application in many plastic and other operations, when it is desirable to avoid the irritation arising from the presence of the ligature. 4. Inversion with rupture of the two internal coats.— This is effected by Amussat by seizing the artery between two pairs of forceps, one of which is to be placed transversely and the other applied lower down in the direction of the vessel, as shown at PL 5, fig. 5. With the. lower pair of forceps, the two inner coats are ruptured, and the fragments, pressed or stuffed upwards as it were, into the cavity of the vessel. It is a process, however, deserving of but little reliance. 5. Torsion.—This may be em- ployed on arteries of small calibre with far greater prospect of success. Process of Amussat. (PL 5, fig. 7.)—The artery is to be isolated and drawn out so as to expose it for half an inch above the free surface of the wound. With the narrow round pointed forceps it is then to be seized transversely on a level with the wound and mashed so as to rupture its two inner coats, while the proper torsion forceps are applied transversely on the free end of the vessel to hold it drawn out. With the latter a half turn of the vessel is given so as to twist it on the first pair of forceps which holds it tight. The torsion forceps without loosening its hold is then to be brought down in the direction of the vessel, and the artery twisted upon its axis from three to eight times, according to its size. The upper pair of forceps is then to be removed, and the operation is completed by sinking the twisted end of the vessel into the flesh with the other pair. Process of Fricke. (PL 5, fig. 8.)—This is much more simple than the above. It consists in isolating the artery so as to expose half an inch or more of the end by pushing back the tissues which cover it, in order to grasp it with the thumb and fore finger of the left hand. The end is then to be seized with a pair of forceps and twirled eight or nine times completely round. 6. The Seton. (PL 5, fig. 11.)—To complete the description of these various processes, which we owe to the ingenuity and the desire to originate something novel on the part of various surgeons, it may be necessary to mention the following. It has been proposed to make two openings in the side of the vessel just above its open mouth; the free end of the vessel is then to be folded and pushed into the cavity with a pair of deli- cate forceps, and made to protrude on each side through the slits. It is a process long and difficult, and, as it could only be per- formed on a vessel of large calibre, deserving of no confidence. Several of the various processes above detailed for arresting hemorrhage after operations, may be found occasionally useful in practice; but the surgeon who would wish to leave his patient with the nearly positive certainty that he will not be troubled with secondary hemorrhage, should tie the vessels. In regard to the use of refrigerants, astringents, styptics, absorbents and cau- terizing substances for the arrestation of capillary bleeding, the reader is referred to the usual treatises on surgery. PART SECOND. GENERAL OPERATIONS: OR THOSE PRACTISED WITH REFERENCE TO ONE OR MORE PARTICULAR TISSUES. UNDER THIS GENERAL HEAD ARE CONSIDERED: 1. THE OPERATIONS WHICH ARE PRACTISED UPON THE VEINS; 2. THOSE FOR LIGATURE OF THE TRUNKS OF THE ARTERIES; 3. THOSE FOR DISEASES OF THE BONES AND JOINTS; AND, 4. AMPUTATION OF THE LIMBS. I. OPERATIONS UPON THE VEINS. The operations that are performed upon the veins consist of those for phlebotomy, which have already been described ; those for the transfusion of blood ; and of various processes for the cure of varicose veins, and the troublesome ulcers to which these affec- tions give rise. -. TRANSFUSION OF BLOOD. The wound of an artery, the rupture of an aneurismal tumour, and various other causes, may give rise to such sudden and ex- cessive loss of blood, as to leave the heart without a supply of fluid sufficient to maintain it in proper action. Under such cir- cumstances, it has been proposed to make a transference of blood from the system of another individual into that of the patient. This custom, which was formerly much in vogue, had until lately been completely abandoned. The favourable results obtained by its experimental employment on animals, and the benefit arising in some cases from its use on the human subject, render it proper that the processes for its performance should be briefly mentioned. Operation.—The instruments usually employed consist in the ordinary ligature for venesection, a scalpel, a thumb lancet, a pair of forceps, and a small metallic syringe, perfectly clean and fur- nished with a shifting tube or pipe. The orifice of the tube which receives the nozzle of the syringe should be large, and to make the operation more rapid, the parts should be made to fit tight without screwing. Having all the apparatus prepared and at hand, a ligature as for phlebotomy is applied both upon the arm of the patient and the individual from whom the blood is to be taken. The largest superficial vein found in the bend of the elbow is to be exposed on the patient by a longitudinal incision isolated by careful dissection, and raised upon a probe. At the upper and lower part of the wound the vein should be compressed by an assistant, while the surgeon opens it in the middle by a lon- gitudinal incision: the pressure at the upper part is for the pur- pose of preventing air from entering the circulation, and that at the lower of avoiding any effusion of blood. Into the opening of the vein, it is advised to insinuate next the small end of the metallic shifting tube, the larger end of which is prepared to receive the nozzle of the syringe; both instruments being raised to near blood heat, by having been previously placed in water of the proper temperature. The ligature on the arm of the patient is then to be removed ; the pressure being still kept up with the fingers of the assistant. The tube in the vein is then ready to receive the pipe of the syringe, when the latter has been charged with blood from the veins of the other individual. A better process, inasmuch as it would be less likely to injure the coats of the vein, and more effectually obviate the possibility of any introduction of air, would, as it appears to me, be the fol- lowing : Take a caoutchouc tube, one end of which shall by trial be found to enter the orifice of the vein, attach to its larger end a metallic pipe that may in a moment be affixed to the nozzle of the syringe, to which it should closely and securely fit. Then withdrawing the piston of the syringe, (this instrument having been previously raised to the proper temperature,) receive into its cavity about four ounces of blood taken in full stream from the arm of the healthy individual. The operator then adjusts the piston, attaches quickly the metallic extremity of the caoutchouc tube to the nozzle of the syringe, holds the instrument with the OPERATIONS UPON THE BLOOD-VESSELS. 37 handle downwards till by pressing up the piston he expels all the air from its cavity, and finds the fluid appear at the mouth of the caoutchouc tube. The instrument is then brought horizontal, and the end of the flexible tube insinuated into the opening of the vein, and carried on, above the upper point at which the vessel is com- pressed ; the assistant shifting his finger so as to renew the com- pression upon the vein and tube. The operator then injects the blood gently into the vein, so as to avoid any sudden shock as it reaches the heart, an assistant at the same time making gentle friction with the finger towards the armpit along the course of the vessels. The process thus described in detail to render it intelli- gible, should be executed without a moment's loss of time, lest the blood should chill or coagulate in its transit. It is necessary to warm the syringe as above directed, but care must also be observed that it does not much transcend the proper temperature, as the excessive heat might curdle the serum. Another danger to guard against is the introduction of air, as this in all probability would be attended with fatal consequences. This accident has not, however, taken place in any 0/ the cases reported, and may be readily obviated by observing the precautions mentioned. As a further measure of protection, and especially if there was any dribbling of blood from the end of the caoutchouc tube, this might be flattened by pressure between the thumb and fore finger, and thus inserted into the vein. The introduction of four ounces of blood has usually been found sufficient to prevent death from anaemia ; but if this amount did not produce the requisite effect, the process might be repeated. The wound in the skin is to be after- wards closed, so as to cause it to heal by the first intention. The injection of medicated fluids into the venous system has been practised according to the same method, though it is questionable that any case can arise that would justify the measure. Dr. Blundell, who may be said to have revived this operation in England, invented an apparatus for the purpose of transfusing the blood in an almost continuous stream, which, as it has been modified by the makers, consists of a syringe, to which a tubule and basin are permanently attached. It is employed in the fol- lowing manner, and should be preferred when at hand to the more ordinary instruments described above. The blood is permitted to flow into the brass basin attached to the extremity of the syringe. As it accumulates in the basin, it should be absorbed by raising the handle of the syringe, and then propelled onwards through the tubule attached to it. When the air has all been expelled from the tubule, and blood unmingled with any bubbles issues from the end, the beak should be inserted in the vein. The blood is then to be alternately drawn up from the basin and propelled into the vein, not more than an ounce and a half ever being per- mitted to accumulate in the basin. This process should be steadily and gently performed, the operator watching from time to time the expression of the patient's countenance, and if unpleasant symptoms occur after two or three ounces of blood have been transfused, the proceeding should be suspended for a moment to allow them to subside. Dr. Blundell thinks that seldom more than half a pint or a pint of blood can be needed. A case has recently been re- ported by Dr. J. C. Prichard,* in which a pint was successfully transfused at a single operation. * Prov. Med. Journal, cited in Phil. Med. Examiner, Sept., 1843. 10 VARICOSE VEINS. (PL. V.) The permanent dilatation of the veins is known under the name of varix, the most frequent seat of which is in the lower extremity. It is attended by various forms of pathological alteration. In the varicose vein, there may be either a simple dilatation without change of texture, or a dilatation with thinning of the coats; or there may be a general or partial thickening of the coats, with elongation of the vessels so as to cause them to assume a flexuous direction. • The valves are sometimes so thickened and enlarged as to form pouches across the cavity of the vessel in which the blood lodges and becomes coagulated, and in which also small rounded osseous bodies occasionally form, known under the name of phleboliths. A great number of processes have at different times been em- ployed in the treatment of this affection, viz., compression, ligatures, suture, resection, section, incision, excision, and cauterization. Compression.—Simple compression is but a palliative measure, and if employed at an early stage, and habitually continued, will check the progress of the disease, so as to render it a source of but little inconvenience. In the old and infirm and in individuals with much constitutional irritability, compression is almost the only means of relief to which the surgeon can with propriety re- sort. It is made with a laced stocking, or a roller bandage, neatly and closely adjusted to the limb, and extended from its extremity to a little above the upper limits of the affection. Surrounding the limb with a succession of adhesive straps is a measure that has also been occasionally employed for this purpose. Compression with the immovable apparatus applied as in the treatment of fractured limbs, has been employed by Mr. Teale, of Leeds, Eng., and alleged to have been successful in effecting a permanent cure. Compression at several points, so as to close the vessel by adhesive inflammation. (Process of Sanson, PL 5, fig. 1, c.)—The instru- ment employed by this surgeon consists of two small parallel plates forced together by a screw. Between these two plates the vein, raised in a fold of skin, is to be placed. The pressure made with the screw should be but moderate, and at the end of twenty-four hours shifted to another portion of vein, in order to avoid pro- ducing mortification. Several cases of successful treatment by this method have been reported. It is, however, but little used. The same process has been applied to the veins of the cord and scrotum. Compression after incision. (Process of Delpech.)—This consists in laying bare the vein by a longitudinal incision an inch long, and gliding below it a piece of prepared spunk over which the vein is to be flattened by the application of two adhesive strips, with the object of causing its sides to unite by adhesive inflamma- tion. This process has been but little employed, and is little deserving of confidence. Compression over a pin or needle. (1st Process of Davat, PL 5, fig. 1, a, and fig. 3.)—Raise the vein in a fold of skin, through the base of which and below the vein a pin or needle is to be passed transversely. Around this needle is to be wound a hare- lip suture, sufficiently tight to keep the anterior and posterior surfaces of the vein in close contact. Several pins, from four to ten or twelve, should be employed at little distances from each other, upon the main trunk and its principal branches, so as to cut 38 off'effectually the route of the blood through the superficial veins, and cause it to return by the deep-seated. Velpeau prefers to sur- round the two ends of the pin merely with the thread in vertical turns (PL 5, fig. 1, No. 2,) rather than in the form of a figure oo, as it is less disposed to cause ulceration of the skin. An elliptical wrapping of the pin, however, as shown at fig. 4, is decidedly preferable to either. -2/iiu, 1'ubl.ijsh.eiL by C„ ,vy .(• //,<,/ l'.;\ Dii,;././., II, !>/,,/» OPERATIONS UPC which are laid down in each case with almost mathematical pre* cision. It is prudent also in most instances, before and during the operation, to determine by the touch whether there be any neighbouring or anomalous branch in the way, which, if such should be the case, it would be desirable to avoid. The tourni- quet or other means of compression need not usually be applied ; as, by interrupting the pulsation, it would destroy a useful guide to the discovery of the vessel. But if a large artery is to be tied, and the surgeon has not had experience in the particular case, it is a useful measure of precaution, and may be tightened during the operation in case of sudden hemorrhage. If, however, the operator intends to open the sac of an aneurism, turn out the blood and apply a ligature to the vessel above and below the tumour, it is a step which should not be neglected. b. The integument is now to be opened. If the artery be su- perficial, the skin should be incised directly over its track. If it be somewhat deep, it is better, as giving a greater certainty of falling upon the muscular interstice, to divide the skin, after the direction of Lisfranc, somewhat obliquely over the course of the vessel. Having decided upon the most accessible or appropriate point for operation, the surgeon, making the skin tense in the ordinary manner without altering its relation to the artery, di- vides it carefully from without inwards, with the scalpel, for an extent of two to four inches, according to the depth of the vessel from the surface. Or, placing his thumb and fore finger on the course of the vessel, raises up with the aid of an assistant a fold of skin, and divides it from within outwards, with the bistoury entered at its base. By raising up one lip of the wound with the thumb and finger, the incision can then be readily enlarged to the requisite extent. This latter plan is not applicable in all parts of the body, for where large superficial veins exist along the line of incision, they run a greater risk of being wounded by this method than by the incision from without inwards. It has been suggested by M. Lisfranc, that the ends of the fingers of the left hand should be plated vertically over the line of the vessel, and the incision made along their dorsal edge. This method I have found very satisfactory in practice. Care, however, must be observed to make the pressure directly down upon the pulsa- ting vessel so as not to disturb the relations of parts, and confuse the subsequent steps of the operation. c. The fascia superficialis, and the superficial aponeurosis, which cover even the most superficial of the trunks that require a ligature, are next to be opened. These may be divided, if the vessel be deep, directly over its course with the knife; if super- ficial, slightly to one side. But it answers equally well, and is safer and surer, to make a small puncture through these mem- branes at the lower end of the wound, push in the grooved di- rector so as to raise them up one at a time, and having observed that there is no superficial vein or nerve in the way, run the knife along the channel in the instrument the whole extent of the in- cision of the skin. If the artery be superficial, it is now seen in its sheath; if.deep, we must seek the proper muscular interstice, according to the rules given in each case, open it by breaking the cellular tissue with some sweeps of the finger, the point of the director, or the handle of the scalpel, and, if need be, with a few touches of the edge, until the shining surface of the second apo- neurosis which covers the deep vessels is brought into view; this 11 " THE ARTERIES. 41 is then to be opened in like manner as the first or superficial apo- neurosis. If the tension of the superficial fasciae presents an ob* stacle to the separation of the muscles, it may be cross cut with the scalpel at the ends of the wound. If the surgeon follow method* ically each of these steps, avoiding all precipitancy in searching for the vessel, he will accomplish his object in a short space of time, and with great certainty and safety. 2. The isolation qf the artery, a. The lips of the incision are to be held asunder with the fingers of an assistant, or a pair of blunt hooks, and the blood removed from the bottom of the wound by pressing in a sponge wetted with cold water. If compression has been employed on the main trunk of the artery, it is to be slackened in case of doubt as to the position of the vessel, in order to render this evident by its pulsation. When the sheath of the vessel is fairly exposed, it is to be raised with a pair of forceps over the artery, and opened by a horizontal cut with the point of the knife, the edge of which is to be held so that no accidental slip will endanger the parts below. Without loosening the hold of the forceps, the end of the grooved director is entered at the opening thus made. If the sheath be found too resisting to be readily torn with the point of the director, it is to be raised on this instrument and slit for a few lines along the groove with the scalpel or a probe-pointed bistoury. Then breaking cautiously the cellular tissue on either side of the artery, so as to separate it from the veins and nerve, the operator passes the point of the grooved director below and brings it out on the opposite side of the vessel. This last step is the most difficult part in the isolation of the vessel. The end of the fore finger of the other hand should be placed at the point of emergence, so as to present resistance to the instrument, and push out of the way the nerve or vein, in order that neither may be contused or raised with the artery. If the cellular tissue, which is pushed before the director, does not yield to its point, it may be nicked with the edge of the knife. If the vessel be super- ficial, the director is to be carried at right angles to it. If some- what deep, it should be passed rather obliquely to its course, the deeper sides of the wound offering less obstacle in that direction: at the same time the instrument should be bent near the end; the common silver or steel director being sufficiently flexible to take any curve requisite for the occasion. But in vessels still deeper placed, as the posterior tibial, iliac, and subclavian, some one of the various kinds of curved aneurismal needles must be em- ployed. 3. Application of the ligature. Having ascertained, by careful examination, that the artery alone is raised on the director, a common eyed probe, threaded with the ligature, and slightly bent upwards at the entering end, is passed along the groove of the instrument. This end of the probe is to be seized with the thumb and fingers, or a pair of for- ceps, and carried through, at the same time that the director is withdrawn in the opposite direction. If the ordinary aneurismal needle be employed, no director is required ; the ligature, which is carried near the point, is passed with the instrument under" the vessel, and is to be seized on the opposite side with the forceps. A very admirable instrument for securing deep-seated vessels, on 42 GENERAL OPERATIONS. the plan of Bellocq's tube, has been devised by Professor Gibson, of the University of Pennsylvania. Professor Horner, of the same institution, employs an instrument shaped like the shoema- ker's awl, notched near the point for the attachment of a ligature with a slip-knot. Many surgeons employ the needle of Mott, which unscrews near the end, so that the beak may be detached and drawn through with the ligature. Various other aneurismal needles will be shown in connection with the plates, the two best of which, accord- ing to my own experience, is that of Graefe, which is curved on the side; and that of Physick, consisting of a blunt-pointed needle, held in the artery forceps of that surgeon, a drawing of which is given in the operation for suture of the palate. b. Knotting the ligature.—Having raised the artery by< draw- ing on the two ends of the ligature, to see whether it arrests the pulsation below, and thus avoid all possibility of a mistake which has sometimes been made—that of tying a nerve instead of the artery—the ligature is to be firmly secured with the common double knot. It should be tied directly across the vessel, for if the direction of the loop be oblique, it might, by descending on one side, become so loose as not sufficiently to compress the ar- tery. If the vessel lay at the bottom of a deep and narrow wound, each fold of the knot should be firmly tightened by the ends of the fore finger of either hand passed down, back to back, upon the artery; a method which will be found in almost every case superior to the use of any of the complicated serre-nceuds that have been invented. It was till recently considered indispensa- ble, for the safe obliteration of the vessel, that the ligature should be tied so tight as to divide the middle and internal coats; and though this is more usually and properly the result, experience has shown that the blocking up of the vessel by the formation of a coagulum and the effusion of lymph, is as completely effected when the inner walls of the vessels are merely held in close but firm contact. Abernethy and John Bell were in the habit of ap- plying two ligatures, and dividing the vessel between them, in order to allow it to retract as an additional precaution against hemorrhage—a practice which is now abandoned. c. Dressing.—The dressing of the wound should be simple. It has for its object the accomplishment of union as far as possible by first intention. One tail of the ligature is to be cut off' near the knot, and the other brought out' over the nearest portion of the skin. The French practice of carrying it out at the lower end of the wound is not always the most advisable, as it may, from the length and obliquity of the tract, lead to the formation of a sinuous ulcer. The wound is to be closed with adhesive straps, and lightly secured, when practicable, with a compress and roller. The member is to be placed in a position that will relax the mus- cles. If the artery tied has been a large one, as for instance the iliac, femoral, or subclavian, the limb, to preserve the vital warmth, should be for a time wrapped with flannel, or what answers better, as serving to prevent the weight of the part from interfering with the enlargement of any of the superficial capillaries, laid upon a bed of loose soft wool. If the loss of temperature in the limb that at first attends the operation be persistent, friction should be made in addition, with a slightly stimulating and aromatic lini- ment. The ligature is to be left untouched for eight to ten days for the smaller arteries, and for two weeks or more for the larger • and is not in any case to be removed till it follows a very slight pull, as that is the only evidence we have of its having divided the vessel by ulcerative absorption, and of the probable closure of the calibre for some little distance above. The three principal classes of accidents to be dreaded, are, 1. Those which may result from plethora, on account of the mass of blood being confined to a smaller circuit than usual. This is to be obviated by blood-let- ting and the usual antiphlogistic regimen. 2. Hemorrhage about the period of the separation of the ligature. From whatever cause this may arise, it requires immediate compression to be made on the surface of the wound, or over the trunk of the vessel above, or, this not sufficing, the tying again of the vessel, if practicable, at a higher point. 3. Gangrene, where the principal trunk of the limb has been tied for aneurism. This disaster has sometimes, though very rarely, been known to follow. It occurs more fre- quently when the ligature has been required on account of a severe gun-shot wound, compound fracture of a bone, or other severe injury. But it is more especially to be dreaded when, in conse- quence of a previous wound, or from bungling during the opera- tion, the large conducting vein from the limb has been likewise injured, or where an aneurismal communication has been formed between the artery and its accompanying vein. When gangrene, notwithstanding the use of all proper precautionary measures, follows, the only chance for the ultimate safety of the patient is speedy amputation. The rules for the application of ligatures to the different vessels, are as follows. LIGATURE OF THE DIFFERENT ARTERIES. OF THE ARTERIA INNOMINATA. Surgical anatomy.—The arteriainnominata is, after the aorta and pulmonary arteries, the largest arterial trunk in the body. It is given off from the top of the arch of the aorta to the left of the middle part of the upper bone of the sternum, and a little more than half an inch from its upper margin. It passes from this place obliquely upwards and outwards, to a point immediately behind the sterno- , clavicular articulation of the right side, at the upper margin of which it divides into the right primitive carotid and right subcla- vian. In its rout it traverses the superior thoracic fascia of Coo- per, (which is an important means of protection to the cavity of the chest,) about four lines below its place of bifurcation. The trunk of this vessel is usually found from an inch and a quarter to an inch and a half long. Its diameter, in a well developed adult, is about half an inch. The place of its division is deep behind the sternum, from half an inch to three inches from the inner face of the top of that bone. In front, the vessel is separated from the sterno-hyoid and thyroid muscles by some loose cellular tissue, in which .are lodged many of the inferior thyroid veins that dis- charge into the left subclavian. Between these and the bone lies one part of great importance, the transverse vein, (left vena inno- minata,) which passes over from the left to the right side, but so near the root of the vessel; however, as to be out of the way of the operation. When the head is thrown forcibly backwards and to the left side, the arteria innominata is drawn upwards, so that its point of bifurcation, as seen in Plate 9, fig. 1, is considerably above the LIGATURE OF THE I sterno-clavicular articulation. Posteriorly, it crosses obliquely the root of the trachea. On its inner face is the left carotid, and in the angle of divergence between these two vessels, projects the trachea. Externally, it rests for the greater part of its course upon the pleura covering the upper surface of the right lung. The right subclavian and right jugular vein, and the common trunk they form, as well as the pneumogastric nerve, are placed so much on the outer side of the artery at the point where it is tied, as not to be endangered in the operation, unless the surgeon errs by hunting too far outwards for the vessel, which, it is to be recollected, is lodged between the right margin of the trachea and the right sterno-clavicular articulation, immediately behind the sternal origin of the sterno-cleido-mastoid. Anomalies.—This great trunk is but rarely seen to deviate from the usual description. It occasionally, however, varies in regard to its direction and length, and has been found altogether wanting. I have in my cabinet several specimens of transposition of the great vessels coming off from the arch of the aorta. In one, the right subclavian originates on the left side, and crosses to the right between the trachea and oesophagus. In another having the same origin, it passes behind both these tubes. In a third, the two carotids spring from a common trunk, etc. Anastomosis.—Spontaneous aneurism of the arteria innomi- nata itself, has many times been met with, and instances have been noted by two observers,* where it was found with one or both of the branches that arise from it, obliterated after death. The anastomosing branches that may restore under such circum- stances the circulation to the right side of the head and neck, are the branches of the left vertebral and carotid; the thyroid, cervical, intercostal and internal mammary of the two sides, anastomose together so as to be able to return the blood to the right arm by the way of the supra and sub-scapular, external thoracic and circumflex vessels. The fact of its accidental obliteration serves in a measure to show the possibility of a successful result in the case of its being tied. The honour of having first performed this most serious, but as yet unsuccessful operation, is due to Professor Mott, of the University of the city of New York. Operation. Process of Mott. (Plate 9, fig. 1.)—The patient is placed in the recumbent position, with the neck slightly flexed and supported with a pillow, and the face turned to the opposite side in order to relax the sterno-cleido-mastoid muscle. The surgeon, standing upon the right of the patient, makes a trans- verse incision of three inches in length, commencing at the me- dian line of the neck, and extended outwards parallel with but half an inch above the upper border of the clavicle. Another incision of the same length is made along the internal border of the sterno-cleido-mastoid, terminating at the commencement of the first. The platysma muscle and the superficial fascia are next carefully opened so as to expose the sternal portion of the sterno- cleido-mastoid, which is to be divided on the grooved director previously passed behind it. The inner two-thirds of the cla- vicular origin of the muscle is to be cut in a similar manner; the muscle is then to be reversed upwards and outwards, as seen in Plate 9. The sterno-hyoid and thyroid muscles are now to be divided, after having been cautiously raised on the director. The • Pelletan and Dr. Wm. Darrach. FFERENT ARTERIES. 43 surgeon then opens with the finger or the director the cellular tissue lying above the vessel, carefully avoiding the right internal jugular vein, which is found a quarter of an inch to its outer side, and the inferior thyroid veins, which usually cover it in front, and are to be drawn off laterally. The finger falls first upon the primi- tive carotid near its root. The surgeon traces this vessel down- ward, and cautiously tears the cellular tissue till the innominata is exposed! The vessel in question being now discovered, it is to be separated on its outer or right margin from the vena inno- minata of the same side with the end of the director, and then pressing off lightly from it the vein and the recurrent laryngeal nerve, the ligature is carried with a curved aneurismal needle from without inwards around the vessel. In operations upon the subject, I have found it more convenient to make the longitudinal incision first, as the skin becomes relaxed after the transverse one is made. Before attempting to pass the ligature, I find it also best to raise with the forceps and di- vide on the front of the vessel a dense cellular layer, which is an extension downwards of the deep-seated fascia of the neck. Pro- fessor Mott secured the vessel with the ordinary silk ligature. Several other processes have been devised for the ligature of this artery. Graafe, who followed Dr. Mott in the operation, made only a longitudinal incision, along the inner side of the sterno-cleido-mastoid, and partly with his finger, and partly with the handle of the scalpel, separated the parts down to the carotid near its place of origin. Following this vessel, he reached the innominata, which he detached behind the upper part of the sternum from its sheath, so as to get his finger around it. M. Manec directs only the transverse incision to be made, and through that proceeds to isolate the vessel. Process of King.—This as last modified consists of an oblique incision, carried inwards and upwards from the right sterno-cla- vicular articulation over the supra-sternal fossa, to the left sterno- cleido-mastoid muscle, the surgeon standing on the left side. The artery is to be sought for between the trachea and the sterno- hyoid muscles, and surrounded with a ligature passed from with- out inwards. This process, though brilliant in its execution on the dead body, must be attended with great difficulty in its appli- cation to the living, from the contraction of the muscles and the effusion of blood in so narrow a wound. That of Mott is to be preferred to all, as the most judicious in its plan, and leaving less to hazard in the delicate manipulations required. In each of the several instances in which the operation has as yet been performed, the patient sunk from hemorrhage between the periods of nineteen and sixty days; and it is yet a question whether the great size and depth of the artery, its proximity to the heart, and the probability of its disease in aneurisms of the Carotid and subclavian do not present such difficulties in regard to the formation of a clot on the side next the heart by the time the ligature separates, as to offer insurmountable obstacles to its successful performance. In Manec's experiments upon the inferior animals, in which the effusion of coagulable lymph takes place with greater facility than in man, the safe obliteration of the vessel, even when previously healthy, occurred but twice in four times. Still, circumstances might possibly arise to justify its performance, especially when it is considered that the only alternatives presented are little to be relied on, viz: the securing of the carotid or subclavian on the 44 GENERAL OBSERVATIONS. distal side of the tumour after the methods of Brasdor and War- drop, or the uncertain process of Valsalva. LIGATURE OF THE COMMON CAROTID—PLACE OF ELECTION. Surgical anatomy.—The primitive carotid arteries pass out at the root of the neck upon either side of the trachea, placed about an inch apart, and ascend obliquely upwards and backwards in the direction of the angle of the jaw. The higher they ascend the farther they recede from the front line of the neck. On a level with the superior margin of the thyroid cartilage, they divide into two branches, the internal and external carotid. The position of the head materially influences the relative distance of the angle of the lower jaw from the place of bifurcation. When the head is depressed or the mouth opened, the arteries are covered by the angle of the jaw. When the base of the skull is horizontal, the point of division is nearly an inch below it; and if the head be carried backwards, the distance is of course increased. The right carotid is shorter than the left, and somewhat more super- ficial near its origin, in consequence of its coming off* from the arteria innominata. The left primitive carotid arises from the aorta, and as it passes up the neck, crosses the root of the trachea, is separated from the first bone of the sternum by the vena trans- versa, and has passing at a little distance behind it, the arched ex- PLATE IX.—LIGATURE OF THE ARTERIA INNOMINATA AND SUBCLAVIAN, Fig. 1. (A)—Ligature of the arteria innominata. (Process of Mott.) The neck of the patient is slightly flexed, the head thrown back, the surgeon standing on the right side. The process for laying bare this great trunk exposes also the origin of the subclavian, carotid, and several other important parts. 1. Triangular flap of the skin and superficial fascia, raised and pushed upwards and outwards. 2. Sternal portion of the sterno-cleido-mastoid muscle, divided and reflected back. 3. Divided tendon of the same portion of this muscle left connected with the sternum. 4. Clavicular portion of the same muscle left undivided. 5, 6. Place of division of the sterno-hyoid and sterno-thyroid muscles. 7, 8. Upper section of the same muscles retracted and pushed inwards precisely as they appear on the operation upon the dead body. 9. Deep-seated cervical aponeurosis, forming a covering to the artery in front, above which it has been divided on the grooved director—lower section only seen. a. Arteria innominata, raised above the sternum by the head being thrown backwards. b. Origin of the right primitive carotid. c. Origin of the subclavian. d. Anterior edge of the internal jugular vein. e. Thyroid vein crossing to the internal jugular. f. Phrenic nerve crossing in front of the subclavian artery. g. Descendens noni nerve crossing obliquely over the outer face of the carotid sheath to the sterno-hyoid and thyroid muscles. A ligature is seen applied about the arteria innominata, at the proper place for securing that vessel. Two more are thrown around the roots of the carotid and subclavian, showing the manner in which these vessels may be secured by the process of Mott for tying the arteria innominata. Fig. 1. (B).—This represents a similar opening of the integuments and soft parts as in fig. 1, A, with an exposure of the roots of the vessels that come off from the subclavian near its origin, a ligature being placed below each, to show the possibility of tying them in case of accident. 1. Line of the transverse wound at the root of the neck. 2. Line of the longitudinal wound along the inner border of the sterno-cleido-mastoid. 3. Reflection of the triangular piece of integument. 4. Deep-seated fascia of the neck, involving the sterno-hyoid and sterno-thyroid muscles, and covering the trachea. 5. Lower end of the scalenus anticus. 6. Internal jugular vein. 7. Graefe's aneurismal needle carried under the arteria innominata. 8. Origin of the subclavian. 9. Vertebral artery, embraced by a thread near its root, and raised 10. Inferior thyroid artery. IL Internal mammary. 12. Transverse cervical artery. up so as to come into view. Fig. 2.-—Ligature of the subclavian below the clavicle muscle. (Process of the author.) or more properly speafdng, of the axillary under the pectoral Plate- 9. JTiy. 1. 0: 'v^- eaggsse* lriq X. 'W / k f/t iladdph Ki: Publtilheob by (ktrey & Jfart- PS.Duval.Utlv. Phil( LIGATURE OF THE DIFFERENT ARTERIES. 45 tremity of the thoracic duct, which above the level of the sternum gets into the space between it and the left vertebral artery. With the exception of their lower end, they have similar rela- tions with surrounding parts. Each is enveloped in a sheath, behind which and separating it from the muscles on the front of the vertebrae, is the trunk of the great sympathetic nerve, and at the lower part of their course the inferior thyroid artery and recur- rent laryngeal nerve. The sheath embraces besides the artery the par vagum nerve and the internal jugular vein. The artery lying upon the inner side next the trachea and larnyx, the vein without, and the nerve between but somewhat posterior to the two. Delicate processes of the sheath pass between these parts, from behind forwards, so as to keep them asunder; but not so as to prevent the vein from slightly overlapping the artery. Just above the middle part of their course, the omo-hyoid muscle runs obliquely upwards and inwards over the front part of the sheath. Above this point the sheath of the vessels is covered only by the skin, platysma muscle and superficial fascia, and the descendens noni nerve which runs obliquely downwards and forwards. The artery is so superficial, that it may be seen or felt pulsating in a trian- gular space, bounded without by the anterior part of the sterno- cleido-mastoid, within by the ascending portion of the omo-hyoid, and above by the digastric. At its superficial position here, oppo- site the larynx, the ordinary operation for ligature of the carotid is performed. Below the omo-hyoid, the artery is more deeply placed. It is covered there, in addition to the parts above men- tioned, with the sternal portion of the sterno-cleido-mastoid, and the sterno-hyoid and thyroid muscles. Anomalies.—Anomalies in the course or origin of these vessels are very unusual. They have been referred to in the preceding article. Anastomosis.—>The anastomosing communications between the branches of these arteries and the surrounding vessels, are so nu- merous, that the circulation is readily re-established after the trunks have been tied. The vertebral, the internal carotid, the thyroid, lingual, facial, temporal, &c, of the two sides, communicate so freely together, that the pulsation in the trunk above the ligature returns in a short space of time. It is for this reason that ligature of the carotid is now so commonly abandoned in the treatment of erectile tumours seated on the branches of that vessel. Remarks.—The ligature of this vessel is rarely practised now, except for the cure of aneurism of the trunk or some of its branches, or in extensive wounds of the face and neck. In former times, it was much employed as a preparatory measure in resection of the jaws, removal of tumours from the face, and ablation of the parotid gland. But it has been found by experience, that secondary hemorrhage is apt to follow from the return of blood into the divided vessels, and that it is better to secure these as they spring, as the loss of blood may be temporarily checked so as to give time to find the divided branch, by pressure of the lower part of the carotid against the spine, which is sufficiently superficial for that purpose. Both carotids have been obstructed by ligature in the The patient is inclined upon the left side, with the right shoulder raised as high as the case will admit. An assistant places his thumb above the clavicle so as to make pressure on the main trunk between the scaleni muscles, in case it should be needed by an accidental wound of the vessels. The incision of the integument is made directly over the interstice, which may be felt through the skin separating the sternal from the clavicular portion of the pectoralis major muscle. The upper section consisting of skin and clavicular portion of the muscle, has been divided on the finger or director from within outwards, and in a direction at right angles with the course of the muscular fibres. a. Portion of the pectoralis major muscle, which takes its origin from the sternum. b, b. Clavicular portion divided across, and the ends reflected to expose the parts below. c. Posterior fascia of the pectoral muscle, found immediately on its inner face. d. Part of the same fascia, all the intervening portion having been removed. e. Tendon of the pectoralis minor near its insertion on the coracoid process, drawn slightly downwards with a blunt hook. f Axillary vein at the front and inner side of the artery. g, g. Axillary artery—both these vessels are seen just as they got below the clavicle, where they take the name of subclavian. h. Anterior root of the brachial plexus of nerves, lying behind and to the outer side of the artery. Posterior to this root are seen the other branches of the brachial plexus. i. Cephalic vein of the arm crossing in front of the nerves and the artery, to empty into the axillary vein. Above this, another small vein is seen winding over the artery to reach the axillary vein. A third small venous branch is seen coming up in front of the artery. k. Origin of the external thoracic arteries by a common trunk from the axillary, as was the case in the subject from which this drawing w7as taken. I. One of the external thoracic nerves. A ligature is seen applied about the artery in the upper part of the wound near the clavicular fossa, at the usual place of operation. Another at the lower part of the wound, embraces the artery just above the pectoralis minor and below the cephalic vein. One of the many advantages which attend this process, is the facility of largely uncovering the vessel without much dissection, so as to apply the ligature upon either one of these points as may be desired. 12 4»i GENERAL OPERATIONS. same individual. Professor Mott tied them nearly simultaneously in a case of desperate necessity. The patient died in the course of twenty-four hours, and it is questionable whether the human brain could sustain the sudden deprivation of two such columns of blood as those sent up by the carotids. Where a considerable interval of time has elapsed between the operations for ligature of the two vessels, the result has been more successful. The artery may be tied at two points, either above or below the omo-hyoid muscle. LIGATURE AT THE PLACE OF ELECTION OR UPPER THIRD OF THE CAROTID. (PL. X.) Operation.—The patient is placed in the recumbent posture, with his shoulders a little elevated, the face turned to the opposite side and supported by an assistant, and the chin carried back so as to extend the integuments on the front of the neck. An inci- sion is then made on the anterior edge of the sterno-cleido-mastoid, commencing an inch below the angle of the jaw, and extended half-way down the neck. Before commencing the incision, de- press with the fingers of the left hand, the groove intermediate to the trachea and the edge of the muscle, so as to make the latter more conspicuous. After section of the skin, raise and divide successively on the director the platysma muscle and superficial fascia, taking care to avoid wounding the anterior jugular vein,— a branch usually met with connecting this with the external jugu- lar—or any of the lower superficial nerves. The deep-seated layer of fascia, connecting the edge of the sterno-cleido-mastoid to the sterno-thyroid and hyoid muscles, is to be divided in like manner on the director. The scalpel is now to be laid down, the chin lowered to its usual position so as to relax the muscles, and the margins of the wound held asunder by blunt hooks or the fingers of an assistant. With the point of the director or forceps, or the end of the left fore finger, break the cellular tissue so as to expose the sheath of the vessels, over which and partly through which will be seen crossing the descendens noni nerve. In some operations on the living subject, I have seen this nerve as large nearly as the par vagum, but easily distinguished from it by its oblique and superficial position. Raise the sheath carefully with the point of the forceps, and open it upon its inner side over PLATE X.—LIGATURE OF THE ARTERIES OF THE HEAD AND NECK, OF THE PRIMITIVE CAROTID AND EXTERNAL CAROTID ABOVE THE OMO-HYOIDEUS. The incision is made along the internal edge of the sterno-cleido-mastoideus and is larger than necessary in operations on the living subject, in order to render the plate more useful, by showing fully the relation of the different parts involved. The head is represented thrown back, and the face a little inclined to the opposite side. (A). One edge of the divided platysma-myoides. (B). Anterior margin of the sterno-cleido-mastoid. (C). Anterior belly of the omo-hyoid, running up to its insertion on the os hyoides. (D D). Sheath of the vessels, laid open so as to show the primitive and external carotid arteries. 1. External carotid, with a ligature below it, showing that this vessel maybe taken up by a slight extension upwards of the ordinary incision for ligature of the common trunk. 2. Primitive carotid. It is raised on the ordinary aneurismal needle, which, previous to being used on the living subject,' is to be threaded with the ligature. 3. External jugular vein. 4. Descendens noni nerve, pushed a little out of its course by the needle. The pneumogastric or par vagum nerve lies between the carotid artery and jugular vein, and is not seen in the drawing. OF THE FACIAL ARTERY. The incision is made just in front of the masseter, and, for the reason above given, it is made of large size. (A). Anterior edge of the masseter muscle, exposed by an incision through the skin and the platysma. 1. The facial artery, raised on the needle. 2. The facial vein. 3. Branches of the portio dura nerve. OF THE TEMPORAL ARTERY. The incision is made just in front of the ear. 1. The temporal artery, which is seen branching at the upper part of the wound. The trunk is raised on a ligature. 2. Temporal vein. POSTERIOR AURIS. A curved white line is drawn below the ear, to indicate the place of incision for the posterior auris artery. Plate, 10. '"^^SaSSa?** On Stone iy S. Ciohot*-sJc^ Philadelphia, Published by Carey £>Sa.rt PS.J)vLva.l,Jsit/l f/t.it:'- LIGATURE OF THE DIFFERENT ARTERIES. 47 the carotid, so as to avoid the nerve, and enlarge the orifice on a director in order to expose the vessel. At the lower part of the wound the middle tendon of the omo-hyoid is seen crossing the sheath. If it be in the way in opening the latter, it may be de- pressed, or, if necessary, divided. The internal jugular vein is to be held slightly downward and outward; and if it swell up so as to obscure the artery, as is apt to be the case when we operate on a struggling patient, it may be compressed with the finger at the upper angle of the wound. With the point of the director, isolate the artery for a little space first on its outer and then on its inner side. The end of the grooved director, slightly curved, or an aneurismal needle, is to be passed from without inwards behind the vessel, so as to avoid disturbing the par vagum,—placing the index finger of one hand on the inner side of the artery to give it a point of support. The ligature is then to be placed and secured as described at page 41. If the operation be neatly done, the pneumogastric nerve is not brought into view, and provided the rules above detailed are carefully observed, neither the sympa- thetic nerve behind the sheath, nor the recurrent laryngeal on its inner side, parts of great functional importance, run any risk of being injured. If the internal jugular vein should by accident be punctured, a casualty which has sometimes happened, it is to be seized at once with the thumb and finger; a couple of fine pins are then to be passed through the edges and across the orifice, and a delicate silk ligature tied below so as to embrace the opening; the pins may then be withdrawn. If the opening be of much size, the vein should be tied both above and below the orifice. In a case of extensive wound, Mr. Simmons, of Manchester, tied the main trunk of the vein, and was so fortunate as not to lose his patient. In wounds of this vein, it might be possible even to save the patient by plugging and compression, as was the case with an ancestor of the distinguished Mirabeau. But it is an accident which ought not to occur in an operation like this, which is one of no great difficulty. LIGATURE OF THE COMMON CAROTID AT ITS LOWER PART. PLACE OF NECESSITY. (PL. XI.) Circumstances that would render this operation necessary, as the existence of an aneurism of the carotid occupying a consider- able part of the side of the neck, must, of course, from the addi- tional embarrassment presented, make it one of considerable difficulty. It has, however, several times been successfully per- formed on the living subject, under such embarrassments. The difficulty encountered is in laying bare the root of the carotid, between the tumour and the sternum. The method, therefore, which shall best expose the parts to the eye, is the one to which preference should be given. The difficulties here are much the same as in ligature of the innominata, and for reasons given when treating of that operation, the plan of Mott, somewhat modified as to the length of the incisions, as it has been by Coates, will in the author's opinion be found most appropriate. An incision of three inches in extent is to be made along the inner margin of the sterno- cleido-mastoid, terminating at the top of the sternum ; an inch from the top of the sternum another incision parting from this is made parallel with the direction of the clavicle, ending just beyond the sterno-clavicular articulation. The sternal portion of the muscle is to be divided in the latter direction, and turned up- wards. The remaining steps of the operation for the isolation of the carotid is nearly the same as that detailed in the operation of Mott, p. 43. When the aneurism of the carotid is small and placed near its bifurcation, the vessel may be readily uncovered- and tied for OF THE SUBCLAVIAN ABOVE THE CLAVICLE. A large transverse incision is made just above the clavicle, and the two lips of the incision are pushed in opposite directions to enlarge the surface of the wound. The sterno-cleido-mastoid is in part divided near its origin, for the purpose of exhibiting the parts below more distinctly in the drawing. (A). Clavicle, bared by the depression of the inferior lip of the wound. (B). Platysma-myoides, divided in the whole length of the cutaneous incision, and seen on both the lower and upper lips of the wound. (C C). Clavicular portion of the sterno-cleido-mastoid divided. (D). Anterior edge of the trapezius at its insertion on the clavicle. (E). Scalenus anticus, seen at its insertion on the first rib. (F). Commencement of the anterior belly of the omo-hyoideus from its middle tendon. 1. Subclavian artery raised on the aneurismal needle at the place for applying the ligature. 2. Transversalis colli, or posterior scapular artery. Very commonly we find here another artery with which it is important the operator should be familiar, called the supra-scapular, that comes off' either from the subclavian directly, or, which is more usual, from the thyroid axis, crosses the cellular space in which the subclavian is lodged, and skirts the inner and upper margin of the clavicle, being connected to the subclavius muscle by some cellular tissue. When the artery has this position, it is liable to be wounded in the operation on the subclavian, unless care is observed. In the subject from which the plate was taken, the supra-scapular artery was a branch of the axillary. 3. Internal jugular vein, emptying into the subclavian vein near the junctionof the latter with the internal jugular. 4. Vein corresponding to the branches of the supra-scapular artery. 5. Brachial plexus of nerves, lying on the outer and posterior side of the artery. 6. Phrenic nerve, passing to the inner side of the insertion of the scalenus anticus muscle. 48 GENERAL OPERATIONS'. some distance below the omo-hyoid, by an incision along the anterior surface of the sterno-cleido-mastoid muscle, as shown at PL XL following the same rules as for the operation above the omo-hyoid. Great care is required to avoid wounding a vein of considerable size, which is usually found descending behind the inner border of the lower third of the sterno-cleido-mastoid. Process of Sedillot and Zang.—If it should ever become necessary to tie the carotid at its lowest point in the neck, when the relation of the parts is not disturbed or marked by the presence of a tu- mour or effused blood, it may readily be done in the following manner. The head being thrown back and to the opposite side in order to make the sterno-cleido-mastoid tense, an incision two and a half inches long is to be made in the direction of the fissure between the sternal and clavicular portions of this muscle. The cellular interval between them is to be carefully opened; the head is now to be inclined towards the side of the operation, and the two portions of the muscle thus relaxed, held asunder with blunt hooks. The sheath of the vessel is next to be exposed at the bottom of the wound, and carefully opened with the point of the director. In the attempt to do this, the internal jugular vein first comes into view. This vessel is to be drawn outward and back- ward, and the artery will be found on its inner side, lying in front of the pneumogastric nerve, and is to be raised from without in- wards with the curved aneurismal needle or bent director. In the operation on the left carotid low in the neck, it is to be recol- lected that the artery, in consequence of its origin from the de- scending turn of the aorta, is deeply placed. From this cause, and the presence of the thoracic duct behind it, it will be found one of greater difficulty and delicacy than on the right side. The operation terminated and the wound dressed, the patient is to be placed in bed with his head elevated so as to keep the artery in a relaxed position. LIGATURE OF THE EXTERNAL CAROTID. (PL. X.) Surgical anatomy.—The primitive or common carotid divides, as has been before observed, into its two branches, external and internal, nearly on a line with the upper border of the thyroid cartilage. But in females it is well to remember that, in conse- quence of the greater proportionate length of the neck, the divi- sion usually takes place lower—nearly opposite the middle of the cartilage. The external is found at its origin, a little in front and to the inner side of the internal carotid, and it, as well as the in- ternal, is readily found by tracing up the course of the common carotid. Both are sufficiently superficial to be tied, if necessary on the hvmg subject. The course of the internal is short, before it enters the carotid canal of the temporal bone to supply the brain- it has never been the subject of operation. The external carotid is covered in front only by the integuments, the platysma-myoid muscle, and the superficial cervical fascia. It is crossed in front shortly after its origin, by the posterior belly of the digastric muscle and the hypoglossal nerve, and is lodged in a groove, the walls of winch are formed by the pharynx and os hyoides on its inner side, and the internal edge of the sterno-cleido-mastoid without and the submaxillary and parotid glands above. In this reo-ion it sends off its various branches, the superior thyroid, lineal facial occipital, and posterior auris. The continuous trunk passes up deeply through the substance of the parotid gland, and divides in the space between the neck of the lower jaw and the external auditory meatus, into the temporal and internal maxillary. Remarks.—It is only in its cervical portion that the artery can be cut down upon and tied. It is most superficial and accessible below the digastric. The extension upwards for near an inch higher than usual of the ordinary incision for the common carotid, serves, as shown in PL X., for the exposure of the lower part of its external branch. Above this point the difficulty of the operation is much increased, from the number of important parts which sur- round the vessel. It has been several times tied, and the patients have recovered without secondary hemorrhage, a result which is always to be dreaded when a large artery is secured near the place of its ramifications, even though they be on the distal side of the ligature; for it has been shown by Mr. Porter, that this serious accident may arise from blood returned by large anastomosing trunks into the vessels beyond the place of its obstruction. It has been tied for wound or aneurismal enlargement of its branches; and as a preparatory step against hemorrhage—in operations for the resection of the jaws and parts of the tongue, for tumours of the antrum, and the removal of the parotid gland. But it is ques- tionable, as before observed, whether, in consequence of its nume- rous anastomoses, this artery should ever be tied except in cases of wound where its cut extremities are exposed ; and it is con- sidered better, in hemorrhage from operations on the face, not to be checked by ligature of the divided vessel or the use of the actual cautery, but to proceed to the simpler and safer process of tying the common carotid. Usual operation.—To tie the external carotid, an incision should be commenced half an inch below the angle of the jaw, and ex- tended as low as the middle of the thyroid cartilage, parallel with but half an inch in front of the edge of the sterno-cleido-mastoid muscle. The platysma-myoides and cervical fascia being divided on a director, and the sheaths of the submaxillary and parotid glands loosened from their attachment below, the glands them- selves are to be pushed upwards and forwards. The digastric and stylo-hyoid muscles are now to be laid bare at the bottom of the wound with the point of the director or forceps. The muscles are to be drawn upwards and forwards with a blunt hook. The sheath of the vessel is now exposed, crossed in front by the hy- poglossal nerve and the facial vein. The sides of the incision are to be held widely separated, the nerve and the vein are to be carried backwards with the end of the finger, the sheath of the vessel cautiously opened, and the artery, which is seen pulsating by the side of the pharynx, separated and raised with the aneu° rysmal needle. LIGATURE OF THE SUPERIOR THYROID. Surgical anatomy.-Thh is the first branch given off by the external carotid; it arises a little above the place of bifurcation of the primitive trunk. Passing first upwards and forwards to the corner of the os hyoides, it then turns downwards, forming an arch convex towards the chin, to reach the upper part of the thyroid gland and the larynx. As it passes upwards and inwards it is superficial-covered only by the integuments, platysma-myoides and superficial fascia. In the lower part of its course it gets be- LIGATURE OF THE DIFFERENT ARTERIES. 49 side, and the position of the sterno-cleido-mastoideus on the other, keeping the skin, platysma, and superficial fascia stretched between them, at some distance in front of the vessel. This ope- ration has been but little practised. It was proposed by Beclard as a precautional measure, in wounds or extensive operations on one side of the base of the tongue, where the artery is found so large, that there is reason to fear, that the eschar produced by the actual cautery, the usual means of arresting hemorrhage in opera- tions on this organ, would not be sufficient to check it. It has been tied by Amussat and Mirault on the living subject, with the view of arresting the progress of cancer of the tongue, a project presenting little prospect of success. Operation. (Process of the author.)—-The patient is placed as for the ligature of the carotid. The operator ascertains with the finger, as a fixed point of guidance in the operation, the exact position of the body and great cornu of the os hyoides. An in- cision of about two inches in length is to be made carefully through the skin, beginning it about three-eighths of an inch above the junction of the cornu and body of the os hyoides at a point equi- distant from the ramus of the jaw and the chin, and extended outwards to the inner margin of the sterno-cleido-mastoid. The incision should be directed slightly downwards, so as to pass above the extremity of the cornu of the os hyoides. The super- ficial fascia and platysma muscle are next to be opened at the inner border of the wound, and divided for the same extent in the previous direction. The submaxillary gland covered by its cap- sule is now exposed to view. The cellular tissue below it is to be ruptured with the point of the director, and the gland drawn upwards on the blunt hook. The facial vein, which is observed passing across toward the external jugular, is to be drawn to the back part of the wound. The shining tendon of the digastric muscle is now seen crossed above by that of the stylo-glossus. The anterior belly of the digastricus, immediately adjoining this tendon, is to be denuded and slightly raised with the point of a director. Immediately below it is seen the hypoglossal or ninth nerve, and one line belowr this nerve the artery may be felt pulsat- ing under the hyo-glossus muscle. The fibres of this muscle are to be cut on the director, and the artery is found, unaccompa- nied with either vein or nerve, and may be readily raised and tied. The artery may likewise be laid bare, posterior to the stylo- hyoid, over the extremity of the cornu. For this purpose, the posterior belly of the digastricus is to be drawn downwards. The hypoglossal nerve then comes into view below this nerve, and a little deeper lies the artery, which may be secured and tied at a point not far from its origin. Several processes have been detailed for the ligature of this vessel; but the one given above appears to me preferable, as it is attended with greater certainty of finding the vessel, less embarrassment from the sur- rounding parts, and admits of at least equal celerity in its per- formance. neath the omo-hyoid, sterno-hyoid and thyroid muscles. The hypoglossal nerve is placed above, and the superior laryngeal a little distance behind it. Remarks.—This artery, in consequence of its anterior position, is frequently divided in abortive attempts to commit suicide. If in the gaping wound which is left, the two orifices of the divided vessel can be discovered, they are to be seized and tied ; but from the effusion of blood in the surrounding cellular tissue, and the heaving motion of the parts in respiration, which is always more or less laborious, I have found it in some cases difficult to discover them, and especially the one on the side next the origin of the vessel. Under such circumstances, I have been obliged to have recourse to ligature of the primitive carotid. Walther, Theden, Langenbeck and others, have tied the superior and inferior thyroid artery of each side, in the hope of diminishing by atrophy the size of the thyroid gland in goitre. These vessels have also been tied by surgeons who have deemed it prudent to attempt the extirpa- tion of this gland, for the same species of enlargement. The pro- cess by which the superior thyroid is tied, varies but little from that for the ligature of the facial, to which the reader is referred. OF THE LINGUAL ARTERY. (PL. XI.) Surgical anatomy.—The lingual artery is given off a little above the last named, above which it forms a small arch, convex to- wards the ramus of the jaw. It is found near its origin on the outer surface of the middle constrictor muscle of the pharynx, and runs upwards for half an' inch, almost in contact with, and obliquely across the extremity of, the great cornu of the os hyoides, to get beneath the hyo-glossus muscle. In the second part of its course, the artery continues ascending obliquely forwards and up- wards, but much curved for the distance of an inch, when it turns, vertically, into the substance of the tongue, giving off its raninal and sublingual branches. In the first part of its course, from its origin to the hyo-glossus, it is at first merely covered by the integuments, platysma, fascia, and a few small veins; but it is crossed near the cornu by the tendon of the digastric, the stylo- hyoid muscle, and the ninth nerve, which, placed below it in the neck, ascends so as to cross it at this point. In the second part of its course it is covered by the hyo-glossus and mylo-hyoid muscles, and is separated by the former muscle from the ninth nerve, which is here placed higher up than the artery, but again gets lower than the vessel at the anterior border of the hyo-glos- sus muscle. At the end of its second course the vessel is found three-quarters of an inch above the body of the os hyoides. The glosso-pharyngeal nerve is placed above the artery, so as to be out of the way in the operation. Anomalies.—The artery, instead of coming off as a separate trunk from the carotid, may have a common origin with the facial or the superior thyroid, or the three may arise together by a single root. Remarks.—The ligature of this vessel on the living subject is by no means easy, and requires a thorough knowledge, on the part of the operator, of the structures concerned. The vessel is invariably found deeper than the description' of "its pdsition, or its appearance after the superficial parts are cut away would lead one to suppose ; the prominence of the os hyoides and larynx on one 13 OF THE FACIAL ARTERY. (PL. XL) Surgical anatomy.—This artery usually arises from the external carotid just above the lingual, but sometimes by a common trunk with the latter. It mounts over a groove in the lower jaw, at the 50 GENERAL OPERATIONS. anterior border of the masseter muscle, where it may be felt pul- sating. It supplies the lips, abje nasi, and adjoining portion of the face. The best place for tying it is at the edge of the mas- seter after it has turned over the bone. It is somewhat deeply placed in consequence of the thickness of the masseter, and is covered by the integuments, platysma myoides, and a layer of dense yellowish cellular tissue. The facial vein is at its posterior or temporal side, and it is crossed by some branches of the facial nerve. Remarks.—This vessel may be readily compressed under the jaw, as has been before observed, (page 32,) with a graduated compress and bandage, or the pad of Charriere; though if the pressure be protracted it becomes too painful to be borne. Tem- porary compression with the finger is more often employed, in order to diminish the hemorrhage, in plastic or other operations about the face. Its trunk has been many times tied in front of the masseter for the same object, but unnecessarily, as the position of its branches is superficial, and may readily be secured during an operation; the communication between the branches of the two sides is so direct, that it sometimes becomes necessary to twist or tie both orifices of each divided branch. Operation.—An incision through the skin and platysma an inch and a quarter long, is to be made across the jaw bone at the anterior edge of the masseter, which, with the artery, may be readily felt at this point. The cellular tissue covering the vessel is to be opened on the director, avoiding the branches of the portio dura. The artery will be found immediately below. PLATE XL—LIGATURE OF THE ARTERIES OF THE HEAD AND NECK, LIGATURE OF THE PRIMITIVE CAROTID BELOW THE OMO-HYOID MUSCLE. The artery is here more deeply placed and more difficult of access, than it is above the omo-hyoid. (A). Platysma-myoides divided with the skin and superficial cervical fascia. (B). Sterno-cleido-mastoid drawn to the outer side of the wound. (C, D). Sterno-thyroid and sterno-hyoid, drawn in the opposite direction. (E). Anterior belly of the omo-hyoid. (F). Portion of the sheath of the vessels laid open over the carotid. 1. Primitive carotid. 2. Internal jugular vein. 3. Anterior jugular vein, usually found on the inner edge of the sterno-cleido-mastoid. 4. Descendens noni nerve, drawn to the tracheal side of the wound. LIGATURE OF THE LINGUAL ARTERY. The incision is made a little below the base of the jaw, from the os hyoides to the sterno-cleido-mastoid muscle. (A). Platysma-myoides divided with the integument. (B). Anterior belly of the digastric muscle, after its middle tendon has pierced the stylo-hyoid. (C). Stylo-hyoid muscle, inserted on the os hyoides. a. Inferior edge of the submaxillary gland. 6. Greater cornu of the os hyoides. 1. Lingual artery raised on the ligature thread. 2. Hypoglossal or ninth nerve. 3. Facial vein, running down to form the anterior jugular. 4. Hyo-glossus muscle. The fibres are divided to expose the lingual artery, which, in this part of its course, is found below the muscle. 5. Posterior part of the mylo-hyoid muscle. 6. External carotid, raised to show its position. 7. Anterior edge of the sterno-cleido-mastoid. LIGATURE OF THE OCCIPITAL ARTERY. The incision is made from just behind the point of the mastoid process obliquely upwards and backwards. (A). Position of the mastoid process. Tendinous expansion of the sterno-cleido-mastoid muscle. Splenius capitis muscle divided. Posterior border of the trachelo-mastoideus muscle. Superior oblique muscle. Occipital artery, raised on a ligature. The two occipital veins, which are seen sending branches of communication over the artery. (B). (C). (D). (E). (G). 7. FPttr //. On. Stontby S.Cichc, *A:i Phr/aJeijB.hi'*; ■'■'■■•■■■/, by ('. lift Vu*al. LifJi I LIGATURE OF THE DIFFERENT ARTERIES. 51 OCCIPITAL ARTERY. Surgical anatomy.—It arises from the posterior part of the ex- ternal carotid, nearly opposite the facial, and at the lower border of the digastric muscle. It runs obliquely upwards and back- wards to the inner surface of the mastoid process of the temporal bone, where it is covered by all the muscles that are inserted into the mastoid process. From this part it runs rather horizontally backward, parallel to, but above, the inferior ridge of the occi- pital bone, lodged between the splenius and the complexus and superior oblique muscles; after which it turns upwards to be distributed over the posterior part of the cranium. It is in its middle or horizontal portion only that it can readily be taken up, between the insertion of the sterno-cleido-mastoideus and the trapezius. At this point it is surrounded by two veins closely united to it by dense cellular tissue, covered by the splenius, the aponeurosis of the sterno-cleido-mastoid which is attached to the superior ridge of the bone, and the thick integument. Remarks.—The ligature of this vessel has not yet, I believe, been made upon the living subject. The position of the artery is such that in cases of wounds involving it, it may either be secured at the place of injury or compressed against the bone. Circumstances, however, may possibly arise,—such as aneurism, or a tendency to erysipelas presenting an obstacle to compres- sion,'—that may render its ligature necessary. A wound of the vessel near its origin, in consequence of the depth at which it is placed, and the difficulty of ascertaining precisely the trunk from which the hemorrhage arises, must be met by ligature of the external or rather of the primitive carotid. Operation.—The scalp having been shaved behind the ear, an incision is made through the skin an inch and a half to two inches long, beginning it at the posterior border of the sterno-cleido-mas- toid, about half inch behind and a little below the point of the mastoid process, and carrying it obliquely backward and upward in the direction of the superior curved line of the occipital bone. The aponeurosis of the above muscle is next divided, and the splenius exposed just below the line of its insertion. The splenius is next to be divided the whole length of the wround, either by incision from above downwards with the knife, or on the groove of the director. The artery, which may now be felt pulsating, is to be isolated and tied. M. Manec has observed that particular care should be taken not to open either of the accompanying veins, as from their connection with the lateral sinuses of the brain through the mastoid foramen, they might bleed very freely. POSTERIOR AURIS. Surgical anatomy.—The posterior auris, or stylo-mastoid artery, arises from the external carotid just above the digastric muscle. It escapes from under the parotid gland, on a level with the mas- toid process, and runs obliquely backward and upward towards the roots of the hair on the occiput. It crosses the styloid process in the neck, and sends a branch in at the stylo-mastoid foramen. It has passing in front of it near the same point, the portio dura nerve. More posteriorly, it is found crossing the surface of the mastoid process, in the interval between this protuberance and the concha of the ear, and about a quarter of an inch below the latter. It is here covered with a dense subcutaneous cellular layer, through which the artery may be indistinctly felt pulsating, and is attended by the posterior auricular branch of the facial nerve, and usually one or two filaments from the auricularis magnus of the neck. Remarks.—In former times it was the custom to bleed from this artery by opening it in front of the mastoid process; and though the practice has been abandoned by all reputable practitioners, it is still resorted to occasionally by empirics in certain portions of this country. The nerves which attend this vessel render com- pression after arteriotomy painful, and false aneurism sometimes follows as a consequence of the operation. I tied the vessel, according to the following process, for a tumour of this descrip- tion occurring in the case of a gentleman who had been his own bleeder, and which, after it had attained the size of a small walnut, burst and flooded him with blood. Operation.—An incision is to be made from an inch to an inch and a half long, somewhat obliquely across the course of the vessel. It should be begun near the lower point of the mastoid process, on a level with the lower end of the lobe of the ear, and carried obliquely downwards in the direction of a point half-way between the lobe and the angle of the jaw. In dividing the super- ficial fascia,—which, on account of the density of the tissues of the part, has usually to be done without a director,—two branches of the great auricular nerve will be observed passing upwards and backwards. Between these, though somewhat deeper, lies the artery, which may be tied either after or before it has given off the auricular branch. The line for the cutaneous incision is shown in Plate 10. TEMPORAL ARTERY. (PL. X.) We have already, in treating of arteriotomy, (page 19,) spoken LIGATURE OF THE SUBCLAVIAN BELOW THE CLAVICLE, SOMETIMES CALLED THE HIGH OPERATION ON THE AXILLARY. The incision is made a little below and nearly parallel with the clavicle. From the depth at which the vessel is placed, and its intimate connection with the vein and nerves, this, which is the ordinary process for ligature of the artery below the clavicle, is perhaps one of the most difficult of any required for the treatment of aneurism. (A A). Portion of the pectoralis major, cut through after the section of the skin and platysma. (B). Anterior edge of the deltoid muscle. (C C). Pectoralis minor muscle, coming up from under the pectoralis major to attach itself to the coracoid process. (D). Lower edge of the clavicle, occupied by a few of the divided fibres of the pectoralis major. 1. Subclavian artery, raised on the ligature. 2. Subclavian vein, a little in front and to the inner side of the artery. 3. Plexus of nerves, behind and to the outer side of the artery. GENERAL OPERATIONS. of the points at which may be laid bare for the purpose of bleed- ing, the trunk and anterior branch of this vessel. The ligature of this artery is sometimes required in consequence of aneurism formed either spontaneously, or as the result of a wound. It is in general considered most advisable in such cases, to open the tumour by an incision and turn out the clot, and secure the vessel above and below the place of enlargement after the old method. The author has, however, succeeded perfectly, in several instances, by an operation of much less severity, and which leaves a less deforming cicatrix,—that of cutting down upon and tying the vessel on the cardiac side of the tumour. The tumour afterwards disappears by absorption, accelerated by the use of cold evaporat- ing lotions and compression with a roller bandage. An aneurismal tumour formed on the middle meningeal artery may, after it has produced an absorption of the walls of the cra- nium, project without, and be mistaken, if proper caution be not observed in the diagnosis, for one of the temporal artery. A swelling formed in this manner below the temporal muscle, in which no pulsation was noticed, has been mistaken for one of the common cystic tumours of the scalp, and the attempt at its removal followed by death.* LIGATURE OF THE ARTERIES OF THE UPPER EXTREMITY. OF THE SUBCLAVIAN. Surgical anatomy.—The subclavian artery of the right side arises from the arteria innominata, at its termination behind the sterno-clavicular articulation. That of the left side comes off directly from the arch of the aorta, and is at first nearly vertical in its course. The right is consequently shorter than the left, and situated on a plane more superficial, as far as the inner edge of the scaleni muscles. After either vessel has passed below the clavicle, it takes the name of axillary. The artery in its course is divided in reference to its surgical relations into three portions. 1st. That between its origin and the scaleni muscles. 2d. That between the scaleni muscles. 3d. That which crosses obliquely- over the first rib. The arteries of the two sides vary so much in regard to their direction and surgical relations, as to require a separate description. First portion.—On the left side it passes nearly vertically, hav- ing but a slight inclination externally till it reaches the level of the top of the lung. At this point it suddenly turns horizontally outwards to get at once between the scaleni muscles. The point at which it turns is on a level with the upper surface of the clavi- cle. The artery is covered by the pleura in front, where this membrane passes off to form the posterior mediastinum; the par vagum passes down on its inner side and nearly parallel with it. It lies at first on the trachea and recurrent nerve, then on the (esophagus which projects to the left of the trachea, then on the thoracic duct which crosses beneath to get between it and the carotid; it is next situated on the body of the first dorsal vertebra and resis at the place of its turn on the last cervical ganglion of the sympathetic, at the upper margin of the first rib. The left • Aneurism, Diet, de .Med. et de Chir. Prat. vena innominata crosses in front of it, behind the upper bone of the sternum. The right subclavian, from the place of its origin, is directed obliquely outwards and upwards; and instead of form- ing a right angle at the place of its entry between the scaleni, it reaches it by an arch which is convex upwards. It lies in front of the pleura, with which it only comes immediately in contact at the margin of the scalenus. Anterior to it lie the muscles of the sternum, the junction of the internal jugular and subclavian veins, the par vagum and phrenic nerves, the latter of which crosses it obliquely from without inwards just at the margin of the scalenus. Over all these parts lies in addition the clavicular portion of the sterno-cleido-mastoid muscle. Behind, it is crossed by the recur- rent nerve. The five branches supplied by the subclavian are given off at irregular intervals during the first portion of its course, and near the internal margin of the scalenus. In the second and third portions of their course, the subclavian arteries of the two sides have nearly similar relations. The second portion has a length equal only to the breadth of the anterior scalenus, (the insertion of which covers it in front,) and terminates at the external margin of the first rib. The ex- ternal surface of the right subclavian alone touches the rib. The left subclavian closely embraces it, so that the latter is even here more deeply placed than the right. The third or last portion of the artery extends from the outer border of the scalenus obliquely downwards and outwards in the direction of the axilla, to the lower border of the first rib, where it takes the name of axillary, as before observed. The curve which it thus describes, rests in a superficial groove on the upper surface of the rib. The point where the artery first touches the rib, is, in a well-formed adult with a clavicle of near six inches in length, about two inches and a half from the sterno-clavicular articulation, and a quarter of an inch to the outer side of the internal third of the clavicle. The point where it leaves the lower margin of the rib, is three inches and three-eighths from the same articulation, near the outer termination of the middle third of the clavicle; so that the oblique course of this portion of the artery may be considered as lodged under the middle third of the clavi- cle, when the shoulders remain in their natural square position. The artery is found always, immediately at the outer side of the tubercle upon the first rib, on which is inserted the anterior scale- nus muscle ; on the outer side it is bounded by the brachial plexus of nerves, the large cords of which run down over the rib parallel, and nearly of equal size, with the artery, so that they resemble somewhat the four fingers of the hand laid over a sur- face convex and sloping backward, of which the first one is repre- sented by the vessel. By this arrangement, the artery is placed about a quarter of an inch more in front, and a quarter of an inch more within than the front cord of the brachial plexus; a fact which it is important for the operator to bear in mind, as he may hereby avoid the risk of tying a branch of the plexus instead of the artery,-an accident which has been known to occur. Below and anterior to the artery, runs the subclavian vein, separated from it by the scalenus anticus muscle. At the outer side of the muscle the vein is closely in contact with the artery, and receives there the external jugular, supra-scapular, and sometimes the anterior jugular and acromial veins. Between the vein and the clavicle lies the subclavius muscle. LIGATURE OF THE DIFFERENT ARTERIES. 53 The position of this third portion of the subclavian is superficial, when the clavicle is depressed, as it is lodged in a fossa above the middle part of that bone into which the fingers can be readily sunk, called the supra-clavicular triangle. The sides of this tri- angle are formed by the clavicle below, by the anterior margin of the scalenus behind, and in front by the posterior margin of the sterno-cleido-mastoid. Covering the vessel at the base of this triangle just above the clavicle, we have 1st, the integuments; 2d, the superficial fascia and platysma muscle—between the layers of this fascia passes downwards and obliquely inwards the external jugular vein; 3d, a layer of cellular tissue surrounding a chain of lymphatic glands ; 4th, the superior scapular artery, which passes across the space in a second fascia just above the clavicle, and the transverse cervical which is found a little higher up: below these we find the artery and brachial plexus, lodged in a smaller trian- gle called the omo-clavicular, formed by the posterior belly of the omo-hyoid, the clavicle and sterno-cleido-mastoid. The depth below the skin at which this superficial portion of the vessel is usually found, is about an inch. But this distance may be greatly increased by the presence of a tumour which has displaced the clavicle, or by an enlargement of the chain of lymphatic glands. Anomalies, in regard to this vessel, are very rare. The vein and the artery have been known to change positions, and Manec has found both in front of the scalenus. The omo-hyoid muscle sometimes has an anomalous insertion by its middle tendon upon the clavicle; and in certain cases, still more rare, is attached to it by the intervention of a small muscle, called the supra-clavicular. Anastomosing vessels.—If the artery be tied on the inner side of the scaleni muscles, and within the origin of the five large branches it gives off, the restoration of the circulation to the upper extremity can only take place by the same branches that perform this office after ligature of the trunk of the arteria innominata. But if the artery be tied on the outside of the scaleni, the blood will be restored to the limb chiefly by the anastomosis of the in- ternal mammary, the posterior cervical, and the supra-scapular,— with the thoracics, the common scapular, and the circumflex, which are connected with the great axillary trunk. Remarks.—Compression of this artery, which it is often desira- ble to make in the diagnosis of axillary tumours and in operations upon the shoulder and breast, can only be efficiently established at the point where the vessel crosses the rib, and when the shoulder is depressed. It is, however, exceedingly difficult, by the ordinary measures, to check completely the circulation for any length of time ; the involuntary elevation of the clavicle having a tendency to carry away from the vessel the compressing force. And it is yet to be seen, whether the lately devised and com- plicated instrument of Bourgery (pi. vii.) will prove an effectual means of producing permanent compression. The artery has been tied, in cases of w-ound or axillary aneu- rism, in each of its three portions. The operation has been done in all between fifty and sixty times, but the result appears to have been more unfavourable thau the ligature of any of the other great vessels, with the exception of the arteria innominata and the aorta; death having followed in about one-half the number of cases, the consequence apparently of the great size of the vessel; its proxi- mity to the heart; the dimension and number of the branches it gives off; its unhealthy condition when the operation has been 14 performed for spontaneous aneurism of the axilla ; or of a singular tendency in this variety of aneurism to suppurate after ligature of the main trunk, and form a communication, either with the cavity of the pleura, or with the branches of the bronchia where the lung had been rendered adherent by inflammation to the walls of the chest. After the operation the circulation is generally re-estab- lished with great rapidity in the upper extremity. It returned at the end of forty-eight hours in a patient of M. Roux. Though gangrene is little to be feared, serious disturbances of the lungs, heart, and brain, may occur in consequence of the sudden change produced in the movement of the circulating fluid. In the several instances reported of ligature of the trunk on the inner side of the scaleni muscles, the result has been always unsuccessful, and it is a serious question whether it should again be attempted. On the left side it has been but once tied* in this first portion of the vessel, and the complicated surgical relations which it has in that region, will serve to show that the operation, though not wholly impracticable, must be hazardous in the extreme. The greatest difficulty is encountered in the safe isolation of the vessel. Apart from this, the smaller size and greater length of this portion of the left subclavian would seem, by giving a better chance for the formation of a coagulum, to offer more hope of its safe obliteration than the ligature of the same portion on the opposite side. The only alternatives, where circumstances will not admit of the tying of the vessel more externally, are the method of Valsalva, the plans of Brasdor and Wardrop, or the seemingly shocking propo- sition of Mr. Ferguson to amputate the arm at the shoulder joint, and keep up afterwards regulated pressure on the diseased part. But these are so disheartening, as regards the prospect of a cure, that the operation upon the right side, even within the scaleni, must still be considered justifiable. LIGATURE OF THE OUTER PORTION OF THE ARTERY, OR OVER THE FIRST RIB. Lines of incision.—Surgeons vary in opinion in regard to the best method of making the external opening. Roux has proposed an incision nearly perpendicular to the clavicle along the outer edge of the sterno-cleido-mastoid. Ramsden, who first tied this vessel,! made his incision in the shape of a J_ reversed, the hori- zontal cut being made along the upper border of the clavicle. Physick recommended an incision in V ; Hodgson one merely- horizontal. Under ordinary circumstances, where simple ligature only is required, the horizontal incision of Hodgson will enable the operator with great ease and facility to uncover and tie the vessel. But in cases of large aneurismal tumour, which keeps the clavicle elevated, or where the neck is unusually thick and short, a necessity for a wider separation of the lips of the wound may exist. This may be gained, even during the course of the opera- tion, by the addition of a vertical cut. Ordinary process. (PL X.)—The patient is to be placed upon his back, with his chest moderately elevated, his head turned to the opposite side, and the shoulder carried dowmwards and back- wards as much as practicable, in order to make tense the skin and muscles, and render the artery more superficial. The surgeon, • By Air. Colles of Dublin. The patient died on the ninth day. f In 1809. 54 GENERAL OPERATIONS. > standing by the side of the patient, feels for the edge of the sterno- cleido-mastoid and trapezius, ascertains if possible the direction of the external jugular vein, and makes a horizontal incision merely through the skin, from near the edge of the trapezius, on to the sternal edge of the first named muscle. This gives in the adult an opening of about three inches in extent. If the indivi- dual be fat, the incision may, according to the direction of Lis- franc, be carried within an inch of the sternal edge of the clavicle. The wound should be about half an inch above the upper border of the clavicle.* Raise carefully on the director, and divide the superficial fascia and platysma, avoiding the external jugular vein, which may now be seen either at the external border of the sterno- mastoid, or at the middle of the wound. If it is in the latter position, and cannot well be drawn out of the way, it, as well as some other veins that are occasionally found in this place, must be tied with two ligatures and divided.! Some small arteries will have been cut, which may require to be tied. The wound care- fully absterged with the sponge, and some loose cellular tissue broken with the point of the director, we come to a portion of the deep-seated fascia, which connects the omo-hyoid to the clavicle. This is to be cautiously opened, raised on the director, and, satisfy- ing himself that there is no artery astride the instrument, the ope- rator divides it. If an artery exist there, as I have occasionally seen, and it cannot be drawn out of the way, it must be tied and cut. With the point of the director or forceps, or with the finger nail, we tear the cellular tissue below the fascia, in which are lodged lymphatic glands and veins; at times some of the layers are found so resisting as to require to be raised on the director and touched with the point of the knife. The omo-hyoid muscle, which is now exposed, is to be drawn upwards and backwards by an assistant. The edge of the scalenus may next be felt and traced down to its tubercle of insertion; if the clavicular margin of the sterno-mastoid overlaps it, as it does in most muscular sub- jects, it should be divided for the space of half an inch or an inch. Before attempting to look for the vessel, the end of the fore finger should be brought in contact with the sharpened point of the tubercle of the first rib; if this is not readily found by tracing down the scalenus, carry up the finger along the rib from the ex- ternal margin of the wound. Once found, we are sure of the artery, which is usually felt beating just at its outer side. But if the beating be obscure, or not at all obvious, as has been observed in consequence of a thickening of its coats, we may still satisfy ourselves, by pressure upon it so as to stop the passage of blood into the limb, that the rounded body immediately to the outer side of the finger is the vessel in question. The nerves of the brachial plexus, recognizable by their whiteness and hardness, will be found to the outer and back part of the artery. With the fino-er on the tubercle as a guide, move the point of the director up and • Some operators direct the incision near the margin of the bone; others an inch above. But the height prescribed in the text, I find, as we proceed in the operation, furnishes the best security against the accidental wounding of*the scapular artery, which is placed near the margin of the clavicle or the transver- salis cervicis, which is an inch to an inch and a half above. f The ligature of the vein, if it be divided, must by no means be neglected, and especially if there be any consolidation of its surrounding tissue, as there would otherwise be a possibility of air passing down it to the cavity of the heart, and producing a dangerous syncope. A large vein should be tied, when this is practicable, previous to its division. down upon each side of the vessel, so as to isolate it in its groove upon the rib; next conduct the beak of a bent director, or an aneurismal needle not too much curved, along the finger to the rib, between the vessel and the tubercle; insinuate it under the artery ; then shift the finger over so as to depress the nerves, using it at the same time to guide and receive the point of the instru- ment as it is carried obliquely round the artery from within out- wards, and from below upwards. On the left side it is equally if not more convenient, to enter the instrument between the artery and first branch of the nerves, and carry it from below upwards and from within outwrards. If the operation be featly performed, neither the subclavian vein, which lies in front and to the inner and lower part of the vessel, nor the superior scapular artery, will come into view during the operation. It has been proposed by Cruveilhier in cases where there was such difficulty in discovering the vessel as to lead to the abandonment of the undertaking, as happened to Sir A. Cooper, to saw through the clavicle and look for the artery below it. This has not yet been put in practice in the living subject, and as it would have to be done in all probability over an aneurismal tu- mour, the walls of which not unfrequently form an attachment to the bone, it is a proposition of very questionable utility. It would be much better, under the circumstances, to follow the practice of Dupuytren, and tie the vessel in the second part of its course by the following process. LIGATURE BETWEEN THE SCALENI. This does not, however, deserve to stand apart as a separate method; since the mode of its performance by a vertical incision, as first practised by Dupuytren, has been abandoned for the com- mon transverse cut, made as described above. When the artery is to be tied between the scaleni, a measure which has often been practised with success, all that is required in addition to the former process, is to extend the incision of the skin inwards to near the sterno-clavicular articulation, divide the clavicular origin of the sterno-cleido-mastoid, and expose completely the front surface of the scalenus anticus, underneath which a director is to be passed downwards and inwards, and brought out immediately by the inner side of its insertion so as to avoid the phrenic nerve, which, after crossing it just above, is separated from it by a little triangu- lar interval. The muscle is now to be divided on the director by cautious cuts, in order to avoid all risk of wounding the in- ternal mammary at its origin, which lies more deeply and just at the outer side of the phrenic nerve. The retraction of the divided ends of the muscle leaves the artery exposed, which runs here obliquely upwards and outwards, and may readily be raised and tied. The common scapular artery I have often found, shortly after its origin, crossing the scalenus near the place of operation; it may easily be discovered by its pulsation, and drawn out of the way by an assistant. The vessel is here so much within and above the first rib, that no elevation of the humeral end of the clavicle can prevent our finding it. If from the commencement it was determined to tie the vessel between the scaleni, the incision of the integuments need not extend farther back than within an inch of the trapezius. LIGATURE OF THE DIFFERENT ARTERIES. 55 LIGATURE WITHIN THE SCALENI. If this perilous operation should be attempted on the living subject, the following process appears entitled to a preference over any other, as it exposes the field of operation more com- pletely to the eye, and enables us to avoid the three principal and immediate sources of danger—the injury of the par vagum or its recurrent branch, and that of the internal jugular and subclavian veins. The general details of the operation will be much the same as for ligature of the innominata. The patient is to be placed as for the latter operation. The surgeon, standing at the end of the table, so as to look over the patient's head, makes an incision, beginning in the fossa at the top of the sternum, three inches in length, along the inner border of the sterno-cleido-mastoid. A second transverse one, commencing half an inch above the top of the sternum, is to be carried from the first, just beyond the sterno-clavicular articulation. The fascia superficialis and a layer of the deep-seated fascia, which extends to the border of the muscle, are to be divided along the vertical incision. The sternal portion of the muscle is also to be cut and drawn upwards by an assistant. The sterno-thyroid and hyoid muscles are, next to be cautiously raised on a director and divided. With the finger or the handle of a scalpel, the operator clears away the cellular tissue at the bottom of the wound, keep- ing to the outer and lower part, in the direction of the inner end of the clavicle. The aim is to expose the artery between the par vagum nerve and the internal jugular vein. In consequence of the oblique direction outwards of the latter, sufficient space is here found to pass the ligature. The aneurismal needle in passing round the artery should be kept closely in contact with it, and at the same time be directed upwards and outwards in order to avoid injury of the pleura, (which was wounded in the operation of Mr. Colles,) and the inclusion of the recurrent nerve, which is sent upwards and inwards round the vessel. If applied at this point, the ligature will rest at the inner side of the origin of the branches given off by the subclavian. The exact position of the internal jugular and par vagum ought to be previously ascertained, and both held carefully out of the way with a blunt hook. Either of these might serve as a guide to find the vessel. If the surgeon work too much at the inner border of the wound, he will fall on the carotid. This vessel may then, however, as in the operation on the innominata, be followed downwards to the origin of the subclavian, and the latter traced outwards, for the space of three- quarters of an inch, to the point where the ligature ought to be applied, just at the outer border of the par vagnum. If the ligature of this artery should be attempted on the left side, the same process would be found the most appropriate. Great care would be required to avoid injury of the pleura and of the thoracic duct which are close behind the vessel. Greater embar- rassment w-ould be presented on this side by the inferior thyroid and deep cervical veins ; the latter forming a large trunk immedi- ately in front and nearly parallel with the artery. OF THE BRANCHES OF THE SUBCLAVIAN. The arteries furnished by the trunk of the subclavian, which may in case of necessity, be exposed and tied, are the vertebral, inferior thyroid, and internal mammary. The necessity for secur- ing the other two branches given off is little likely to occur; it could only exist in case of an accidental wound, at the bottom of which they might be found and tied. Of the vertebral.—This artery runs up to the brain, through the foramina in the transverse processes of the six upper cervical vertebrae. Two instances of wound of this artery in its course have been lately reported. One, that of a French soldier, stabbed in the back of the neck with a knife, the point of which divided the artery between the transverse processes. The other case, in which the artery was divided by a side cut made upon the throat with a razor, occurred in this city. In both, the hemorrhage was fatal. In such cases there is no resource, when the nature of the injury is ascertained, save ligature of the vessel at its origin, or of the subclavian trunk. The former, when practicable, is of course to be preferred. The parts are to be opened precisely in the same manner as for ligature of the subclavian between the scaleni. With the finger carried to the bottom of the wound, we may feel, about two inches above the clavicle, the projection of the transverse process of the sixth cervical vertebra, distinguished as the carotid tubercle by M. Chassaignac. The vertebral artery is found immediately below this projection, when about to enter the foramen at its base, just at the inner margin of the scalenus anticus. Nuntiante Ippolito* relates two cases, in which this artery was tied at its origin with success. Inferior thyroid.'—This vessel passes a little above the carotid tubercle in a direction upwards and inwards behind the sheath of the carotid artery and jugular vein, to reach the lower border of the thyroid gland. To find this artery, an incision may be made along the inner border of the sterno-cleido-mastoid. The muscle is then to be drawn outwards with a blunt hook, and the sheath of the vessel separated from the side of the trachea and oesophagus. The artery, though somewhat variable in regard to its origin, will be found in its course to the outer side of the recur- rent laryngeal nerve. Several thyroid veins cross the line of operation. If it becomes necessary to seek the vessel near its origin, the same process as described for ligature of the vertebral will answer. The thyroid originates from the subclavian, just before it enters between the scaleni, and commonly at the outer side of the vertebral. Internal mammary.—This vessel runs down obliquely by the side of the sternum, between the pleura and the posterior face of the costal cartilages, and intercostal muscles. In the middle part of its course it is near half an inch distant from the side of the sternum, but is almost in contact with it below. In case of aneu- rism or wound of the vessel, it may very readily be exposed and tied in the third or fourth intercostal space. The operation has not, however, been done on the living subject. Operation.—Make an incision through either one of these spaces, outwards from the side of the sternum for the distance of an inch and a half, in the middle line between the costal cartilages. Divide the intercostal muscle cautiously on a director, upon the thin aponeurosis which is stretched between the ribs, and we per- ceive the artery, which may readily be isolated from its veins, and raised and tied without risk of injuring the pleura. Scarpa re- commends the incision to be made between the first and second ribs, dividing the pectoral as well as the intercostal muscle. But * Froriep's Notisen, 1835. S. 304. 56 GENERAL OPERATIONS. this position should not, except in case of emergency, be selected, as the position of the artery is here so close to the sternum as to offer some embarrassment. OF THE AXILLARY ARTERY. We understand by this name, that portion of the arterial trunk of the upper extremity, extending from the lower border of the first rib to the inferior border of the tendon of the latissimus dorsi muscle. It is continuous above with the subclavian, and below with the brachial. Surgical anatomy.—The axilla or armpit is that space between the side of the chest, and the inner side of the shoulder and upper part of the arm. It is triangular in shape, the apex being above at the outer termination of the inner third of the clavicle. The base which is below is bounded by the tendon of the pectoralis major in front, and by the tendons of the latissimus dorsi and teres major behind. The serratus magnus, which covers the side of the chest, forms its internal wall. The depth of this hollow be- tween the tendons will vary according to the relative position of the arm to the trunk. When the arm is rotated outwards and raised to a right angle with the body, the depth is the greatest; but if the arm is carried still higher, the depth is diminished, as the head of the humerus then descends into the hollow, the folds of the axilla being overstretched. Through this space the axillary artery runs down in a line which is gently curved. The vessel is deeply placed just below the clavicle. Proceeding from with- out inwards, we find it here covered, 1st, by the skin, superficial fascia, and platysma muscle; 2d, by the thick belly of the pec- toralis major, which arises by two sections with an intervening cellular space, one of which comes from the internal two-thirds of the clavicle, the other from the side of the sternum; 3d, by the pectoralis minor muscle the fleshy tendon of which, running to the coracoid process, crosses the artery about an inch below the clavicle. From this tendon a dense cellular layer* passes to the subclavius muscle, covering the artery above; and another descends into the armpit, covering the vessel below. When these two aponeurotic layers are laid open, we find the artery divided as it were by the pectoralis minor, into three portions; one be- tween it and the clavicle; one immediately behind and covered by it; and a third situated below the muscle, or, more properly speaking, at the inner border of the arm, near the lower margin of the armpit. In each of these three positions the artery has been the subject of operation. 1. When the clavicular portion of the pectoral muscle is raised, the upper portion of the artery is found lodged in a sort of trian- gle, the base of which is formed above by the middle third of the clavicle, the inner side by the upper edge of the sternal portion of the pectoralis major which runs from above downwards and outwards, and its outer side by the pectoralis minor, which runs from below outwards and upwards. The artery is placed be- tween the brachial plexus of nerves, (which lies here, to its outer and posterior side,) and the great axillary vein, which lies to its inner side, slightly overlapping it in front. The plexus is sepa- rated from the artery by a cellular interval, and consists here of • Commonly called the costo-coracoid membrane, from its connection at its inner end with the costo-coracoid ligament. two large trunks which lie side by side. The great cephalic vein of the arm crosses this triangular space immediately in front of the artery, to throw itself into the axillary vein. Three branches, the superior, the inferior, and acromial thoracic, are given off' from the axillary artery in this triangle, immediately below the course of the vein. Sometimes they come off" by a single and sometimes by a double trunk. 2. The middle part of the axillary artery, or that behind the pectoralis minor muscle, is completely surrounded by the plexus of nerves, behind which is seen the subscapularis muscle. Seve- ral arterial branches are given off at this point. The axillary vein is still found at the inner side of the artery, and is here crossed by the small nerves which go to the thorax. 3. Below the pectoralis minor, the artery is found crossing near the head of the os humeri, and passing down to the inner border of the coraco-brachialis, at the junction of the anterior with the middle third of the space included between the tendons of the pectoralis major and latissimus dorsi muscle. It is here so super- ficial, that when the arm is thrown out from the body its position may be noticed under the skin and brachial aponeurosis, which alone cover it. The artery is either found between the hvo roots of the median nerve, or between this nerve and the internal cuta- neous. The latter nerve soon takes a position in front of the artery. The vein and the other nerves of the arm given off from the plexus are placed to its inner and posterior side. Anastomosis.—In ligature of the axillary artery, high up, the same vessels are concerned in restoring the blood to the arm, as in the common operation on the subclavian. If tied below the origin of the subscapular and circumflex, these vessels, by their anastomosis with the profunda and other branches of the brachial, become the channels of communication. Remarks.—Ligature of the axillary artery has been called for in cases of wounds and aneurisms at the upper part of the arm. When the circumstances of the case admit of the application of the liga- ture in its lower portion, which is, however, rare, the operation is perfectly simple and easy. But in the upper part of its course, in consequence of its depth, the thickness and transverse direction of the muscle which covers it, its intricate connection with the nerves of the brachial plexus and the axillary vein, and the num- ber of secondary vessels which are liable to be cut in reach- ing it, it is justly considered one of the vessels the most difficult to secure. Dupuytren was compelled in one case to tie twelve or thirteen arteries which were divided in the operation. In the hollow space below the clavicle, the true aneurismal tumours of this vessel, when they have attained much size, usually make their appearance. In false aneurisms of some standing, the loose oozy cellular substance placed about the vessels and filling up the whole axillary space as high as the region of the clavicle, yields readily to the pressure of the effused blood, from which region, owing to the peculiar arrangement of the fascia of the part, the .fluid is notable to escape. The sac of a large aneurism is in consequence modeled on the form of the axillary space; thus rendering it almost impossible to expose the artery below the clavicle, without opening the sac. For these various reasons, surgeons of the present day usually prefer, and especially in cases of aneurism, to cut above the cla- vicle, and tie the sucblavian in the third part of its course. Seve- LIGATURE OF THE I ral surgeons of distinguished eminence, White, Pelletan and Desault, in attempting to tie the artery below the clavicle, have ' been compelled, from the difficulties they encountered, to termi- nate their operations unsatisfactorily. It has, however, been many times successfully tied in this region; and in suitable cases, where we have reason to believe the artery is healthy, and that the aneurism has not encroached upon the subclavian hollow, the desire to place the ligature as far from the heart as we can with safety, leaving room for a second operation on the subclavian in case of disaster from secondary hemorrhage, the process will still be practised. The ligature of the vessel immediately behind the pectoralis minor has been justly abandoned, leaving now but two points for operation;—that above the pectoral muscle, and that in the hollow of the axilla. There is one circumstance which the surgeon should bear in mind, that occasional instances of anomaly occur, where the axillary divides into its radial and ulnar branches as high up as the subclavius muscle. 1. Ligature above the pectoralis minor, called the high operation upon the axillary, and sometimes spoken of as ligature of the subclavian below the clavicle. (PL XII.) a. Ordinary process.—Horizontal incision.—The patient is to rest upon his back with his head and shoulders raised, the shoulder of the diseased side moderately elevated, and the elbow carried out from the body at an angle of forty-five degrees. Compression may be made by an assistant upon the artery above the clavicle. The surgeon then, depressing with the fingers of the left hand the clavicular portion of the pectoralis major muscle, makes, half an inch below and parallel with the clavicle, an incision through the integuments and platysma muscle, three or four inches long, ex- tending from near the margin of the deltoid muscle to within an inch of the sternum.* The fissure between the deltoid and pecto- ral muscles, may previously be readily ascertained by putting them into contraction; in this fissure is lodged the cephalic vein, which must be carefully avoided. Next, the whole thickness of the pectoral muscle is to be divided layer after layer for the entire length of the wound, tying or twisting the branches of the thoracic arteries as they spring, which, though not large in their normal state, are found dilated in cases of aneurism. Having reached the posterior face of the muscle, (in doing which there is usually little difficulty,) the firm aponeurosis behind it is to be divided on a grooved director. The subclavicular triangle is now exposed; the lower and outer boundary of which,—the pectoralis minor— may be felt with the finger, and will serve as a guide to find the vessel which lies at its upper and inner side, between it and the clavicle, surrounded by some loose cellular tissue that is covered in with a thin fascia connected with this muscle. The arm is now to be brought to the side of the trunk, and rotated inwards so as to put the parts in complete relaxation. With the end of the finger or the point of a director, we cautiously break up the cellular structure in the triangle, and lay bare the edge of the pectoralis minor, which is afterwards to be held downwards and outwards with a blunt hook, or the fore finger of an assistant. Sometimes the fascia running up from the pectoralis minor is so strong as to • In very fat or muscular subjects the incision may, if necessary, be carried still nearer to the sternum, the operator recollecting that the artery is to be found considerably to the outer side of the internal third of the clavicle. 15 FFERENT ARTERIES. 57 require to be raised with the director and touched with the point of the knife; but care must be observed in so doing to avoid wounding the thoracic vessels which are placed immediately below. The cephalic vein will usually be seen crossing just below the clavicle to reach the axillary vein; this may, if it im- pede the operation, be drawn upwards by an assistant. Of the parts within the triangle, the first exposed to view is the axillary vein. This is seen swelling up at each expiration, partially cover- ing the artery, which is placed behind and to its outer side, and to which it serves as a guide. With the point of a director passed in at the groove at the outer side of the vein, we separate this from the artery and draw it carefully downwards and inwards with a blunt hook. The artery is now to be separated in like manner from the plexus of nerves, which is found without and behind it. The bent director or the aneurismal needle is then to be passed from between the artery and nerves upward and inward, bringing it out between the artery and vein, the latter of which is to be carefully guarded against laceration by being pressed off with the fore finger of the other hand, which serves at the same time as a point of support to the end of the instrument. I prefer to pass the instrument from without inwards, as there is less risk of including one of the branches of the brachial plexus,—an accident which has several times occurred in the operation; it is even passed with greater facility in that direction, since the needle moves from the deeper to a more superficial point of the wound. The ligature is to be placed as far as possible above the origin of the thoracic arteries, lest the blood passing through these vessels should prevent the formation of a proper clot. b. Transverse curvilinear incision. (Process of Hodgson.)— The principal object of this process is to expose largely the subcla- vicular triangular fossa, in which are lodged the vessels and bra- chial plexus. A semilunar incision convex downwards is directed to be made below the clavicle, extending from the sternal end of the clavicle to near the point of the acromion scapulae and carried through both the deltoid and pectoralis major muscles. The flap of muscles is to be drawn upward, and the vessel is then isolated and tied according to the method above given. The injury done to the soft parts in this operation is, in ordinary cases, unnecessarily extensive. It may however be found justifiable, when it is con- sidered requisite to expose completely a circumscribed aneurismal tumour in the subclavicular fossa. If the line of the incision be limited externally to the fissure between the deltoid and pectoral muscles, after the manner of Dupuytren and Velpeau, the objection will be in a great measure obviated. c. Angular incision. (Process of Chamberlaine.)—A horizon- tal incision is made in the usual manner below the clavicle. A vertical incision is dropped from the outer angle of this in the space between the pectoral and deltoid, carefully avoiding injury of the cephalic vein, which is closely adherent to the deltoid, as well as a branch of the thoracic acromial artery lodged in the fissure. The incision will have the form of an -r reversed. The triangular flap formed by these two incisions is to be drawn in- wards and downwards. The pectoralis minor will be brought to view just at the inner margin of the deltoid, and immediately above it will be found the vein, artery, and nerves. This process exposes the artery well in the neighbourhood of the pectoralis minor, which may at want be cut and the artery looked for behind LIGATURE OF THE DII next the fore finger of the left hand under the clavicular portion of the muscle, opposite the middle of the clavicle, we divide it through from without inwards by a careful use of the knife. The direction of the incision must be obliquely upwards and outwards, at right angles with the course of the clavicular fibres. Few arte- ries will be cut; but such as are of much size must be tied at once, to prevent the blood obscuring the latter steps of the operation. The divided portions of the muscle will retract and may be still further separated with blunt hooks so as to leave a wide triangular space in which we are to hunt for the vessel. The posterior fascia of the pectoral muscle is to be opened in the same line on the director. Below this fascia is seen another running from the pecto- ralis minor to the subclavius muscle. This must be raised with the forceps and torn with the point of the director, or divided cautiously so as to avoid injuring the thoracic arteries which are placed immediately below it, or their common trunk which stands out prominently. If we desire to tie the artery near the clavicle, we break away the cellular tissue in a similar manner, above the origin of these thoracic vessels. Crossing near the upper margin of these vessels is seen the cephalic vein of the arm, and above this the artery is found deeply lodged on the first interosseous muscle, with the great axillary vein at its inner side, thrown some- what more in front by the rising prominence of the rib. The nearest root of the brachial plexus is placed nearly a quarter of an inch behind and to the outer side of the artery. A small vein is seen crossing in front of the artery to the great venous trunk, and between this and the cephalic, (which is to be gently drawn down- wards,) we isolate the artery first on its inner and then on its outer side, and pass the ligature from within outwards and backwards, bringing the arm close to the trunk at the time, so as to relax the vessel. If it be deemed expedient to tie the artery at the upper margin of the pectoralis minor, this muscle, if it has not been pre- viously exposed, is to be brought fully into view by breaking away the cellular aponeurosis along its upper border, which will be found on a line drawn from the point of the coracoid process to the junction of the second rib with the sternum. The muscle is then to be drawn downwards with a blunt hook in the direction of the lower angle of the external incision, and the cellular tissue opened as above directed between it and the origin of the thoracic artery. The artery will now be found raised from the ribs over the second head of the scalenus anticus, with the vein within and a little posterior to it, and the first branch of the brachial plexus close at its outer side and slightly overlapping it. The artery is to be isolated with care, and the ligature passed round it, the brachial nerve being pushed outwards with the left fore finger so as to prevent its being included in the loop. After the operation, the parts are to be drawn together by a single suture passed through each angle of the integuments above, and secured to the skin on the opposite margin of the wound. This method of proceeding admits of a ligature being applied upon the artery in any part of its course, which is more than an inch in extent, between the clavicle and the lesser pectoral muscle. It will, I believe, be found attended with less difficulty on the part of the operator, with less hemorrhage, and less liability of injuring important parts, than any other that has been devised. Marjolin and Lisfranc have proposed to tie the axillary artery by simply opening the interstice between the two portions of the ^FERENT ARTERIES. 59 pectoralis major. But the artery by this plan will be uncovered too low, and the resistance offered by the contraction of the undi- vided muscle would render it nearly inapplicable in the living subject. Could it be accomplished, the opening left would not be sufficiently free to admit of the escape of the purulent secretion which is apt to follow the disturbance of the cellular tissue of the part. 2. Ligature of the artery behind the pectoralis minor. {Process of Desault as modified by Delplch.)—The arm is to be carried out from the body at an angle of 45 degrees, and compression made upon the subclavian between the scaleni. An incision three to four inches in length is then made downwards and slightly out- wards, from the junction of the external third with the two inter- nal thirds of the clavicle, along the interstice between the pectoralis major and the deltoid, carefully avoiding the cephalic vein. The arm is now to be brought to the body, in order to relax the pecto- ralis major; the cellular tissue uniting the muscles along the inter- stice is to be divided with the finger or the point of the direc- tor, the border of the pectoralis major drawn downwards and inwards with the blunt hook or the finger of an assistant, and that of the deltoid carried in the opposite direction. The pecto- ralis minor is now exposed, and is to be raised on a director, and divided about three quarters of an inch from its place of insertion on the coracoid process. Passing the fore finger to the back and the outer portion of the wound, the mass of the vessels and nerves is to be hooked up and brought to the surface. The vein is then to be isolated at its outer side from the artery and carried inwards; the artery is next to be isolated from the nerves, and the aneu- rismal needle carried round it from within outwards. The objec- tion to this process is, that the ligature is placed too near the origin of the thoracic vessels, and that the artery closely embraced by the nerves, cannot, from the depth at which it is placed, be brought to the surface without making strong traction upon the parts. 3. In the armpit. (Process of Lisfranc, PI. XII.)—The arm is to be carried from the body so as to form an angle of 80 degrees with the trunk, and rotated outwards. We then feel at the inner edge of the coraco-brachialis,—just at the junction of the anterior with the posterior two-thirds of the armpit,* the pulsation of the vessel as well as the prominence formed by the brachial plexus of nerves. Along this artificial division of the axilla, a longitudinal incision of twro to two and a half inches is to be made through the skin. The basilic vein, lodged in the thickness of the brachial aponeurosis, is then exposed to view along the internal border of the wound. This aponeurosis is to be opened and divided on the director at the external side of the vein. If a simple incision of the aponeurosis does not afford sufficient room to reach the vessel with facility, a cut may be made across the outer portion of the membrane. The vessels and nerves are now exposed. The arm is to be lowered in order to relax the parts; then proceeding from before backwards, starting from the coraco-brachialis as a fixed point, we find first, the median nerve, and immediately within it the axillary vein. Beyond, or to the inner side of the vein, are to be seen the internal cutaneous and ulnar nerves, and the basilic vein.. The sheath of the vessels is to be carefully opened with the point of the director, and the vein carried inwards * Half an inch to three quarters behind the tendon of the great pectoral, accord- ing to Manec. 60 GENERAL OPERATIONS. and backwards. The artery will be found immediately within and behind the median nerve. Denude the artery slightly on either side, and pass the director below it, from within outwards, between the vein and median nerve. The above is the usual direction given, but I find it equally as convenient to carry the median nerve inwards along with the vein, and take up the artery between the nerve and coraco-brachialis. Occasionally the artery is found between the two long roots of the median nerve. It is then to be taken up between them. This method of Lisfranc is the easiest process for ligature of the axillary artery, but is only applicable in affections of the brachial between the armpit and the elbow joint. Before beginning the operation it is well to mark first with the eye the position of the outer border of the scalenus, at the upper margin of the clavicle, which is an inch and five-eighths out from the sternal end of that bone; as this is in the line of direction of the axillary artery. LIGATURE OF THE BRACHIAL ARTERY. (PL. XII.) Surgical anatomy.—This artery, which is a continuation of the axillary, descends in a straight line in the muscular groove found between the inner edge of the coraco-brachialis and biceps in front, and the triceps extensor cubiti behind. About an inch and a half above the elbow joint, it bends slightly outwards along the interior edge of the biceps, and crosses the face of the brachialis anticus so as to reach the middle of the bend of the arm. At this point, it is covered by the aponeurotic expansion sent off inwards and downwards from the tendon of the biceps, and divides into the radial and ulnar arteries, just at the insertion of the muscle on the tuberosity of the radius. The brachial artery, in a sub- ject moderately muscular, is found about half an inch below the surface. It is covered by the integument, a superficial fascia consisting of two thin layers, and a deep-seated muscular or bra- chial aponeurosis. Just above the elbow joint, it is slightly over- lapped by the internal edge of the belly of the biceps. On its inner side, and in close connection, is found the trunk of the bra- chial vein; but where there are two satellite veins, the artery is placed between them. The median nerve has important relations with the artery, and serves as a guide for its discovery in ligature of the vessel. At the superior and middle third of the arm, the nerve is found at the external and front margin of the artery. About two inches and a half above the elbow joint, it crosses obliquely in front of the artery so as to get completely to its inner side. The ulnar nerve passes down the arm at some little distance within and behind the artery, in the direction of the back part of the internal condyle. The internal cutaneous is found at the inner surface and somewhat in front of the vessel. The vessels, in their descent along the arm, are surrounded by loose cellular tissue rather than a distinct sheath. The artery, in a healthy state of the parts, can be felt pulsating through the skin, and may be tied in any portion of its course. Anomalies,-*-Nothing is more common than anomalies in the distribution of this vessel. It may divide, as before observed, into its radial and ulnar branches as high as the armpit; or at any part of its course down the arm. The frequency of this irregular distribution should be well understood. It is said by Prof. Quain to occur in one case out of five. Fortunately, it may usually be detected by careful examination ; otherwise, the surgeon might become embarrassed in attempting to check a hemorrhage or cure an aneurism, in finding that he had exposed a vessel which was not the subject of disease. He may, before beginning the incision, by alternately compressing the respective branches, be able to discover which is the proper subject of operation. It may be necessary even to tie both branches, as they are sometimes found to have direct communication with each other at the elbow ; and this double operation could be attended with no greater danger than the single ligature of the undivided trunk. In cases of divi- sion high up, the branches are usually found running down near together, (the radial usually being the more superficial and exter- nal,) to the neighbourhood of the elbow joint where they diverge. Anastomosis.—The anastomosing branches by which the cir- culation is carried on after obliteration of the brachial trunk, are the profunda major, profunda minor, and the anastomotica on the part of this artery. The profunda major is usually given off near the armpit, the principal branch of which, the rausculo- spiral, winding round the bone with the nerve of that name, forms a continuous trunk with the recurrens radialis in front of the external condyle, and is connected also by a branch with the interosseal recurrent at the back part of the joint. The pro- funda minor, descending behind the brachial artery as far as the middle of the arm, sends a branch of considerable size down with the ulnar nerve behind the inner condyle, which inoscu- lates with and forms a continuous tube with the recurrens ulnaris. The anastomotica, coming off' an inch or two above the elbow joint, winds across the brachialis anticus, and divides into two branches, one of which, passing in front of the outer condyle, unites with the radial recurrent, and the other dips down between the capsule and olecranon process to anastomose with the inter- osseal recurrent. Remarks.—The brachial artery, in consequence of its proximity to the bone, may be readily compressed in any part of its course with the extremities of the fingers or a compress and bandage. If the latter means be used, the compress should be of moderate size, so as to admit of being pressed under the edge of the biceps. It is well to avoid making compression at the point where the artery passes over the insertion of the coraco-brachialis muscle, as here the median nerve is placed in such relation to it as to be pain- fully affected by the force applied. From the mobility and exposed position of the arm, and the frequency of venesection at the elbow, it is of all the larger arte- ries most exposed to traumatic injury. If there be lesion of the vessel above the elbow, we may tie it either at the place injured, or, if there is such infiltration of blood as to mask the parts, cut down upon it in any point above. In case of puncture of the artery in venesection at the elbow, the course to be pursued varies according to circumstances. Pressure made with gradu- ated compresses, covered with a piece of coin or other metal, or with a special apparatus for the purpose, may, particularly if the wound be longitudinal, so diminish the calibre of the vessel as to allow the wound both in the artery and vein to heal. But to suc- ceed, it must be immediately applied, and is not even then a cer- tain measure. If it fail, or the case be altogether neglected in its first stage, even though the wound on the two surfaces of the vein should heal, we may have a false aneurism developed in its sheath or in the surrounding cellular tissue, constituting a resisting LIGATURE OF THE DIFFERENT ARTERIES. 61 pulsating tumour below the bicipital aponeurosis, limiting the extension of the arm, and as it grows in size bulging up just above the upper margin of this membrane, where the fascia is weakest. Or there may be instead, direct communication between the artery and superficial vein. The posterior wound in the vein and that of the artery not healing by first intention, and being brought into close contact by the compression necessary to stop the hemor- rhage, the blood of the artery leaves its route to the hand, and turning in a direction in which it meets less resistance, forms an oblong prominent pulsating tumour in the superficial veins at the elbow, constituting what is called a varicose or arterio-venous aneurism. The communication, as has been observed, may be made di- rectly between the artery and the superficial vein, both of which become matted together by the effects of the compression, and closely adhere to the opposite surfaces of the intermediate bicipital aponeurosis; or it may be indirect, the cyst of a circumscribed false aneurism being formed, which receives the blood at its bot- tom through the opening in the artery, and discharges it at its top, through the orifice in the posterior wall of the vein. The punc- ture in the anterior wall of the vein is always found closed through union by first intention. Or another kind of arterio-venous aneurism may be formed ; the artery first pouring out its blood into one of its satellite veins, through which as well as the superficial vein, the lanCet has in that case passed; the two orifices of the latter vein healing up, while the blood of the artery poured into its satellite, finds its way through the deep communicating radial vein (see page 16) into the super- ficial veins, and generally into the median basilic, which is often found dilated and pulsating in all its course up the arm. Three cases only of this description have been well reported,* and a fourth has lately occurred in this city, which came under the notice of Dr. John Wilson Moore, with whom I saw the patient in consulta- tion. But they must be unquestionably of much more frequent occurrence; for the manner in which the satellite veins overlap the brachial artery, show that they are more or less exposed to injury whenever the lancet is carried so deep as to open the latter vessel; and the discrepancies which exist among writers, in their description of arterio-venous aneurism- at the bend of the arm, show that the pathology of this form of the disease has been but imperfectly understood. This latter form, to which, for the sake of distinction, I would restrict the name of aneurismal varix, is an affection not to be lightly attacked by an operation, and perhaps only with safety in its early stages; a retaining bandage or a laced sleeve, serving even where the disease is advanced, to check the distension of the vein, and preserve in a good degree the uses of the limb. Each vein, cut in these cases at the bend of the elbow, bleeds as an artery in consequence of the arterial blood being mainly directed through the veins. Profuse irrepressible hemorrhao-e, gangrene, and subsequent death, followed an attempt to cure by operation an aggravated case of this kind, in the hands of M. Roux.t It is to be distinguished from the ordinary kinds * One by Park, of Liverpool, (Bell's Principles of Surgery. Vol. I. p. 302,) one by P. Adelmann, (Tractatus Anat. Chirurg. de Aneurysmatice Spurio Vari- coso, Wurceburgi, 1821,) and one by Claudius Tarral, (Cyclop. Pract. Surg.) f Vide Cyclop. Pract. Surgery, article Bend of Arm, by C. Tarral. 16 of aneurismal varix, by the general dilatation and pulsation of the vein, (owing to the oblique direction in which the blood comes from the communicating branch,) rather than by a single rounded prominence; by the fact that the blood is found to enter below the cicatrized puncture of the vein; and that by pressure of the thumb below the puncture so as to flatten completely the commu- nicating vein, we stop without arresting the action of the artery all pulsation in the superficial vessels. In the commoner form of aneurismal varix, when the communication between the super- ficial vein and artery exists at the place of puncture, either directly or by the intervention of a cyst formed out of the intermediate cellular tissue, pressure made as described, at the entrance of the communicating vein, will have little or no influence on the pulsa- tion of the superficial vessels. As soon as the injury of the artery by venesection or other means is detected, it is incontestably the surest course at once to recur to the ligature of the vessel, in order to prevent either of the consequences that may follow—the common form of false aneurism, varicose aneurism, or that to which I have limited the term of aneurismal varix. Two methods of proceeding are then open to the practitioner—to incise the parts at the bend of the arm, and tie the artery above and below the place of puncture; or follow the method of Hunter, and tie it where it is more readily exposed in its course along the biceps muscle. If the operation be done shortly after the occurrence of the injury, the former method is not ordinarily the best, inasmuch as it is desirable to avoid an incision at the elbow, in consequence of the deeper covering of the artery, its complex relation with the veins of that region, and its obscuration from the extravasation of blood which to more or less extent takes place. The method of JHunter is a more simple process, and if soon applied is equally successful; for it has been fully proved by experience, that the anastomosing vessels will not dilate so as to restore the circulation of the wounded trunk till sufficient time has been allowed for the healing of the puncture made in it by the lancet; and to this, compression may if necessary be added at the bend of the arm. A great accumulation of ef- fused blood at the bend of the arm, pressing on the origin of the recurrent radial and ulnar arteries, might, however, as a case of exception, render it better to cut down, turn out the clot, and tie the brachial above and below the place at which it is wounded. The principles involved in the Hunterian operation of tying the artery at a remote distance from the tumour, are not so bind- ing here, where we have to deal with a sound vessel accidentally injured. A distant ligature, though it may answer if applied immediately after the injury, is not to be relied on in case much time has elapsed since the occurrence of the injury, if a large aneu- rismal tumour has been formed, or if compression has for some time been made from without; for from all these causes the anas- tomosing branches become enlarged, and the blood will find its way into the trunk at the elbow, both by the inferior arteries of the joint and the superior branch called the anastomotica magna. For these reasons I prefer always to tie the trunk an inch to an inch and a half above the joint and below the origin of the anas- tomotica. This simple operation has in my hands succeeded per- fectly in four cases, which were respectively of four, five, eight, and nine weeks standing, in each of which, tumours of considera- ble size had already formed. In another of nine weeks stand- 62 GENERAL OPERATIONS. ing, a case of proper aneurismal varix, upon which firm pressure had been steadily kept up, so as to cause great enlargement of the profunda minor, the pulsation of the veins, though not entirely removed by the ligature of the brachial, was and still remains considerably reduced by the operation, so that the arm has been restored to very nearly its former degree of usefulness. A circum- stance connected with the operation in this case is worth noting; —pressure made upon the brachial (which was a single trunk) through the integuments above the elbow, stopped all pulsation in the artery and veins below; the profunda minor, which was after- wards found greatly dilated, having been at the same time in the line of compression. But after the ligature of the brachial, the profunda served to keep up some pulsation in the vein, through its anastomosis with the vessels below the joint. In old cases, the profunda minor has been found enlarged to a size nearly equal with that of the brachial, and in calculating the effect of a single ligature above the elbow, it is necessary that pressure should be made separately on the brachial trunk so as not to interrupt the current in the profunda minor. Such is the tend- ency to rapid dilatation of the branches in general about the joint, that in instances of longer standing than those already specified, and much less even if strong compression has been employed, the method of operation commonly deemed proper is the old plan of opening the parts at the bend of the arm, and tying the artery above and below the place of puncture. Yet there are unques- tionable exceptions to this rule. Within the last two months the author has applied a single ligature upon the brachial artery within an inch of the tumour, in the case of an elderly lady, a patient of Dr. Ridgway, residing in Columbus, New Jersey. The tumour, which consisted of a varicose aneurism, was of sixteen weeks' standing, and of very large size. Pressure upon the brachial artery being found to arrest all pulsation in the tumour, and believing that the anastomosing vessels would yield less readily to the dilating forces in old persons, I deemed it proper to try the effect of a single ligature, in the manner above described. A complete and speedy cure was the result. The basilic vein was found as large as the finger, pulsating like an artery, and crossed the line of the incision just above the base of the tumour, rendering it necessary to observe great caution in the use of the knife in open- ing the sheath of the vessels. In conclusion, it may be observed that Dr. Colles, of Dublin, has stated that in no case of aneurism at the bend of the arm, has he found it necessary to open the sac, or apply more than one ligature, and that immediately above it. LIGATURE AT THE MIDDLE PART OF THE OS HUMERI. (PL. XII.) Operation.—The arm is to be moderately carried out from the body, the forearm placed in extension and supinated. The shoul- der is to be sustained by one assistant, and the forearm and hand by another. The surgeon feels along the inner edge of the biceps (or of the coraco-brachialis, if the operation be done higher up) for the groove formed between it and the triceps, in which are lodged the vessels and nerve. Lisfranc's direction is, to place the four fingers of the left hand on the median nerve, and incise the skin along their inner border. But in the living subject, the pulsation of the artery itself forms a better guide. The cellular tissue may, however, from inflammation, be found so cedematous and pasty, as to obscure both vessel and nerve. I prefer, there- fore, in all cases, to cut neatly down immediately upon the in- ternal edge of the biceps muscle, upon which the ends of three fingers of the left hand are to rest. An incision of two and a half inches in extent, beginning below, if it be the left arm, and above, if it be the right, is to be made first through the skin merely, for fear of wounding the basilic vein. The brachial aponeurosis is then to be opened and slit at the bottom of the wound its whole length on the director, the basilic vein being carried out of the way and to the outer side of the wound. Immediately adjoining the edge of the muscle, we find J.he median nerve. This, with the muscle, is to be drawn gently outwards with a blunt hook, or, which is to be preferred, the fingers of an assistant. Sometimes; however, from the position of the nerve, it will be found most convenient to draw it to the inner side. Below it is seen the sheath of the vessels, and to its inner edge, the internal cutane- ous nerve; the ulnar nerve lying about half an inch farther back. The sheath is to be carefully opened and the artery will be found either lodged between two veins or with one large venous trunk at its inner side. Isolate the artery on either side with the point of the director, and glide the instrument below from within out- wards, pushing up with the left fore finger the median nerve, so as to prevent its being raised with the artery. If by any blunder with the knife, the artery be wounded during the operation, the hemorrhage may be instantly arrested by pressure made above with the fingers of an assistant as shown in Plate VII. Some apply a tourniquet upon the arm, but t,his arrests the pulsation of the ves- sel, and renders the finding of it less easy. If used at all, it should merely be laid loosely upon the arm as a measure of precaution. LIGATURE IMMEDIATELY ABOVE THE ELBOW JOINT. (PL. XIII.) Operation. (Process followed by the author for aneurism at the bend of the arm.)—The arm, placed in the same situation as above described, an incision two and a half inches long is to be made over the inner edge of the inferior termination of the belly of the biceps. The lower end of the incision will be just above the fold of the elbow, and its direction will be upwards and slightly inwards. The skin alone is to be first divided. The superficial fascia is to be punctured on the edge of the muscle, raised on the director and carefully opened. The basilic vein will be found parallel with and to the inner side of the wound. The deep- seated or brachial aponeurosis is next to be raised and cut in the same manner. The inner edge of the biceps is now to be moved outwards with a blunt hook, and the basilic vein and internal margin of the wound carried in the opposite direction. Adjoin- ing the edge of the muscle we observe first the median nerve, distinguished by its whiteness, which has crossed over in front and now lies to the inner side of the artery, covering the inner brachial vein; it is to be drawn inwards and the vessels will be seen about a quarter of an inch behind it, previously overlapped by the belly of the muscle. The sheath is to be carefully raised with the forceps, and opened with the point of the director. The artery is now seen lodged betw-een its two satellite veins, from which it is to be isolated on the director. The ligature is then carried round it in the usual manner. Occasionally the median nerve has different relations with the artery, crossing behind it • LIGATURE OF THE DI1 instead of in front, and getting at the place of this operation near a quarter of an inch to its inner and posterior side. In such cases the first part seen by the edge of the muscle would be the artery itself. LIGATURE AT THE BEND OF THE ELBOW. (PL. XIV.) Operation.—It is practised for recent traumatic injury of the vessel, for false aneurism, or one of the forms of arterio-venous aneurism. The arm is to be placed in the position, and secured as indicated above. The artery is to be compressed with a tour- niquet or the fingers of an intelligent assistant. The surgeon ascertains with his finger the course of the artery from the middle of the elbow joint inwards and upwards1 along the inner edge of the biceps, and which is usually well indicated by the course of the median basilic vein. Depressing the skin in this direction with the fingers of the left hand, he makes an incision which should extend an inch above and an inch below the level of the condyles. The skin, which is very thin in this region, should alone be divided by the first incision. The median basilic vein and the internal cutaneous nerve will be seen lodged in the su- perficial fascia, at the inner side of the cut. Raise and open the superficial fascia carefully on the director, and carry the vein to either side that is most convenient;—usually it will be found easiest to move it downwards and inwards. The brachial apo- neurosis next comes into view, strengthened at this point by the expansion of the biceps tendon. With the forceps, raise at the middle of the wound a fold of this double membrane, puncture it with the scalpel, and then open it upwards and downwards on the director. The artery and its veins and the adjoining nerves next come into view. To the inner side of the artery, and more super- ficial than it, may be felt first the median nerve at the top of the wound. At the middle of the elbow it is removed farther from the line of incision, and is sometimes not brought into view at all during the operation. The nerve, whether felt or seen, is to be carried gently inwards with a blunt hook. The sheath of the vessels, which lies about a third of an inch to the outer side of the nerve, is now to be opened in the usual manner, and the artery is found lodged either between two veins, or, as occasionally hap- pens, with a single large venous trunk to its inner side. Isolate the artery from the veins with the point of the director, first upon its outer and then on its inner side; or if there have been much inflammation and thickening of the cellular structure, it may be necessary, as I have found it in one case, to raise the vein with the forceps, and separate it from the artery with gentle touches of the point of the scalpel. The director is then to be passed below the artery from within outwards, carefully excluding the vein or veins, and the ligature passed as usual. The passing of the di- rector will be facilitated by a slight flexion of the forearm. OF THE ARTERIES OF THE FOREARM. LIGATURE OF THE RADIAL ARTERY. Surgical anatomy.—The radial artery usually arises from the brachial near the bicipital protuberance of the radius, and descends FFERENT ARTERIES. 63 nearly in a straight line from the middle of the bend of the elbow to the inner margin of the styloid process, at the lower extremity of the same bone. In the upper half of the forearm the artery lies between the fleshy belly of the supinator radii longus on the outer side, and that of the pronator radii teres on the inner, and in thin subjects is covered only by the skin, superficial fascia and brachial aponeurosis; but in muscular subjects it is concealed by the edge of the supinator, which projects over it. It rests on the supinator brevis above, and somewhat lower on the tendinous insertion of the pronator radii teres. The radial nerve is placed above, at some distance on the outer side of the artery, and comes in contact with it only (and still at the outer side) near the middle of the forearm. The lower half of the radial is very superficial, lies just in front of the bone, and can be felt pulsating. It has the tendon of the supinator longus immediately at its outer side, and the tendon of the flexor carpi radialis within. It turns round the base of the thumb under its extensor tendons, to get to the back of the hand, and dips down between the metacarpal bones of the thumb and fore finger to reach the palm, where it forms the deep-seated palmar arch. Before it turns to the back of the hand, it sends a branch over the ball of the thumb to form a direct anastomosis with the ulnar or superficial arch. This branch, the superficialis voice, is sometimes so large that when cut it will require to be tied, or have a ligature thrown upon the*radial. The radial nerve is in contact with the artery only at the middle third of its course, leaving it four inches above the wrist to pass under the tendon of the supinator, and becomes cutaneous on the back of the hand. Two satellite veins attend the artery. The radial artery may be tied at its upper, middle, or inferior third. Anomalies.—The principal anomalies in reference to the origin of this vessel and the ulnar have already been described. # It may be observed, that the radial of one side sometimes receives the anterior interosseal artery, which, when large, serves to explain many of the cases of disparity existing in regard to the size of the arteries of the two wrists. AT THE UPPER THIRD OF THE FOREARM. (PL. XIV.) Operation.—The arm is to be extended and laid on its dorsal aspect. The artery is to be sought for along the inner margin of the supinator longus. If the artery can be felt pulsating, or this muscle can be made to contract so as to show its inner border, the line of incision is at once designated. But if neither of these rules can be applied, we are to recollect that the course of the artery at this region is exactly in that of a line drawn from the external border of the tendon of the biceps to the inside of the styloid process of the radius. In this direction the skin is to be incised for two inches, crossing the line of the vessel a little at its outer border. Any superficial vein crossing the wound is to be drawn to one side; the superficial fascia and brachial aponeurosis are to be divided on the director. The inner margin of the supi- nator is then to be sought for. The first yellow line observed starting from the lower and outer part of the incision, indicates the interval between this muscle and the pronator. The muscles are to be separated with the point of the director, and the supi- nator with its investing fascia drawn outwards. The artery and its veins are now exposed in their sheath, the radial nerve run- 64 GENERAL OPERATIONS. ning down at a little distance on their outer side. The sheath of the vessels is sometimes seen masked with fat. Tear this as well as the sheath of the vessels with the point of the director, a fold of the latter being previously raised with the forceps. The vessel may now be isolated and secured in the usual manner. AT THE MIDDLE OR LOWER THIRD OF THE FOREARM. (PL. XIII.) Operation.—In either of these situations, the artery is super- ficial and the operation easy. Placing the arm in the position designated above, and tracing the line of the vessel already given, we find it pulsating at the inner border of the tendon of the supi- nator longus. In the groove between this tendon and that of the flexor carpii radialis, we depress the skin and divide it for the space of two inches. The superficial veins and nerves crossing the wound are to be drawn to one side, and the superficial and deep-seated fasciae divided. The sheath of the vessels is now exposed. This is to be opened, and the artery isolated and raised on the director, which is to be passed from within outwards. LIGATURE ON THE BACK OF THE WRIST. (PL. XIV.) Operation.—The radial artery may readily be tied on the back of the wrist, as has been proposed in case of wound of the deep- PLATE XIIL—LIGATURE OF THE ARTERIES OF THE ARM. (Fig. 1. A A2). OF THE ULNAR ARTERY IN ITS MIDDLE THIRD. The incision is made along the radial edge of the flexor carpi ulnaris muscle. The position in which the arm is placed, to show the other operations, brings the wound apparently too near the inner edge. a. Forefinger of an assistant drawing off the inner lip of the wound. b. Blunt hook, of a convenient form, curved at the end so as to resemble in shape a bent finger, with which one lip of the wound and the flexor sublimis of the fingers are drawn outwards and depressed. 1. Line of division of the skin. 2. Section of the aponeurosis. 3. Flexor carpi ulnaris drawn inwards. 5. Flexor sublimis digitorum drawn outwards and depressed. 6. Ulnar nerve. 7. Ulnar artery, raised on the aneurismal needle. 8. Ulnar vein. (B B2). OF THE RADIAL IN ITS INFERIOR THIRD. The skin is divided along the inner edge of the supinator radii longus. 1, 2. Division of the skin and aponeurosis. 6. Radial artery between its satellite veins (7). (C C2). OF THE ULNAR NEAR THE PALM. 1, 2. Section of the skin and aponeurotic layers. 5. Ulnar artery raised on an eyed probe, accompanied by a satellite vein (6) on either side. (D D2). OF THE BRACHIAL JUST ABOVE THE ELBOW JOINT. (Process of the author.) The incision is made over the inner edge of the biceps just above its insertion, and the lips of the wound widely separated to show the neighbouring parts. 1, 2. Skin and brachial aponeurosis divided. 3. Median basilic vein drawn inwards; a branch of the internal cutaneous nerve passing at its outer side. 4. Inner edge of the biceps drawn outwards. 5. Median nerve. 6. One of the deep-seated or satellite brachial veins, as seen in the subject from which this drawing was taken. 7. Brachial artery raised on the ligature from between its satellite veins. (E E2). OF THE ANTERIOR INTEROSSEAL. (Process of the author.) The incision is made at the lower part of the middle third of the arm, so as to cross slightly the intermuscular depression between the superficial and deep-seated flexor muscles. Flute 13 ■j.;-,, / ■;.. :,- '> N' '^.»: ■ '■■■ . 4- A &* Oh Stone t'l i' < '/■/,.„, sA, Philadelphia. Published by i PS Duval.I.ith Phil? LIGATURE OF THE DIFFERENT ARTERIES. 65 seated palmar arch. But the process is unused; preference being justly given to ligature of the radial in its lower third, since the volar branch would still be left to supply the superficial arch which is intimately connected by anastomosis with the deep- seated. To tie it on the back of the wrist, the hand should be placed in half pronation, with its radial edge upwards. The thumb is to be extended and abducted so as to render prominent the tendons of the extensor major, and the extensor minor pol- licis manus. From the triangular depression between them, the artery will be felt pulsating in the cleft between1 the posterior ex- tremities of the first two metacarpal bones, an inch and a half to an inch and three-quarters above the commissure of the thumb and forefinger. The tendon of the extensor major pollicis in a fleshy hand cannot be very distinctly felt; that of the extensor 1. Skin and brachial aponeurosis divided. 2. Flexor sublimis drawn outwards. 3. Deep-seated flexor muscle of the fingers drawn strongly inwards with a blunt hook, the fingers being flexed so as to relax the muscles. 4. Margin of interosseous ligament, seen below the fibres of the muscle over which runs the interosseous nerve. The nerve, before it is drawn outwards, lies slightly to the radial side of the artery. 5. Interosseous artery, with its vein (7). The artery is raised on a ligature. (F). OF THE TERMINAL PALMAR BRANCHES OF THE ULNAR ARTERY. These will scarcely ever require to be tied, except in case of wound. The palmar aponeurosis has been excised so as to expose the course of the vessel. 1. Ligature placed round the termination of the ulnar trunk, which has here formed the superficial palmar arch. 2. A ligature round the branch, by which it anastomoses with the radial. 3. Another ligature round a branch which goes to the outer side of the forefinger. Fig. 2. This is intended to show the surgical relations of the ulnar and radial arteries in their descent. (A). 1, 1, 2, 2. Section of the skin and aponeurosis. 4. Humeral artery raised at its place of bifurcation. 5. Common radial vein. 6. Median basilic. 7. Median cephalic. 8. Deep-seated humeral or brachial. 9. Median nerve. (B). 1, 22. Section of skin and aponeurosis. 3. Flexor carpi ulnaris drawn inwards. 5. Flexor sublimis drawn outwards. 6. Ulnar nerve. " 7. Ulnar artery between its two veins (8, 8). (C). 2. Section of the aponeurosis investing the artery over the anterior palmar ligament. 5, 5, 5. Ulnar artery between its two satellite veins (6). 7. Ulnar nerve. (E). 3. Tendon of the supinator radii longus. 5. Radial nerve. 6. Radial artery. 7, 7. Radial veins. (F). 2. Section of aponeurosis. 3. Pronator radii teres and palmaris longus drawn inwards. 4. Supinator muscle drawn outwards. 5. Radial attachment of the flexor sublimis digitorura. 6. Radial nerve. 7. Radial artery. 8. Inner radial vein. minor pollicis, and that of the extensor ossi-metacarpi pollicis, lying immediately on the radial side of the extensor minor, can always be found. On the ulnar side of the two latter, the artery may be felt. Divide the skin between the tendon's above men- tioned for the space of an inch and a half, draw to one side the superficial radial vein and nerve, and open the aponeurosis below to the same extent on a director. The artery is then to be isolated from its veins, and a ligature placed about it in the usual way, just where it crosses the os trapezium to dip into the palm. LIGATURE OF THE ULNAR ARTERY. Surgical anatomy.—It arises from the brachial artery at the same point with the radial, and for the upper third of the fore- 66 GENERAL OPERATIONS. arm runs obliquely downwards and inwards, under all the muscles which are attached to the internal condyle of the os humeri, and in the direction of a line drawn from the external border of the tendon of the biceps, to the radial margin of the ulna at the junc- tion of its upper and middle third. The artery is here deeply placed, lying between the superficial and deep-seated layer of muscles, resting as it does on the anterior surface of the flexor profundus, and covered by the deep-seated aponeurosis which separates these muscular layers. In the middle and lower third of the arm, it runs perpendicularly downwards, in the course of a line drawn from the epitrochlea* of the os humeri to the radial margin of the pisiform bone. In its middle third the artery is * The epitrochlea is the internal tuberosity of the os humeri above its surface of articulation with the ulna. overlapped by the bellies of the flexor carpi ulnaris, and the flexor sublimis digitorum, which are often in muscular subjects united together by a line of dense yellow cellular tissue over the vessel. In the inferior third of the forearm the artery is lodged between the tendons of these muscles, and is superficial, being covered only by the skin, superficial fascia and brachial aponeurosis. From the side of the pisiform bone, the artery is extended over the annular ligament of the wrist so as to form on the palm the superficial palmar arch, and is covered by the skin, palmaris brevis muscle, some den*se layers of fatty cellular tissue, and the palmar aponeurosis. It is attended by two satellite veins throughout its course. The ulnar nerve joins the artery just above the middle of the arm, and is continued down on its ulnar side to the palm. With the exception of the recurrent to the elbow, the ulnar artery PLATE XIV.-LIGATURE OF THE ARTERIES OF THE FOREARM, (Fig. 1. A2.) OF THE BRACHIAL AT THE BEND OF THE ELBOW. The integuments are divided in the direction of a line drawn from the middle of the space between the condyles of the humerus obliquely upwards and inwards towards the inner margin of the biceps muscle. (A). Median basilic vein. (B B). Aponeurotic expansion of the biceps, divided. (C). Pronator radii teres. 1. Brachial artery with its accompanying vein. 2. Median nerve. The vein is seen lying between the nerve and the artery. The ligature is seen placed around the artery. (B2). OF THE RADIAL AT THE MIDDLE THIRD OF THE FOREARM. In the drawing, the operation is placed a little too high. The incision is made over the inner edge of the supinator radii longus muscle. a, a. Superficial aponeurosis of the forearm divided. (B). Supinator radii longus muscle. (C). Outer edge of the flexor sublimis digitorum. 1. Radial artery raised on a ligature with a satellite vein on either side. (C2). OF THE ULNAR ARTERY AT ITS LOWER THIRD. The incision is made along the radial or outer edge of the flexor carpi ulnaris muscle. a, a. Superficial aponeurosis divided. 1. Ulnar artery with its venae comites. 2. Ulnar nerve. (D). OF THE SUPERFICIAL PALMAR ARCH FORMED BY THE ULNAR. The ligature of this vessel is rarely practised, except in wounds of the palm, which it is merely necessary to dilate in order to reach the vessel. 1. Incision of the skin. 2. Section of the palmar aponeurosis. 3. Ulnar artery between its two veins. One ligature is passed below the artery where it appears in the palm • and another under the first digital branch, which might continue the bleeding in the case of a wound in consequence of its anastomosis with the deep-seated arch formed by the radial artery. (rig. 2.) LIGATURE OF THE RADIAL ON THE BACK OF THE HAND. The skin and superficial aponeurosis are seen divided, and the artery raised on a ligature just before it sink^ in'o the palm to form the arcus profundus. Fiff 7 Hlata A Philadetii/tia /'ubtis/ted hr (arty ■( Hart i'il-jy.U / On .Stone by J. Oueeu. Philadelphia, Published by Carey &r Hart. P.J.Su val.Zith.Flvd? LIGATURE OF THE DIFFERENT ARTERIES. 75 the vessel at a distance varying from two to four inches below the ligament. Below the muscle is found a firm fascia covering the artery, extending from the vastus internus to the adductors. The artery as it descends into the ham, is at the inner side of the thigh bone and passes through a long fibrous channel in the ten- don of the adductor magnus, which in the operation at this point may be slit open on its upper surface, so as to expose still more of the course of the artery on the front of the limb. The line of the vessel from the pelvis to the knee joint, will be marked with a string drawn from near the middle of Poupart's ligament to the middle of the popliteal region, turning obliquely round the inner face of the thigh. The great saphena vein is imbedded in the superficial fascia, and opens into the femoral about two inches below Poupart's ligament. It is found .in a line between its place of termination and the back of the internal condyle. Traced up- ward from the condyle, it is found first at the anterior or outer margin of the sartorius ; crossing this muscle obliquely as it ascends, it gets to its inner or pubic margin about six inches below the ligament of Poupart, and then continues by the side of the muscle for three inches, when it leaves it to proceed direct to the femoral vein. Anastomosis.—The femoral artery is subject to few anomalies. When it is tied below the ligament, and above the origin of the profunda, the circulation is re-established in the limb chiefly by the branches of the gluteal, ischiatic, internal pudic, and obturator, which anastomose with the branches belonging to the thigh. In cases where the artery is tied below the origin of the profunda,— the great muscular artery of the thigh,—the circulation in the leg is scarcely at all interrupted, the blood finding its way down through the inter-connections of the perforating and anastomotic arteries of the thigh with the several articular arteries of the knee joint. Remarks.—The artery may be tied in any part of the course described. 1. Above the origin of the profunda, the place at which it was tied by Larrey previous to amputation at the hip joint. A serious objection to the operation at this region, is the frequent high origin of the profunda, and the danger of second- ary hemorrhage from the speedy return of blood through the anastomosing branches so as to fill the artery below the place of ligature. 2. After the manner of Scarpa, in the triangular space at the superior fourth of the thigh, above the point at which the artery is crossed by the sartorius muscle. The artery is here more readily secured than at any other point, but the proximity of the profunda, the origin of which is sometimes four inches from the crural arch, would render less certain the formation of a solid co- agulum. 3. Under the sartorius, or in the middle part of the thigh, according to the process of Hunter. In this region, although the artery is a little more difficult to uncover, there is no large trunk given off* near to prevent the formation of a coagulum, and success may be considered almost certain. 4. At the outer side of the sartorius, below the middle third of the thigh, or more pro- perly speaking, at the junction of the superior three-fourths with the inferior fourth of the thigh, where the artery is lodged in the sheath formed by the tendon of the adductor magnus. The artery is now never tied in the position last noticed, unless there exists some special reason for it, such as a wound of the part involving the artery, or the existence of a tumour or other affection in the middle and upper part of the thigh. Another objection besides the depth at which the artery is placed, is to be found in the fact that there is no depending opening, and when matter forms it is apt to spread through the surrounding cellular tissue by infiltra- tion. It has been customary with some surgeons to tie the artery at this point, in secondary hemorrhage, from the surface of the stump after the high amputation of the leg; but there is no well- founded reason for operating at this point under such circum- stances, rather than at a place higher up where the artery is more accessible. Hodgson has proposed to open the parts so as to tie the artery about five inches below Poupart's ligament, at a point intermedi- ate to those selected by Scarpa and Hunter. The artery is here very readily reached—the inner edge of the sartorius only requir- ing to be raised, and if matter forms it finds a ready outlet. To this plan of Hodgson, I have usually given the preference in prac- AT THE UPPER THIRD. 1, 2, 3, 4, 5, 6, 7 indicate the same parts as in fig. 3. 8. Internal saphena vein. 9. Principal bundle of lymphatic vessels, drawn to one side with the fascia lata. 10. Femoral vein. 11. Crural nerve. 12. Saphenus nerve attending the artery. AT THE LOWER THIRD. 1, 2, 3, 4, 5 indicate the same parts as in fig. 4. 6. Tendinous margin of the vastus internus, serving as a guide in finding the vessels, which are placed more deeply. 7. Tendon of the gracilis muscle. 8. Falciform aponeurotic expansion of the abductor longus and magnus muscles, forming the fibrous canal for the vessels as they pass to the popliteal region, which it is necessary to lay open in order to reach the artery at this point. 9. Internal saphena vein. 10. Femoral vein. 11. Crural nerve. 12. Saphenus nerve attending the artery. 76 GENERAL OPERATIONS. tice. I have repeated the operation by this process for the fourth time for the cure of popliteal aneurism, and in each instance with perfect success, the wound uniting almost entirely by first intention. The ligature of the femoral artery is called for in wounds in- volving this vessel, in popliteal aneurism, and in cases of disease or injury of the large arteries of the leg, when the vessel imme- diately affected cannot be tied with sufficient chance of success. On the femoral artery, Hunter first employed his celebrated prin- ciple for the cure of aneurism without opening the sac, by ap- plying a ligature on the cardiac side and at a considerable distance from the tumour. Anel and Guillemeau had previously tied the artery just above and without the opening of the tumour; but the important surgical axiom, in cases of spontaneous aneurism, of tying the artery at a distance from the tumour in order that the ligature may embrace a healthy structure, is derived from Mr. Hunter. In cases of popliteal aneurism, the great freedom of anastomosis between the upper part of the thigh and the ham frequently allows a return of pulsation in the tumour before its contents are absorbed, without-interrupting the cure.* 1. Ligature above the prof unda or at the crural arch. Operation.—The patient is to lie on his back, with the pelvis slightly elevated. The surgeon standing on the outer side of the limb, makes an incision downwards from the middle of Poupart's ligament for two or three inches directly over the course of the vessel. The several layers of the superficial fascia are to be cau- tiously divided, separating with the point of the director, the su- perficial arteries, veins and lymphatic glands. We come then upon the funnel-shaped sheath of the vessels, formed by the de- scending fasciae of the pelvis. This is to be opened in front of the artery on a director. The proper sheath of the vessels, which is here loose and cellular, then presents itself, and may be divided with the point of the forceps or director. The artery is now in view. The vein lays to its inner side, and if the operation be neatly done, may not at all be seen. The curved director is to be passed from within outwards between the artery and vein, while the surgeon with his left fore finger depresses the crural nerve at the. outer side so that it shall not be included in the loop. If the lymphatic glands of the region be much enlarged, the simple operation above described becomes one of greater difficulty. 2. Ligature at the upper fourth of the thigh and below the origin of the profunda. (Process of Scarpa, PL XVII.) Operation.—It is at the inferior angle of the triangle, described at page 33, that the artery is to be tied. The operator follows * Apian of treating aneurism by making intermittent pressure upon the artery at the Hunterian site, without incision, has been lately adopted by several of the British surgeons, and it is said with considerable success. By means of a com- pressor (see p.32j a moderate degree of pressure is made over the healthy vessel. When this becomes painful, with throbbing at the part and swelling and numb- ness of the limb, the pressure is slackened or altogether removed; but resumed again as soon as the parts have recovered. This process is to be repeated again and again till the circulation in the artery leading to the aneurism is so far mo- derated as to allow the Wood to become solidified in the tumour. A bandage during the treatment should be wound from the end of the limb upwards, to pre- vent oedema and passive congestion. Further experience is yet wanting to test the proper value of this measure,, which ia necessarily much more tedious and painful than the plan by ligature. with his finger the course of the artery. At the point where the pulsation ceases to be obvious, the artery is covered by the sar- torius. Commencing three fingers' breadth below the fold of the groin, an incision three inches long is to be made over the course of the artery, crossing the point at which it gets below the sar- torius. The great saphena vein, lodged in the superficial fascia^ will be found just at the inner side of the incision ; and, if it comes into view, must be carried inwards. The superficial fascia is to be raised and cut on the director. Below this is a layer of cel- lular tissue intermixed with lymphatic glands and absorbent vessels. Open this with the point of the director the whole ex- tent of the wound, using the knife merely to touch with the edge any resisting band. The fascia lata, distinguished by its density and yellow colour, now comes into view. This is to be carefully punctured, raised, and divided on the director for about half the extent of the outer wound. The vessels are now exposed, and the artery is to be isolated, and the director or aneurismal needle passed from within outward. In the method of Hodgson above referred to, the incision is made an inch lower on the thigh, and the inner edge of the sartorius drawn outwards with the finger of an assistant, so as to uncover the vessel below. In other respects, the operation of Hodgson is much the same as that just described. 3. Ligature in the middle third of the thigh, or under the sar- torius. (Process of Hunter.) This middle region of the thigh, as usually described, is of con- siderable extent. The sartorius muscle, as has already been shown, passes from without inwards, winds downward round the thigh, and crosses the artery diagonally so as to cover it for five or six inches. At the upper part of this middle third, the artery lies near the inner edge of this muscle, and may easily be exposed, as in Hunter's operation, by drawing the muscle outwards. At the central part, it is behind the middle of the muscle, and it has been proposed by Desault, in cases of operation at this point, to split the muscle longitudinally, or divide it across in case its contrac- tion interfered with the exposure of the vessel; but in this he has had few supporters. At the lower portion, the centre of the muscle gets so much to the inner and posterior side of the vessel, that it is most convenient, in case the operation be performed at this point, to follow the methods of Hutchinson and Roux, and cut upon the outer side of the muscle and draw it inwards and downwards. A leading objection to the latter mode of proceed- ing, is the depth of the groove in which the artery is placed, and the mischance to which the operator is liable of opening by mis- take some of the interstices between the fasciculi of the vastus internus, instead of merely widening the interval between this muscle and the sartorius. In regard to its surgical effect, the tying of the artery in any part of this middle region is much the same; but in an anatomical point of view, it is decidedly the most advantageous, for the reasons stated, to secure it after the manner of Hunter as given below, or that of Hodgson, unless there should be some special objection, as the existence of an ulcer or tumour at the place of operation. Operation. (Process of Hunter modified by Lisfranc, PL XVI.) —The patient is to be placed so that the thigh-rests on its external side, slightly flexed on the pelvis, and the leg half bent on the thigh. Two assistants steady the limb, one of whom in addition LIGATURE OF THE DII compresses the artery over the pubis with his thumb. The ope- rator, depressing with the fingers of the left hand the oblique groove ..between the internal border of the sartorius and the adductor longus, divides the skin merely, for three inches, in a direction a little diagonal to this line, terminating above, half an inch within the inner edge of the sartorius, and below upon that muscle at the same distance from its inner border. The saphena vein, or one of its accessory branches, will be seen running parallel with or crossing more or less the direction of the wound, and is to be drawn inwards out of the way. The superficial fascia, and a process of the fascia lata which is attached to the margin of the sartorius and keeps it drawn inwards, may be raised separately or together on the grooved director, and divided the whole length of the wound. The inner margin of the muscle is to be denuded with a few sweeps of the finger, and drawn outwards with a blunt hook. Below we find the vessels in their sheath, the artery in front and the vein behind. Raise a fold of the sheath with the forceps and tear it, or lay it carefully open with the knife for the space of an inch. Still holding on to the sheath with the forceps, denude the artery on either side with the director, and glide it below from within outwards. If the sartorius is directed inwards so as to cover the artery to a greater extent than usual, the wound may be enlarged at its upper part, to allow us to come more readily upon the vessel. 4. Ligature at the inferior third of the thigh as the artery passes through the sheath formed by the tendon of the adductor magnus. (Process of Hutchinson and Roux, PL XVII.) The limb is to be placed in the position just described. The operator places the ends of the fingers of the left hand in the groove between the outer border of the sartorius and the inner edge of the vastus internus. If the limb be loaded with fat, it is possible that we may not be able to discover this groove, and the artery lies too deep to enable us to distinguish it by its pulsations. We then cut in the line of direction of the vessels. An incision should be made of about four inches in extent, the centre of which should correspond with the junction of the middle with the inferior third of the thigh. The skin and superficial fascia being cut, we feel for the outer edge of the sartorius; the layer of fascia lata con- nected with the external border of this muscle is to be divided the whole length of the wound; and the muscle loosened in its sheath with the fore finger drawn inwards and backwards by an assist- ant. The posterior part of the sheath of this muscle is next to be freely opened near its middle, so as to prevent our falling between the loose fasciculi of the vastus. The groove between the two muscles is now exposed, at the bottom of which we find the ves- sels as they are about to pass into the tendinous canal of the ad- ductor, which, when the wound has been well cleaned with the sponge, is distinguished at the lower part of the incision, by its density and pearly hue. Undei1 the sharp edge which it presents above we glide a grooved director, and with a bistoury lay open the canal. The sheath of the vessels is now fully exposed ; the nerve lying to the outer side and a little in front, the vein within and behind, and the artery in the middle. The sheath is to be opened, and the curved director or aneurismal needle passed under the artery from within outwards, as in the operation last described. 20 FFERENT ARTERIES. 77 ligature of thf popliteal artery. Surgical anatomy.—This artery is extended from the tendinous sheath of the adductor to about five fingers' breadth below the articulation of the knee joint, w-here, under the fibrous arch of the soleus it divides into the anterior and posterior tibial vessels. It runs somewhat obliquely from above downwards and from within outwards, and occupies very nearly the middle of the lozenge- shaped cavity of the ham, formed by the divergence of the inner and outer hamstring tendons above, and the two bellies of the gastrocnemius externus below. Placed first upon the os femoris, it then passes deeply between the condyles and over the popliteus muscle. In this last position it is found on the average an inch to an inch and a quarter below the surface. The popliteal vein is placed more superficial than the artery, though closely con- nected with it, and crosses diagonally over it, so as to be found external above, posterior in the middle, and internal to it in the lower part of this region. Between the vein and the skin passes downwards the popliteal division of the great sciatic nerve, and more superficial still is the external saphena vein, often accom- panied by another smaller, which comes up from the outer margin of the tendo achillis and opens into the popliteal just above the condyles of the os femoris. The peroneal nerve runs down, sunk under the edge of the biceps flexor tendon, and gets on the outer margin of the external head of the gastrocnemius, where it turns over the fibula just below its head. All these parts are more or less imbedded in fat and cellular substance, and have as their cov- ering, besides the skin and superficial fascia, a strong aponeurotic layer, which is an extension of the fascia lata. There are several lymphatic glands placed in the neighbourhood of the artery, and mostly above the joint. One is found superficial to the artery; and this, when enlarged and moved by the pulsation of the Aessel below, has occasionally been mistaken for an incipient aneurismal tumour. Remarks.—The popliteal artery may be tied in any part of its course, by opening, in the middle line, the lozenge-shaped cavity of the ham; but it is better, in order to avoid the popliteal vein,, to tie it at the superior angle, before the artery gives off* its ar- ticular branches, or at the lower end between the heads of the gastrocnemius and below the entrance of the saphena. The artery- may also be reached and tied by a lateral incision under one of the heads of the gastrocnemius, where it comes nearest to the surface* Hardly any occasion could occur that would render it necessary to tie the artery between the condyles, a situation in which it is deeply placed, and lodged over the posterior ligament of the joint. The great extent and depth of the popliteal space afford room for the development of aneurismal tumours, which occur here more frequently than in any other part of the body, and sometimes attain to a considerable size before they become prominent in the ham. Prior to the time of Hunter the operation for their cure consisted in applying a ligature above and below the tumour, after the plan of Keysler, laying it open afterwards and turning out the elot. This dangerous and painful method is now completely supplanted by the Hunterian operation, in which the femoral only is tied. Even in punctured wounds of the popliteal artery, it will in a great majority of cases be best not to open this space, but to secure the femoral artery in the middle third of the thigh, inasmuch as operations in the popliteal region are apt to lead to 7S GENERAL OPERATIONS. burrowing abscesses under the hamstring tendons which not un- frequently involve the posterior ligament of the joint. A wound of this description, attended with pressure on the articular branches from effused blood, may, however, occur, in which it would be better to dilate the opening and secure the vessel, at or near the place of injury; and it is barely possible that an aneurismal tumour may be formed, so fed with blood from the enlarged anasto- mosing branches, that no means will suffice for its cure short of ligature of the popliteal artery immediately above and below the tumour. 1. Usual process for ligature of the upper part of the popliteal, by which this artery may be tied at any part of its course. (PI. XVIII. fig. 1.) Operation.—The patient is to be placed on his abdomen, with the thigh and leg moderately extended and sustained by two as- sistants, the operator standing upon the outer side. If there be any aneurismal tumour, a tourniquet must be applied upon the upper part of the thigh. The ends of the fingers of the left hand placed in a line are to be sunk into the depression just over the outer border of the middle line of the popliteal space, and along their inner edge an incision of three to four inches in length is to be made from below upwards on the right side, and from above downwards on the left, the upper termination of which is to be opposite the superior angle of the space indicated by the separa- tion of the biceps and semi-tendinosus tendons. If the intention is to tie the artery below the joint, the incision need not extend so high by an inch. The line of incision should be somewhat nearer the inner than the outer hamstring, and at its lower end be directed slightly outwards on account of the greater size of the internal head of the gastrocnemius. It should cross somewhat diagonally over the course of the artery. After the division of the skin, the external saphena vein is to be drawn slightly outwards, and the superficial and deep-seated fasciae divided the whole length of the wound on a grooved director. Open then the fatty cellular tissue that comes into view with the point of the director, relax the muscle by slightly flexing the leg, and have the margins of the wound well separated with blunt hooks. The popliteal nerve may now be seen at the external side of the artery and should be drawn outwards; the curve formed by the saphena vein as it throws itself into the popliteal is to be traced; and half an inch above and behind this curve we will find the artery, with the vein be- hind and at its outer side. The sheath of the vessels is to be carefully opened, the artery denuded upon either side, and a bent director or the common aneurismal needle passed below it from within outwards, the vein at the same moment being pressed downwards and outwards with the left fore finger. If the first incision is prolonged downwards between the heads of the gas- trocnemius, the artery may with great facility be tied in the inferior part of its course after the manner of Lisfranc. If it be extended so low as the fibrous arch Of the soleus before spoken of, we may at will tie either the anterior or posterior tibial arteries near their place of origin. 2. Ligature of the popliteal artery, by incision upon the inner side of the ham. (Process of Marshal. PL XVIII. fig. 11.) The object of this method is to reach the inferior part of the artery under the tibial margin of the gastrocnemius internus. PLATE XVIIL—LIGATURE OF THE POPLITEAL ARTERY, Two different processes for this operation are shown in the plate. Fig. 1. (A A2). Incision in the middle line of the hollow of the ham. (Ordinaryprocess.) a. Index and middle finger of the surgeon's left hand, drawing outwards the external lip of the wound. 6. Fore finger of an assistant, drawing the inner margin of the wound in the opposite direction. 1. Line of section of the skin. 2. Division of the aponeurosis of the thigh. 3. Prominence formed by the semi-membranous muscle. 4. Prominence formed by the biceps flexor cruris. 5. Internal division of the popliteal nerve. 6. External saphena vein. 7. Popliteal vein. 8. Popliteal artery, raised at (9) on the common aneurismal needle, and at (10) on the point of a bent director. 2. (B B2). Incision upon the inner side of the limb. (Process of Marshal.) Fig a The two fingers of an assistant, pressing backwards the gastrocnemius muscle. Edges of the divided integument. Division of the aponeurosis of the leg. Internal saphena vein. Saphenus nerve. Margin of the gastrocnemius interim* ox^oleus. Tendons of the gracilis and semi-tendinosus muscles. Popliteal vein. 8. Popliteal nerve, carried backwards. 9. Popliteal artery, resting on the popliteus muscle. 10. Graefe's aneurismal needle passed under the artery. Ft ate 78 Fig J H •• A'< ■ ^-tMrtfiXSfc^ Stone by S Clcht'fstl Philadelphia .Published by Carey 4 /Pari T S.Mu.rca. Lith Fhil° LIGATURE OF THE DIFFERENT ARTERIES. 79 It has not yet, however, been sanctioned by use on the living subject. Operation.—The patient is to be placed on his back or side, and the limb abducted and laid on its outer border, with the thigh and leg slightly flexed and supported by a pillow. The surgeon feels for the groove which exists between the internal border of the inner head of the gastrocnemius and the internal spine of the tibia, and follows it obliquely backwards till he feels the promi- nence of the soleus. In the course of the groove thus depressed with the fingers, he makes an incision of three inches, commenc- ing just below the point where the tendons of the sartorius, gra- cilis, and semi-tendinosus sweep round upon the tibia. The saphena vein and its attendant nerve, exposed by the division of the skin, are to be drawn forwards, and the superficial fascia and the deep-seated aponeurosis of the leg, which is here very thick, laid open. The internal head of the gastrocnemius is now to be separated with the finger or director, and drawn strongly outwards with the blunt hook. At the depth of about an inch we find the vessels. The vein first appears, covering the artery, which lies to its outer side,—the popliteal nerve being situated between and behind them. The vein is to be slightly denuded, and drawn backwards and outwards with a blunt hook or the fingers of an assistant. The artery then comes into view, resting on the surface of the popliteus muscle, and is to be raised with the aneurismal needle. M. Jobert has proposed to tie the artery above the joint, by a somewhat analogous process—making a lateral incision on the inner side between the vastus internus and the inner hamstring tendons. OF THE ARTERIES OF THE LEG. LIGATURE OF THE ANTERIOR TIBIAL UPON THE LEG. Anomalies.—The anterior tibial artery has been occasionally observed placed quite superficially below the integuments. The posterior interosseal sometimes comes in front of the interosseous ligament, and throws itself as a trunk of considerable size into the anterior tibial. Remarks.—True aneurism of the anterior tibial artery is a rare affection, and the author does not remember to have observed more than two instances of it in the course of his practice; false aneurismal tumours, diffused or circumscribed, the consequence of wounds, are, on the contrary, not unfrequently met with. If the wound implicating the artery be recent, the surgeon may dilate it if not sufficiently open; or if a small aneurism have formed, cut down upon the vessel, and apply in either case a ligature above and below the place of its injury. The necessity of this double application of the ligature always increases the farther the injured vessel is removed from the centre of the body, for the greater then will be the degree of intercommunication which exists by anas- tomosis between the surrounding branches. But if the vessel be affected in the upper fourth of the leg, the depth at which it is placed and the disturbance of the muscles necessary to reach it there, will in general make it preferable to secure the femoral at the middle region of the thigh. The place of election in ligature of the anterior tibial, is the middle third of the leg. At the lower third, the artery is too closely in relation with the sheaths of the tendons and the ankle joint, and in the upper is too deeply placed to be cut down upon except in cases of necessity. LIGATURE IN THE MIDDLE OR UPPER THIRD. (PL. XIX.) Operation.—The patient rests on his back, with his leg ex- tended, and held at the knee and foot by two assistants. The sur- geon takes his position at the outer side of the limb. He traces out in his mind or marks with the handle of a scalpel the line of direction of the vessel, causes the patient to flex and extend the foot so as to render the position of the anterior tibial muscle more conspicuous, and feels with the fingers of the left hand for the groove along the external border of this muscle. The skin is to be opened by an incision three inches long, directly over the vessel lodged in this groove ; or, which I greatly prefer, in a direction obliquely across the course of the vessel, commencing over the anterior tibial muscle, a half or three-quarters of an inch from the spine of the tibia—and crossing the vessel so as to terminate be- low as much at its outer side. On the right side the incision is to be made from above downwards; and on the left from below upwards. The superficial fascia and aponeurosis are next to be slit the whole length of the wound, and divided transversely for half an inch or more at either end of the incision, so as to facili- tate the separation of the muscles. We then seek with the finger for the first cellular groove, or the first yellowish intermuscular line (starting from the end of the incision next the tibia), which will be found between the tibiabs anticus on the outer side, and the ex- tensor pollicis pedis, or the extensor communis digitorum, accord- ing as the operation is in the middle or upper part of the leg. This space is to be opened by rupturing the cellular tissue between the muscles the whole length of the wound with the index finger merely, or the point of a director. The foot is to be flexed, and the muscles in question thus relaxed are to be held asunder by the Surgical anatomy.—This artery, arising from the popliteal just below the muscle of the same name, passes directly forward in an opening in the interosseous ligament, between the head of the fibula and the outer margin of the tibia. From this point it is direct- ed downwards in a straight line to the middle front portion of the ankle joint. In all this course it gives off but one branch of im- portance, the recurrens tibialis. For the three superior fourths of the leg it rests on the anterior face of the interosseous ligament, and upon the tibia in its lower fourth. It is accompanied by two veins, and crossed diagonally by the anterior tibial nerve, so that the latter is found external to it above, anterior in the mid- dle, and internal below. In the upper third of the leg this artery is situated between the belly of the tibialis anticus muscle, (which lies upon its inner side and overlaps it,) and the extensor digi- torum communis on its outer, and is placed on an average about an inch below the surface. In the middle third of the leg it still has the tibialis anticus at its inner side; and is bounded on its outer by the extensor pollicis pedis, which shortly crosses in front of the artery so as to get to the opposite side. At the inferior third of the leg the artery becomes much more superficial, and is lodged between the tendons of the extensor pollicis and the ex- tensor communis digitorum pedis. so GENERAL OPERATIONS. fingers of an assistant, or with blunt hooks. The sheath of the I LIGATURE OF THE ANTERIOR TIBIAL ON THE DORSUM OF THE POOT vessels is now exposed at the bottom of the groove, and is to be raised with the forceps and opened. The nerve is to be drawn Surgical anatomy.—■From the middle of the interval between to one side, and the sheath of the vessels seized on the outer side ,' the two malleolar processes, the artery is continued forwards in a of the artery with the forceps; the artery is then to be isolated [ straight line to the interosseal space between the metatarsal bones from its accompanying veins, and raised on the director. In con- sequence of the depth of the vessel the director should be slightly curved; and if presented diagonally, it will pass more readily under the artery. If the rules here laid down for discovering the groove in which the vessels are lodged, are not regularly followed, the operator may get too far from the tibia, and fall into the space between the two extensors. Should this happen, it will be neces- sary for him to look about a third of an inch to the inner side of this opening for the intermuscular space by the outer side of the tibialis anticus. In the operation for tying the artery at the upper third of the leg, of the first and second toe, where it dips down to the sole of the foot. It rests upon the tarsal bones, and runs between the exten- sor pollicis pedis, which is on its inner side, (and serves as a guide for the vessel,) and the first tendon of the short common extensor at its outer; the muscular fibres of the latter slightly cover the vessel, and constitute the first point to be looked for in the opera- tion. The vessel is situated nearly a third of an inch below the skin, covered by the dorsal aponeurosis, and a second fibrous ex- pansion spread between the extensor tendons, and is accompanied by two veins and a nerve. Its pulsation, nevertheless, can usually be readily felt. Lisfranc proposes to make the external incision in an oblique diree- I Remarks.—This artery, as has already been observed, is occa- tion from the head of the fibula to near the crest of the tibia; it sionally increased in size by union with the posterior interos- has, however, no particular advantage over the process already i seal. On the other hand, it is sometimes entirely deficient, or so described. In ligature of the artery at its lower third, the vessel small that it is with difficulty distinguished in operations on the will be found between the two extensors, and is so superficial that j cadaver. It may be tied in any part of its course, but the middle its position is readily detected by its pulsations. ■ j of the tarsal arch is the place usually preferred. Its proximity to PLATE XIX.—LIGATURE OF THE ANTERIOR TIBIAL ARTERY- Fig. 1. The limb is laid on a pillow, with its external and anterior surface looking upwards. (A A2). AT THE UPPER THIRD. 1. Line of division of the skin. 2. Aponeurosis of the leg laid open. 3. Tibialis anticus muscle, carried inwards by a blunt hook. 4. Extensor communis digitorum pedis, pressed outwards by two fingers of the surgeon's left hand. 5. Sheath of the anterior tibial vessels. 6. Anterior tibial nerve. 7. Venae eomites or satellite veins. 8. Anterior tibial artery raised on the aneurismal needle. (B B2). AT THE JUNCTION OF THE MIDDLE WITH THE INFERIOR THIRD OF THE LEG. 1. Line of division of skin. 2. Aponeurosis of leg. 3. Anterior tibial tendon, carried inwards. 4, 5. Extensor tendons of the toes, carried outwards. 6. Anterior tibial nerve. 7. Vena? coraites. S. Anterior tibial artery raised on the director. (C C2). ON THE DORSUM OF THE FOOT. 1. Incision of the skin. 2. Incision of the dorsal aponeurosis of the foot. 3. Inner margin of the extensor brevis digitorum carried outwards. 4. Tendon of the extensor proprius of the great toe. 5. Anterior tibial artery between its two veins, raised on the ligature. Plate /.9. /'hi/ntle/fi/iiu. Pub/lshed. by Carpj/&Ba.rt PS Durcl Ijlth n- LIGATURE OF THE DIFFERENT ARTERIES. 81 the tarsal bones enables us, in cases of wound, to apply compres- sion with so much advantage that ligature of the vessel at this point may frequently be dispensed with. Operation.—The foot held in extension, an incision two inches long is to be made directly over the course of the vessel, the lower . end of the incision being opposite the posterior angle of the first interosseous space. The subcutaneous cellular tissue, and the dorsal aponeurosis, having been divided on the director, we fall upon the first tendon of the extensor brevis digitorum communis. The inter-tendinous fascia is next to be opened along the inner border of this muscle, and the muscle itself drawn a little out- wards. The sheath of the vessels appears immediately below, which is to be opened, and the artery isolated and tied in the usual manner—the director being passed belowT it from within outwards. LIGATURE OF THE POSTERIOR TIBIAL. Surgical anatomy.—The posterior tibial artery, from its size and direction, may be considered the continuation of the popliteal, from wdiich it comes off about two inches below the articular surface of the tibia. It is placed on the posterior part of the leg, and passes down nearly in a straight line, from the central hollow of the ham to the middle of the space between the internal mal- leolus and the tendo achillis, curved slightly inwards near the middle. Above, it rests by its anterior face on the tibialis pos- ticus muscle; in the middle part of its course, upon the flexor longus digitorum ; and near the ankle, it is separated only by a padding of fat and cellular tissue from the bone. Throughout its course it is covered on its posterior face by the deep-seated aponeurosis of the leg; which separates the superficial from the deep layer of muscles; and for the upper two-thirds of the leg, by the gastrocnemius and soleus. Below, these muscles become tendinous, and depart from the artery so as to leave it superficial where it runs down at the inner side of the tendo achillis, being covered there only by the skin and two aponeurotic layers. It then turns round the os calcis, midway between the tendon and malleolus, from the latter of which it is separated only by the tendons of the posterior tibial, and flexor communis muscles, both of which are lodged in a groove in the bone and protected by a sheath. It is accompanied throughout its course by its two veins, and the posterior tibial nerve which lays to its outer side. At the top of the leg, as before observed, the artery is nearly in the mid- dle line, and an inch to an inch and a half below the surface. In the middle third, it is about an inch from the outer edge of the tibia, and at a hand's breadth above the ankle, only half an inch. Remarks.—This artery is little subject to anomaly ; it has, however, been found in a few instances very small or entirely wanting. It may be tied at the superior, middle, or inferior part of the leg; or, in case of necessity, in any other portion of its course. The operation is usually called for in consequence of a direct injury from a wound; and in such cases, for reasons already mentioned, it is advised to apply two ligatures—one above and one below the place of lesion. True aneurismal tumours occur but rarely in the course of this vessel. Diffused false aneurisms may allain here to a size considerably greater than those observed on the anterior tibial, in consequence of the greater extensibility of the surrounding tissues. The vessel is placed so deeply in the upper third of the leg, that it cannot be reached but by a deep and extensive wound, and very considerable derangement and some destruction of the muscular fibres. In most instances where it would not answer to secure the artery lower down, we should best promote the safety and comfort of the patient, by tying in pre- ference the-femoral in the middle region of the thigh. But in a wound complicated with extensive effusion of blood between the muscles, we have the high authority of Mr. Guthrie for securing the popliteal trunk. This surgeon, in the instance alluded to, pre- ferred to the ordinary operation, the'splitting down of the muscle in the middle line of the calf. LIGATURE IN THE UPPER THIRD. (PL. XX.) Operation.—The leg should be half flexed so as to relax the muscles, and laid flat upon its inner side. Three quarters of an inch to an inch (according to the muscularity of the limb) behind the inner edge of the tibia we make an incision, four inches in extent—parallel with that bone ; or slightly approaching the bone below, which I prefer, as being more directly over the course of the vessel. The superficial fascia and aponeurosis are to be divided to the same extent, taking care to avoid the saphena vein, which runs up nearly in the direction of the cut. A crucial incision should be made across the aponeurosis at the two extremities of the wound. The internal head of the gastrocnemius is now ex- posed, the cellular connections of which, on its anterior surface, are to be separated wdth the finger or director, and the muscle itself drawn outwards on a blunt hook. The belly of the soleus, which arises in great part from the tibia, now comes into view;* this is to be divided layer by layer with the knife after the manner of Manec, in the direction of the external wound, and at the distance of about three quarters of an inch from the tibia. After dividing the belly of this muscle, we fall upon its tendinous fibres of inser- tion, which form a strong, white, shining layer. This is to be raised on the director, and divided the whole length of the wound. We come next to the deep-seated muscular aponeurosis, which is to be cautiously opened and divided in the same manner on the director. The vessels enveloped in their sheath are now fully exposed. The sheath is to be opened, the artery denuded in the usual manner, and the aneurismal needle passed below it from writhin outwards. LIGATURE AT THE MIDDLE THIRD OF THE LEG. (PL. XX.) Operation.—Take for a starting point in this operation, the pos- terior or internal angle of the tibia, which may always be readily discovered by depressing the mass of muscles on its posterior face. By the older method it was customary to open the skin, by an incision parallel with the tibia, and about half an inch from its * By the old method it was customary to shave the soleus off directly at its connection with the tibia, and then draw the muscle outwards, in place of dividing the belly of the muscle as directed in the text. This process serves easily enough to expose the vessels on the dead body; but is attended with much difficulty on the living subject in consequence of the strain of the muscle, and the excessive contraction to which it is provoked. To overcome this resistance, M. Bouchet, of Lyons, was compelled to divide the soleus directly across over the course of the vessel. GENERAL OPERATIONS. internal border. But there is greater certainty of falling directly upon the vessels, by adopting the following modification of Lis- franc. Make an incision of two and a half to three inches in ex- tent obliquely downwards and backwards from the posterior angle of the tibia to the inner border of the tendo achillis, so that it shall form with the axis of the leg an angle of about 35 degrees, and cross diagonally over the intermuscular groove in which are lodged the vessels. Divide in the same direction the superficial fascia and aponeurosis; glide the forefinger, with its palmar face turned backwards, into the bottom of the wound and under the tendo achillis, and sweep it upwards and downwards so as to detach the cellular connections freely; the belly of the soleus comes into view as it leaves the tibia, forming the upper border of the wound, and is to be drawn upwards and backwards, or if it descends low upon the artery, divided together with its aponeurosis of insertion at its origin from the tibia. At the bottom of the wound is next observed the shining deep-seated intermuscular aponeuro- sis, covering the vessels. This is to be punctured so as to admit the grooved director below it, and freely divided. The sheath of the vessels which is now exposed is to be opened, and the artery isolated and tied in the usual manner. The same process as here described is applicable to the ligature of the artery in any part of its inferior third.* * It is perhaps useless to repeat that the incision must be made from above downwards, or below upwards, according as we act on the right or left limb. The description in the text is confined" to the right side. PLATE IX.—LIGATURE OF THE POSTERIOR TIBIAL AND PERONEAL ARTERIES. Fig. 1.— Of the posterior tibial. The leg rests upon a pillow, and is laid upon its outer side. (C C2). AT ITS UPPER THIRD. 1. Division of the skin and superficial fascia. 2. Division of the superficial aponeurosis of the leg. 3. Section of the soleus muscle, made near its attachment upon the tibia. One portion is carried towards the tibia by the left fore finger of the operator; the other is carried.backwards by the fingers of an assistant, so as to make the wound gape. 4. Section of the aponeurotic tendon of the soleus. 5. Deep-seated aponeurosis of the leg covering the flexor muscles of the toes, and separating them from the soleus. 6. Posterior tibial artery, exposed between its satellite veins and raised on the aneurismal needle. (B B2). AT THE INFERIOR THIRD OF THE LEG. 1, 2. Division of the skin and superficial aponeurosis. 3. Division of the deep-seated aponeurosis covering the flexor muscles of the toes. 4. Posterior tibial artery isolated and raised from between its veins on the grooved director. (A A2). BEHIND THE INTERNAL MALLEOLUS. The lips of the wounds are held separate—posteriorly by a blunt hook—anteriorly by the fore finger of an assistant. 1, 2. Division of the skin and superficial aponeurosis of the leg. 3. Division of the deep-seated aponeurosis, which covers the flexor tendons as well as the artery. 4. Posterior tibial artery, raised on the ligature. Fig. 2.—Anatomical relations of the vessel, designed to illustrate the three preceding operations. 1, 2, 3, 4, 5, designate the same parts as in the three side sketches. 6. Internal part of the gastrocnemius externus. 7. Posterior tibial nerve. Posterior tibial artery, between its two veins. Superficial or investing aponeurosis of the leg. Internal saphena vein. Saphenus nerve accompanying the vein. 12. Tendo achillis. 13. Tendon of the flexor longus communis digitorum pedis. aponeurosis. Fig. 3.— Of the peroneal or fibular artery. 1, 2.-Division of the skin and superficial aponeurosis. 3. Peronei muscles carried in front by a blunt hook. 4. Division of the peroneal attachment of the flexor pollicis muscle. 5. Peroneal artery between its satellite veins. The artery is raised on the aneurismal needle. 9. 10. 11. Both these tendons are seen through the deep-seated Tig. 1. Fig. 3. Plate. 20. On. Stone by E- Schnabe.1 Phdn.d*lpUa~, PuMishtd. by Carey 8r Wart P J.J)iLrttJ,Lith..PhUc LIGATURE OF THE DIFFERENT ARTERIES. 83 LIGATURE BEHIND THE MALLEOLUS INTERNUS. (PL. XX.) Surgical anatomy.—The artery is curved, as before observed in its course behind the malleolus, presenting a concavity in front. At the end of this curve it is divided into its two plantar branches. It is lodged in some dense cellular tissue, accompanied by its veins, and with the nerve at a little distance behind it. It is covered by the superficial and deep-seated aponeurotic membranes, which are often strengthened by some fibres from the annular ligament of the joint. It is found about a finger's breadth behind the malleolus, and in the middle of the space between it and the tendo achillis. The tendons of the two muscles which separate it from the mal- leolus are each covered by respective portions of ligament, and ought not to be seen at all in the operation upon the artery. Remarks.—Wounds of the foot involving the plantar branches are the most frequent causes which render necessary the ligature of this portion of the artery; for it would be most unwise, as well as extremely painful and difficult, to cut down upon the plantar branches, which are lodged in the sole at a depth of at least three quarters of an inch. The remarks made in reference to ligature and compression of the arteries of the hand, are equally applicable to those of the foot. It is quite practicable to arrest the circulation of blood in this vessel by compression behind the ankle, but this method becomes after a short time too painful to be borne. The case, however, can hardly be conceived, except there be direct wound of the vessel in this region, in which ligature of the trunk in the inferior third of the leg would not be equally efficacious as that behind the ankle ; and as the latter process is liable to be fol- lowed by chronic inflammation of the ligaments of the joint or the sheaths of the tendons, the former operation ought, in the opinion of the author, to be preferred. Operation.—The limb is to be placed in the position indicated for the two operations last described, and a vertical incision of two inches in length made in the middle line between the tendo achillis and the internal malleolus. The fibrous subcutaneous cellular tissue is to be cut with the skin. The superficial aponeurosis is to be raised carefully and cut on the director. A layer of fatty tissue covering immediately the deep-seated aponeurosis next comes into view, both of which are likewise to be divided on the director. The sheath of the vessels which is now exposed, is to be opened, and the artery isolated on either side and raised on the director according to the usual process. LIGATURE OF THE PERONEAL ARTERY. (PL. XX.) Surgical anatomy.—The peroneal artery comes off from the posterior tibial below the popliteus muscle, and runs down along the internal face of the fibula, from which it is separated only by the flexor longus pollicis pedis. Near the os calcis, it terminates by dividing into two branches. In the upper part of the leg, it is covered by the soleus muscle; in the lower half, it is more superficial. It rests on the interosseous ligament, and in the intermuscular fissure between the flexor pollicis and the tibialis posticus muscles. Very frequently, however, it is found lodged in the midst of the fibres of the first named muscle. It is covered by the superficial and deep aponeurotic membranes, like the artery last described. Remarks.—This artery rarely requires to be tied, except in cases of compound fracture or punctured wounds. Too deeply seated above to become the subject of' operation, and so small below as to render it unnecessary, it is only in the middle third of the leg that it can be requisite to tie it. In traumatic injuries of the upper third, necessitating some remedial measure, it would be better surgery to secure the femoral artery than to do so much violence to the deep-seated structures of the leg as would be necessary to reach the peroneal in that region. The peroneal artery, it is to be recollected, lies between the tendo achillis and the fibula, while the posterior tibial lies on the opposite side of the limb, between the tendo achillis and the tibia. Operation.—The leg is to be semiflexed and placed upon its inner face with the front portion turned toward the operator. The foot should be extended and its external margin elevated so as to relax the gastrocnemial and peronei muscles. An incision below the middle of the leg of two to two and a half inches in extent, is to be made after the method of Lisfranc, between the external border of the tendo achillis and the external face of the fibula, taking care to avoid injury of the external saphena vein, by first cutting merely the skin, and drawing the vein to one side before the deeper parts are divided. The incision should be directed at an angle of about thirty-five degrees with the course of the vessel. The superficial fascia and aponeurosis are next to be cut. With the index finger, we then push inwards the tendo achillis, and destroy the cellular tissue down to the deep-seated aponeurosis, which is stretched between the tibia and fibula. An assistant now draws the tendo achillis inwards. The deep-seated aponeurosis is next to be raised and divided on the grooved director. Starting from the fibula, we look for the first intermuscular space below this aponeurosis, which, if it interfere with the separation of parts, may, as well as the superficial, be cross cut at the two extremities of the wound. This space is to be opened with the finger, and we fall upon the vessel lodged between the two muscles already noticed,—the flexor pollicis and the tibialis posticus. The flexor polMeis is to be drawn outwards, and the sheath of the peroneal vessels comes into view deep behind the fibula. The sheath is to be opened, and the artery isolated and raised upon the aneurismal needle or with a director highly curved and passed diagonally below it. In case the artery be lodged among the fibres of the flexor muscle, these must be eautiously cut till we reach the vessel; or should there be difficulty of succeeding by other means, the muscle with the artery may be cut across, and the bleeding orifice of the latter secured with the tenaculum and ligature—pressure being made at the time on the femoral so as to prevent much effu- sion of blood. By the older method, a straight incision was made directly over the course of the vessel; but it does not afford the same degree of certainty of falling directly upon the artery, especially if we tie it at the usual point, below the middle of the leg, and just at the place where the soleus and external gastrocnemius tendons join. 84 GENERAL OPERATIONS. III. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. Under this bead will be considered:—1. The operations for dropsy of the joints. 2. Those for the removal of foreign bodies from the joints. 3. For ganglions or cysts on the bursal sheaths of the tendons. 4. For hygroma or dropsical tumours of the bursas mucosae. 5. For complicated fractures and luxations. 6. For false joints, or ununited fractures. 7. For deformities from the irregular union of broken bones. 8. For exostosis. 9. For cysts in the bones. 10. For necrosis. 11. For trephining—and, 12. For resection of the bones. HYDRARTHROSIS.—ARTICULAR DROPSY. Every articulation consists of the extremities of two or more bones appropriately fitted to each other, covered with a smooth, polished, elastic substance called cartilage, and held firmly together by strong inelastic bands called ligaments ; and as in all machinery where there is much motion, it is necessary to interpose some unctuous substance to prevent friction, there is in every movable joint a slippery fluid called synovia, thrown out by the inner mem- brane which lines it. This is undergoing a continued process of secretion and absorption, exactly proportioned to the degree of motion to which the joint is subjected. As a sort of secondary ligaments, serving to strengthen the arti- culation, we have the tendons of the muscles playing over them, and sometimes, as in the shoulder, apparently passing through the joint itself. Each of these in the neighbourhood of the joints is provided, for the same purpose as the joints themselves, with the same secreting membrane, which is extended along the tendon in the form of a long purse or bursal sheath, and when distended is about three or four times the diameter of the tendon it embraces. Not only in the joints and around the tendons, but wherever there exists steady friction in the play of parts, as that of the skin or a tendon over a bone or other resisting structure, do we find the same kind of serous sac under the name of bursa mucosa. All these closed secreting sacs, like other serous membranes, are liable to an accumulation of their fluid contents, constituting dropsy. This is, however, most generally but a symptom occa- sioned by a sprain, wound, contusion, some internal affection of the joint, or the development of movable cartilages,—and may usually be removed by antiphlogistic treatment, conjoined with rest and compression. The joints most subject to this dropsical accumulation are the large ones, the knee, elbow, hip, and wrist. The bursal sheaths most commonly affected, forming the tumours called ganglions, are the ones subjected to most frequent move- ment ; viz., those which cover the wrist. The bursae mucosas most commonly found distended, are those most liable to compression —as the one between the skin and ligamentum patellae, forming when enlarged by disease the affection known as the housemaid's knee, and the one covering the olecranon, which, from being commonly observed among miners who rest much on the elbow, constitutes in its morbid condition what has been called the miner's elbow. Dropsy of the knee joint.—When the synovial fluid has in- creased to such a quantity as to properly constitute this disease, we find a soft fluctuating tumour with no change of colour in the skin, which yields to the pressure of the finger, without leaving an impression as in oedema. If the leg be stretched, the patella can be made to strike on the condyles and rebound. If there be a communication, as is most commonly the case, between the joint and the bursa above the condyles of the os femoris, there will also be a great degree of fullness or swelling under the extensor tendons. The capsule protrudes at both sides of the patella and rectus tendon, but most on the internal, and is very tense when the knee is best. A protrusion of the capsule sometimes takes place into the popliteal region when the leg is extended, to which the artery of the ham from its proximity communicates a pulsatile movement. By bending the joint, however, the tumour disap- pears, and its nature is at once made known. In dropsy of the elbow joint, the distension of the capsule forms an oblong tumour on either side of the olecranon process, when the forearm is extended. At the ankle joint, the fluctuating tumour is obvious chiefly in front of the malleolar processes. At the wrist, it is scarcely perceptible on the sides,of the joint; it is observed to some extent on the back part, but is found mainly on the front portion of the articulation. At the shoulder it.is found on the front portion of the joint, and is especially obvious between the deltoid and pectoral muscles. Operation.—All therapeutic measures having failed, after a tho- rough trial to cause a removal of the dropsical accumulation, we may discharge it either by incision with a bistoury, or puncture with a trocar. The great object in the operation is to avoid the entry of air, which might provoke irritation in the cavity of the joint, and give rise either to suppurative inflammation of the serous membrane, or even ulceration of the articular surfaces. The ope- ration is, therefore, not unattended with danger, and is only to be undertaken when the patient is not able, by the aid of a com- pressing bandage, to serve himself with the limb. The bistoury is to be preferred to the trocar, as the incision it makes is not more irritating than the puncture with the latter instrument, and allows better the discharge of the flaky pus sometimes found mixed with the serum, or of a movable cartilage, the presence of which is occasionally discerned only after the fluid has in part escaped. We should select the most depending portion of the tumour, and if possible at the same time the most prominent. If it be the knee, and seldom any other joint requires the operation, the inner portion is selected, as the limb can be so turned as to make it dependent. The skin being drawn to one side, in order to pre- vent any parallelism between the inner and outer portions of the wound, the bistoury is to be passed in perpendicularly to the surface, and the incision moderately enlarged as it is withdrawn. After the discharge of the fluid, a simple dressing is to be laid over the wound, and the limb, which is to be kept for a couple of weeks or more perfectly at rest, covered with a compress wetted with Goulard's or some other resolvent lotion. The fluid is so soon reproduced, that Boyer directs at the end of twenty-four hours to re-open the incision and discharge it anew. If the lips are merely slightly agglutinated he would separate them with a director, or with a bistoury if the union be more firm. If there is a probability of having to make several successive punctures, his direction is to keep OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 85 the passage open, by introducing through it a strip of linen or some charpie. But I have preferred in my own practice, to this constant presence of a foreign body in the cavity of the joint, an occasional oblique puncture under a valvular fold of the skin ; resorting to gentle compression after each operation, in order to overcome the tendency to a re-accumulation of the fluid. Floc- culent portions of pus or decayed membranes maybe occasionally washed out with advantage by emollient injections ; and as a sub- sequent treatment, an injection of the same sort allowed to remain in the cavity of the joint as directed by Recamier, it is said has been attended with advantage. M. Malgaigne prefers the use of the trocar, and, contrary to common experience, asserts that the puncture of the articulations is an operation perfectly innocent. He has operated, he observes^ six times in this manner for dropsy of the knee joint without the least inconvenience. He only regards it as insufficient of itself for a cure, requiring in addition the use of compression, counter- irritation, and the various other therapeutic means to effect radical relief. However, there is.always reason to fear that the paracen- tesis of a joint will be followed either by anchylosis, by suppura- tion from its cavity, by destruction of the cartilages, or caries of the bones. Weak iodine injections, after a partial removal of the fluid by tapping with an oblique puncture, shave been employed with considerable success in this affection, by M. Bonnet of Lyons and M. Velpeau. FOREIGN BODIES OR MOVABLE CARTILAGES IN THE JOINTS. Cartilaginous bodies have been observed in several of the large ginglymoidal articulations, but their most common seat by far is in the knee joint. In the latter they commonly exist singly ; sel- dom more than two or three are ever met with, though Morgagni mentions a case in which he found thirty-five; but when observed in the other joints, they are frequently found to exist in conside- rable numbers. Haller found twenty in the articulation of the jaw, and M. Malgaigne sixty in the elbow. They are variable as to form and size, and are usually smooth and polished. They seldom have the hardness of bone except at their centre, and are formed principally of soft and yielding cartilage, which is readily crushed under strong compression. They are distinguished ac- cording as they are loose or adherent, the consequence of some sprain or injury of the joint, and formed originally, as recent observations would seem to show, in the thin stratum of cellular tissue on the outer side of the synovial membrane ; they- project inwards towards the articular cavity as they increase in size, and finally are left hanging by a small pediculated portion of the invest- ing synovial tissue. The pedicle very frequently gets broken off in consequence of the cartilage becoming pinched between the surfaces of the joint. In this state the cartilages remain afterwards as a loose foreign body and give rise every now and then to symptoms which make their diagnosis easy. Their presence is usually attended by an increased amount of synovial fluid which distends the capsule of the joint. When they rest between the capsule and the sides of the bones, little or no inconvenience is felt. But when they slip between the articular faces of the bones, as they are apt to do in a false step or a quick movement of the limb, violent pain is immediately produced. The cartilage soon sliding 22 back again into its former position, the movements of the joint in the course of an hour or two become perfectly restored. Two measures of relief are resorted to in these cases,—com- pression and extraction. Compression.—This consists in moving the foreign body which may be felt from without, to some corner of the articulation, wThere it will give rise to no inconvenience, and at the same time admit of its being compressed against a resisting base. In the knee, for instance, it may be carried above the patella, or on the side of one of the condyles of the os femoris. In this position, it is to be secured by adhesive strips, and firmly compressed by a well padded knee strap or a laced bandage. By a long continuance of these measures, the foreign body has in a few instances become fixed in its new position, so as to be no longer a source of discomfort. The difficulty of retaining it in its new location, and when we suc- ceed in this, the frequent failure of the attempt to render it adher- ent, has caused'the process to be in a great measure abandoned. Extraction.—It is only in the knee as yet that the attempt has been made for the removal of these bodies. Before undertaking the operation, it is necessary by rest, and other appropriate means of treatment, to remove all pre-existing inflammation of the joint. The patient being laid on the side of the bed, with his knee supported on a pillow, the operator searches for the foreign body. This will sometimes fly from before his fingers into the cavity below the patella or into the space between the condyles, and to displace it, it is necessary to cause the patient to flex or extend his limb. Having secured it, it is to be drawn on the outer or inner side of the joint, as is most convenient, and as high up as possible on the condyle of the femur. It is to be firmly fixed with the thumb and finger, or an acupuncture needle, the assistant at the same time drawing the skin upwards and outwards, so. as to prevent any parallelism after the operation, in the wounds of the skin and capsule. An incision is then to be made in the direction of the limb, of a length in proportion to that of the body to be removed, at once down upon it, through both skin and capsule. The incision need seldom be more than from three-quarters to an inch and a half long. The continued pressure of the thumb and finger, which is not for a moment to be relaxed, brings the body upon the surface, and, if it is entirely loose, causes it to shoot out from the opening. If it hang by a pedicle, the latter is to be drawn out as far as possible, and snipped away with the scissors. If there exist several foreign bodies, they are all, if it can readily be done, to be drawn forwards and removed at the same orifice. If all cannot, however, be got away, without resorting to such manoeuvres as would surely be followed by inflammatory action, it is better to close the wound, and extract them if it become necessary, at a subsequent operation. The orifice in the skin is to be carefully closed with adhesive plaster, and the knee sur- rounded with a bandage, which is to be kept wetted with a cool- ing lotion for the purpose of preventing inflammation. The limb must be kept for two or three weeks after in a state of perfect quietude, a,nd should be sustained with a splint. It is usually recommended to place it in the state of extension, so that in case anchylosis should follow, it would be found in the most useful position. Malgaigne, however, recommends, and with some reason, moderate flexion as being less painful, and exposing less to the consecutive stiffness of the joint. In the course of twelve or fifteen S6 GENERAL OPERATIONS. days after the operation, the author has been in the habit, and he thinks with advantage, of commencing gentle and passive motion of the joint, in order to prevent that union of opposite portions of the synovial membrane, constituting one of the varieties of false anchylosis which is here most apt to occur. This is a measure, however, deserving much care on the part of the surgeon ; for it must be remembered, that the fearful consequences sometimes following these wounds of the joint do not usually show them- selves before the eighth day. To obviate the danger of this incision directly through the skin into the joint, it has been proposed by Goyrand to employ a sub- cutaneous operation. The foreign body being held fixed as above directed, a long shanked tendon knife is to be passed by a punc- ture through the skin, two or two and a half inches below the point at which the capsule is to be incised, and carried above the foreign body so as to divide on its withdrawal the capsule and the synovial membrane immediately covering it. -The. cartilage is to be squeezed out of the joint through this opening, and'lodged in the subcutaneous cellular tissue, where it may be allowed to remain, or, if preferred, extracted at a subsequent period, after time has been given for the subcutaneous cut in the membrane of the joint to close. Before the knife is made to act on the capsule it should be pressed downwards, so as to loosen the integuments, and form a bed into which the foreign body may be readily pushed. This very ingenious method has been successful in several instances in which it has been employed, and appears to the author worthy of imitation, as being less likely to produce the terrible consequences that have sometimes followed the usual method, viz., suppuration and caries of the joint, extensive ab- scesses of the thigh, and even death. ON THE BURSAL SHEATHS OF THE TENDONS. Ganglions or synovial cysts,—hydatiform cysts. The tendons of the muscles, as they play over the joints, espe- cially those of the hand and foot, are placed, as has been before observed, in fibrous canals, the inner face of which is lined by a synovial membrane, reflected, as in the manner of other double serous sacs, over the surface of the tendon. Over the wrist and ankle, the fibrous canals for the tendons are partly formed by the annular ligament of the articulation, which passes on the outer surface of the tendons. From this cause, when the synovial sheaths are largely distended with fluid, the tumours which they form often bulge up irregularly above and below the annular liga- ment ; the fluid when compressed, passing readily up and down underneath the ligament. On the palmar surface of the hand especially, the synovial sheaths are long, extending from a little distance above the wrist, with more or less interruption from trans- verse septae, to the phalanges along the flexor tendons of the fingers. On the sole of the foot, the tendons which are deeply placed are likewise surrounded by bursal sheaths, and there is much reason to believe that many obscure and intractable cases of lameness arising from contusions in this region, maybe attributed to disease of their bursal lining. Ganglions, or synovial cysts.—The consequence commonly of a sprain or contusion, but arising often, like dropsy of the joints, without obvious external cause, they form indolent fluctuating tu- mours without change of colour in the skin, along the tract of the tendons. They diminish or disappear when the tendon is relaxed, but increase when it fs put in a state of tension by the muscle, so as to interfere more or less with the movements of the joint. When they have existed for a considerable period, no topical application whatever, or compression in any way that it can be applied, is to be relied on for their cure. The indication in these cases is to destroy the integrity of the shut sac, so as to allow the fluid it contains to be poured out in the surrounding cellular tissue, from whence it will be removed by the absorbents. This may be effected sometimes by sudden and strong compression with a letter seal wrapped in linen; or, which is more likely to succeed, by a sudden blow with the closed hand, or the back of a book, the extremity (the wrist being the point in which it is most gene- rally observed), being placed on a firm support, as the surface of a table or the back of a sofa. The joint, should be subsequently kept at rest for a few days, and bathed with an evaporating lotion, in order to obviate any tendency to inflammation, which in some cases might otherwise follow. Sometimes the sac will be found so strong as to resist all such efforts. It is then to be punctured with a tendon knife, or a small bistoury, which is to be introduced according to the subcutaneous method, the skin being previously drawn to one side so as to destroy the parallelism between the wound in the skin and sac, and thus prevent the introduction of air. Sometimes a simple puncture of the sac will suffice, the synovia diffusing itself freely into the surrounding cellular tissue under gentle pressure of the finger. It is necessary, however, that the effect of this pressure should be tried before the knife is withdrawn, for sometimes the cyst is divided by partitions into separate cavities, so as to require, in order to leave no pouch unopened, a freer incision of its walls in various directions, which is to be made without enlarging the orifice of the skin, and with- out pricking the tendon or dividing the superficial veins and nerves. If, under these circumstances, the tumour does not subside, and especially if there is some effusion of blood in the cyst, it will I believe be better, for the reasons given in the next article, to make a free external opening at the place of puncture, so as to empty the contents of the sac, or to make a second punc- ture at any point of the tumour which has not subsided. The limb must be kept perfectly at rest for some time, and surrounded with a compress and bandage, and, if necessary, some cold astring- ent or evaporating lotion applied. Distension of the sheaths of the tendons about the fingers, hand and wrist, of an entirely different description, and requiring ope- ration, is sometimes met with. In the case of a gentleman of this city afflicted with granular degeneration of the kidneys, whom I attended in conjunction with Professor Dunglison, we found in addition to the general dropsical tendency, a bursal swelling or hygroma on several of the flexor tendons of the foot. . The accu- mulation of the fluid became so great as to cause much lameness and pain, and finally produced a luxation of the corresponding phalanges from the metatarsal bones. The bones-ultimately be- came fixed in nearly a vertical position, from the flexor tendons sliding over their grooves and getting on the back of the metatar- sal bones, so as to be converted into extensors. On opening the bursal sheath, the cellular and fibrous tissue on its outer surface .was found to have undergone the lardaceous degeneration, for the OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 87 removal of which caustic potash was used, with the effect, finally, of obliterating the cyst. In paronychia, we not unfrequently find the sheaths of the flexor tendons of the fingers involved, so as to become greatly distended by synovial fluid. If this affection be not treated sufficiently early by free incision, in place of the synovial fluid we may find the sheaths filled with pus, attended with great aggravation of the accompanying symptoms. The sheaths of these tendons are com- monly, though not always, separated by transverse septa from the synovial covering of the same tendons in the palm and wrist. Where the septa either do not naturally exist, or have been broken down, we find in extreme cases the same collection of serous or purulent fluid forming tumours in the hand and wrist, and requir- ing to be freely opened. In such instances, it becomes necessary, after the operation, to keep the fingers extended for a considerable period on a splint, in order to prevent the muscular fibres, which become influenced by the disease, from retaining them permanently flexed. There is, however, always a risk of such a result after these operations, of which the patient should be apprised. In a case that I attended in consultation with Dr. Spackman, of this city, in which a poisoned wound on the ball of the thumb had been followed with immense swelling of the hand, suppuration in the theca of its long flexor tendon, and an extensive abscess deep in the palm of the hand, I was enabled to effect a cure without deformity, by laying open the sheath of the tendon on the thumb, and passing a curved probe-pointed bistoury along the tendon up into the palm ; the incision of some resisting fibres with the bistoury at the end of the track, allowed the pus from the palm to gUsh out through the external opening. Hydatiform cysts,—synovial cysts enclosing a number of small white bodies.—In many instances on the back of the wrist and ankle, and on the palmar surface of the fingers, but more espe- cially in the former position, the synovial cysts, which have already been described, are found to contain a great number of small white semi-transparent bodies, of a shape that is very varia- ble, but frequently resembling that of a small bean. In two cases of this kind for which I have operated, (in both of which the swell- ing was on the back of the carpus,) I discharged by incision in one over a hundred, and in the other a still greater number of these bodies; some of these were three-eighths of ah inch in length, and others, so small as hardly to be separately distinguished, were matted together in a heap. Double this number have frequently been met with. Mr. Ferguson speaks of having removed several hundred from an oblong swelling of the sheath of one of the flexor tendons of the finger. The mode of development of these bodies, and of similar ones found in the bursae mucosae, is believed in a great degree analogous to those of the joints. It has been assigned to the effusion of lymph, ultimately converted into a semi-cartilagi- nous state, like the productions found on the pleura and arachnoid. But the opinion of Velpeau, that they arise from effused blood, is certainly in a great many instances that which may be considered the true one. I have known ganglions on the wrist previously free of these bodies, present the evidence of their existence in great numbers after a severe accidental contusion of the part, or an unsuccessful attempt to cure them by incision, which had left the cavity around the tendon filled with blood. It has been supposed that the blood by coagulating in the cavity, and becom- ing divided into many portions by the friction of the tendons, gets macerated in the serum so as to lose its colour, and in the state of fibrin either by becoming attached to the membrane, or simply floating in the serum, takes on an obscure sort of growth. This, however, is but an hypothesis, though a plausible one. Dupuy- tren believed them hydatid cysts, capable of motion; but in this opinion he was unquestionably mistaken. Cysts on the back of the wrist or ankle containing these bodies usually belong to the class of double tumours already noticed, one of which is found above and one below the annular ligament, under which they communicate together. By alternate pressure on these tumours we displace the fluid and the bodies floating in it; this gives a sensation of something slipping, with an indistinct sense of crepi- tation, forming the diagnostic mark of the existence of these little cartilages. The only method of effecting a radical cure in these cases consists in opening the cysts, discharging the cartilages, and causing the obliteration of the cavity. The extirpation of the cyst, from the manner in which it is connected round the tendons, would be an operation as difficult as it might be dangerous. The usual method of proceeding is to open the cyst above and below the annular ligament by an incision parallel with the tendons, and after emptying it, introduce into the cavity a mesh of charpie or a piece of linen, which is to be removed at the end of the second day, so as to cause it to suppurate and close by granulation. But this plan I have found liable to be followed by greater or less stiffness about the joint, and in more than one instance reported, it has been attended by such extensive sub-aponeurotic inflamma- tion of the hand and fore arm, as to cause death. In the two cases referred to On the last page, I made an incision under the skin, (obliquely, in order to avoid the introduction of air,) through which I forced the bodies by gentle effort; the surfaces of the cyst were then compressed together, with a view of obliterating them, with a stout leathern splint buckled tightly round the wrist. In one of the cases, success was immediate ; in the other, there was a re-deve- lopment of the cartilages, requiring a second and third operation, leaving in the end a fibrous knot upon one of the tendons. Du- puytren passed a seton through the cavity, but was compelled to abandon the practice, in consequence of the excessive inflamma* tion it produced. HYGROMA.-ENLARGED BURS^3 MUCOSA. Dropsy of the Bursa. From causes analogous to those above mentioned in reference to the other synovial tumours, but especially from contusion, do we have a dropsical accumulation of the synovial fluid in the bursa?. It may occur in any of the numerous bursal sacs, but those of the knee and elbow are the only ones in general which require any operation beyond that of simple puncture for the removal of the fluid. The former is found between the skin and the ligament of the patella—the latter between the olecranon process and the skin, and is much less frequently the subject of disease. In both instances a prominent, obscurely fluctuating tumour is observed, often from the effect of pressure accompanied with a slight change of colour in the skin. Sometimes the tumour consists of a single cyst; but more often, according to my own experience, especially in hygroma of the knee, (housemaid's knee,) of a series of cells in 88 GENERAL OPERATIONS. the interior of a common cyst, filled with a fluid so viscous and gelatinous as to render its discharge by puncture slow and difficult. Treatment.—The principle of cure consists not only in remov- ing the secretion, but in obliterating the sac, so as to prevent effectually the reproduction of the tumour. Puncture and injection.—A simple puncture will seldom suf- fice for a cure. I succeeded completely, five years ago, in the case of a Methodist preacher, in effectually curing a tumour of this description below the knee, by puncturing the sac, lacerating the enclosed cells with the point of the knife, pressing out the glairy fluid, and injecting into the cavity tinct. iodi. diluted with four parts of water. Pressure was also applied subsequently by the aid of a compress and bandage. This plan of treatment, which is on the same principle as the modern practice in hydro- cele, has lately been employed to a considerable extent by M. Velpeau, and is one deserving of much confidence. By the seton.—It is the custom among some practitioners, when the tumour has become troublesome from its size, as well as sore from continued pressure, to puncture it and introduce a seton through the cavity of the sac. A cure may unquestionably-thus be accomplished, but it is usually tardy, painful, and attended by profuse suppuration. By shaving off the anterior wall.—M. Masnier* has advised, in these and all other encysted tumours, to shave off' the anterior half of the sac, after having previously opened and dissected off the skin; or, if the tumour be small and prominent, shaving off with the point of the sac the corresponding portion of integument. But this is not a method which has received the sanction of gene- ral use. By ablation.—The tumour has in some instances been com- pletely dissected out. This is an effectual means of cure and in many instances the most advisable; but where the tumour is large, and the walls, as is commonly the case, firmly adherent on their outer surface, the proximity of important parts renders it a proceeding accompanied with some danger. Velpeau reports two cases of death following this method of operation. Sometimes, from habitual pressure on the surface, suppuration takes place spon- taneously in the cavity of the sac; the abscess thus formed opens by ulceration, and is commonly followed by a cure. Foreign bodies of the same semi-cartilaginous character as those above described are occasionally met'with in the bursa?, and require a similar method of treatment. ANCHYLOSIS. There are two forms of anchylosis of the joints. 1. That which is called true or complete, resulting from causes that have acted on the interior, of the joint; such as fractures running into the articular cavity, extensive wounds of the joint, abscesses, erosion of the cartilages or ends of the bones, either of which may pro- duce such an ossific union of the articular surfaces, as to prevent all motion between them. 2. That which is called false or in- complete, where the abnormal junction between the ends of the bones, instead of being ossific is ligamentous; or is the result of the adventitious attachment of portions of the synovial membrane of the contraction of the muscles or ligaments or cellular tissue • Theses de la Faculie de Paris, 1803. round the joint, or of extensive cicatrices following burns and ulcers. In fact, the remote causes which may give rise to false anchylosis are exceedingly numerous; but our object at present is to consider the first variety, which, though far less frequently met with, becomes more directly the subject for consideration in this place, where we are treating of the operations upon the bones themselves.* Each of the joints may be affected with anchylosis ; but in those of the hinge-like form, as the knee, elbow, ankle, and jaw, it is most frequently observed. The diagnosis between these two forms of the affection is gene- rally though not always easy, and is of the first importance as re- gards the treatment. In true anchylosis, the joint is solid, perfectly immovable, and all the attempts to produce motion are unattended with pain; and not unfrequently we are enabled to feel through the integuments the uneven surface of the callus which has united the articular faces of the bones. In false anchylosis, on the con- trary, there is in most cases some degree of mobility between the ends of the bones. Occasionally, however, the stiffness and rigidity of the.surrounding parts are so great even where there is no bony union, as to render the joint perfectly inflexible. But here from the previous history of the case, especially if the affec- tion has had its origin exterior to the cavity of the joint, and from the fact that in false anchylosis the joint usually becomes swollen and painful after active efforts have been made in order to pro- duce motion, we are enabled to decide with a great degree of pre- cision in regard to the actual state of the articulation. There are three methods of remedying the inconveniences re- sulting from the solidification of the joint, which constitutes true anchylosis. 1. To re-establish the movements of the joint, by rupturing the adventitious junction between the bones. 2. To establish a new point of motion by the creation of a false joint. 3. To place the limb in a new position by taking out a wedge- shaped portion of bone, when it is anchylosed in a direction that renders it inconvenient or useless. Rupture of the anchylosis.—No surgeon of experience can have failed to observe cases where an anchylosed knee, elbow, wrist or finger, has had its movements restored to a greater or less degree by an accidental rupture of the new bond of union, the con- sequence of a fall, or some external violence. The results in these cases, where in all probability the bony union has been but very partial, such, for instance, as the adhesion of the sides of the patella to the condyles of the os femoris, have led surgeons to imitate the process, by producing a forced rupture of the uniting medium between the ends of the bones. The consequences of these attempts, have not, however, been such as to sanction the adoption, especially as regards the large joints, of a highly dan- gerous experimental operation, for a mere deformity, which does not in itself compromise life. M. Louvrier lost five patients out of twenty-one by this process for straightening bent and anchy- losed knee-joints, and in some of those that survived, the violence employed was followed by excessive inflammation of the sur- rounding parts, luxation of the knee backward, and a secondary anchylosis at an angle more or less obtuse. He has, however, in * The surgical treatment of false anchylosis will be considered under the head of Subcutaneous Operations. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 89 some cases, obtained complete success by rupturing the attach- ments; and instances no doubt may be occasionally found where the union of the bones is so partial, as to justify the attempt. It will be difficult, however, to determine beforehand the cases in which it may be employed with impunity from those where its application would be highly dangerous or fatal. The stretching apparatus of Louvrier is thus arranged :—A linen roller bandage is first fastened tightly around the knee, in order to prevent by its pressure any resistance from the contraction of the muscles, and should embrace both the lower part of the thigh and the upper part of the leg. The inequalities of the surface of the latter are to be filled up with cotton wadding, which is to be sustained by another bandage rolled over it, so as to give the leg the shape of a cone, the basis of which is at the knee. The an- terior and posterior surface of the thigh and leg are then covered with hollow splints of strong leather, (which should be fastened with straps,) in order to protect the soft parts against the pressure of the apparatus. The foot is then covered with a woolen stock- ing and a leather half boot, secured in like manner to the leg by straps. On the inner surface of the heel of this boot is a strong screw with a perforated head. These preparations completed, the patient is placed upon a table, with a pillow for his seat, and with his back leaning against the wall. The diseased extremity is now to be placed in the apparatus. This consists of an oblong box, from which the cover and end pieces have been removed, provided at its foot end with a horizontal beam, turned by a crank on its outside. Around this beam is wound a strong cord, of the thickness of a quill, one end of which is fastened to the screw in the heel of the boot. A very wide leather splint, reaching from the middle of the thigh down to the middle of the leg, is then placed on the posterior surface, so as to surround about two-thirds of the circumference of the extremity. This splint is composed of two pieces, with a circular joint at each condyle, so as to allow the lower part to follow the movements of the leg. Four iron bars, rising perpendicularly from the four corners of the joint, support a metal frame, below which is attached a leathern bolster, to be applied upon the anterior surface of the knee. Through this plate and bolster, the downward pressure upon the knee is made, by means of a cord that runs from the metal frame and turns round a pully to the beam, around which it is tightened by turn- ing the crank. The leg, as it lies on the box, forms with the bottom of the latter a hollow triangle, the apex of which is in the bam. It is now the object of the surgeon to press down the knee, until its posterior surface touches the bottom of the box. This is accomplished by turning the crank of the machine so as to tighten the cords; one of which pulls out the foot and stretches the leg, and the other, by means of the frame and bolster, effects a powerful downward pressure on the knee. In about thirty seconds, the operation is usually completed. The pain during this time is excessive, and is compared by the patient to that caused by the extraction of a tooth, but soon ceases on the removal of the appa- ratus, which is to be taken away immediately after the operation. At the last step of the process, a crackling sound is heard, which denotes the forcible separation of the parts. If the rupture of the anchylosis has been complete, the leg may be moved freely and without pain. The patient is then placed for two hours in a warm bath; and the parts are entirely freed from all local pres- 23 sure. The day following, narcotic poultices are applied about the knee, and a simple support given to the limb, in order to prevent the involuntary contraction of the muscles. 2. Formation of an artificial joint.—This method, for which we are indebted to the ingenuity of Dr. John Rhea Barton, of this city, has been applied as yet but to the anchylosis of a single articu- lation—that of the hip joint. It has, however, been suggested by this skilful surgeon, that it might likewise be found applicable to similar affections of the lower jaw, knee, elbow, fingers, and toes, when the muscles of these respective articulations remain uninjured. The method consists in the uncovering of the bone at or near the diseased point, dividing it across with the saw, and subsequently moving the lower portion from time to time upon the upper, to prevent a solid reunion of the divided parts. By this mode of proceeding, there is the same disposition of parts for the formation of a false joint, as we often find leading to that result in fractures, where the bones are not kept sufficiently at rest. Under such circumstances, the two opposing surfaces of bone may be expected to unite by flexible ligamentous matter, or be- come smooth and polished by the friction: the lower fragment, in the latter case, rounding itself into the form of a head; and the upper hollowing itself more or less into the shape of a cup, in which the lower fragment plays; the periosteum and surrounding cellular tissue becoming condensed and thickened, so as to per- form the office of a fibrous capsule, and the muscles modified to a certain extent, to accommodate themselves to the new articula- tion. For anchylosis of the hip. (Process of Barton, PL XXII, fig. 3.)—The ingenious idea of remedying this deformity by the estab- lishment of an artificial joint, was practised by Dr. Barton, in 1826. A similar operation was repeated four years subsequently by Dr. J. Kearny Rogers, of New York; the two constituting the only instances in which it has yet been attempted on the living subject. The patient of Dr. Barton was a young man twenty- one years of age, in whom the thigh was held immovably bent at a right angle with the pelvis, and the foot turned in rotation in- wards. A crucial incision was made over the projecting portion of the trochanter major, the vertical division of w-hich w-as seven inches in length, and the-transverse five. The four laminae thus formed were dissected and turned back, and the fascia freely opened. The muscular fibres were then detached from over the trochanter by turning the scalpel sideways, so as to allow the two index fingers to be passed freely round the neck of the femur, till they met on the opposite side. With a strong straight saw the bone was then nearly divided through the upper part of the great trochanter and part of the neck of the bone. The operation lasted but seven minutes, and no artery was opened that required to be tied. The limb was then drawn to its proper position, when the undivided portion of the bone separated with a snap. The wound was closed with a few points of suture, and the extremity secured in the fracture apparatus of Desault.* On the twentieth day after the operation the inflammatory symp- toms had in a great measure subsided ; some slight passive move- ments were then made with the limb, in directions natural to the healthy joint, which were cautiously repeated from time to time. * North Amer. Med. and Surg. Journal, April, 1827. 90 GENERAL OPERATIONS. By the sixtieth day the wound was completely healed; the patient was able to stand erect with the aid of crutches, and could advance bis limb exclusively by muscular exertion. At the end of four months he was able to walk without apparent lameness, and all the movements of the limb were executed without pain. The foot could be carried twenty-two inches forward, twenty-six back- wards, and twenty outwards, and could be rotated inwards to the extent of six. The patient enjoyed the use of his artificial' joint for a period of six years, at the end of which time, from causes attributable to intemperance and repeated falls upon the hip, the new joint became permanently anchylosed. The operation of Dr. Rogers was equally successful, and his patient left the hospital at the end of four months, apparently with a perfect use of the new joint, as he could walk with ease by the assistance of a cane. The new joint, however, in the end became anchylosed in this case, as in that of Dr. Barton. In conse- quence of the shortening of the limb of the opposite side from fracture, Dr. Rogers, instead of making a simple section, re- moved a wedge-shaped portion of the bone, in order to render the relative length of the two limbs more equal. In place of dividing the bone after section of the soft parts, as above described, it has been proposed, by M. Louvrier, to produce directly by mechanical means a fracture of the neck of the thigh bone, a measure which he believes less dangerous than the former, and affording equal facilities for the formation of a false joint. But provided it were possible to succeed in fracturing the bone at the desired point, there would be such danger by this method of doing violence to the surrounding parts, that it can offer no proba- PLATE XXL—OPERATIONS UPON THE BONES, (Fig. 1.) RESECTION OF THE ENDS OF THE FRAGMENTS IN UNUNITED FRACTURE OF THE OS HUMERI. (Process of the Author.) The operation is represented on the left arm, which is raised at the shoulder joint and depressed at the elbow, so as to cause the bones to^protrude at the wound. The limb is seen on its outer face. The incision has been made in the intermuscular space between the brachialis anticus and the triceps muscles, just below the insertion of the deltoid. The parts are slightly dissected, so as to render the anatomy clearer than it would appear during the operation. In other respects the operation is precisely the same as one performed by the author for false joint at this part of the arm. a. Insertion of the deltoid muscle, which is exposed along the inner border of the incision. b. Outer edge of the brachialis anticus. c. Triceps extensor cubiti muscle, the fibres of which have been divided across at the upper part of the wound, to give a better view of the false joint. d. Lower end of the upper fragment of the bone, which has been turned partly out of the wound, after the section of the ligamentous matter which had connected the ends of the two fragments together. e. Upper end of the lower fragment. The ligamentous matter is represented as removed from the end of the bone, showing that it is covered with a compact lamina like the extremity of a bone after amputation. /. Musculo-spiral nerve, winding very obliquely in its groove round the outer face of the bone ; it is, unless great care is exercised, liable to be cut in the operation. g, h. Musculo-spiral artery and vein. i. A long narrow compress, used to raise the end of the bone and protect the soft parts below from the action of the saw or forceps, with which the rounded end is to be excised. (Fig. 2.) INTRODUCTION OF THE SETON, FOR UNUNITED FRACTURE OF THE TIBIA. In this case two incisions have been made on opposite surfaces of the bone, (which is supposed to have been obliquely fractured,) in the manner of Wardrop, and the seton has been carried through, after a perforation had been made with a trephine needle through the overlapping ends of the fragments. In the arm, or wherever the bones can be separated so as to obtain room, the common seton needle may be passed at once without previous (Fig. 3 and 4.) REMOVAL OF A LOOSENED AND NECROSED WALLS OF THE CRANIUM. PORTION OF BONE FROM THE An incision in the shape of a f has been made, and the two angular flaps dissected up and reversed. The point of an elevator is seen insinuated under the edge of the dead bone, in order to raise it up and slide it outwards, so that it can be seized with the forceps and removed. Fig. 4 is the piece of bone shown separate. It is rough and serrated on the edges from the action of the absorbents which have detached it from the livino- tissue. Plate Z/. /"'/// i> Stone by S Ctchuwski Philsrdrl/u/ria. Published by Carey .i Karl l' S Duvut. 1.,/A Ph,l OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 91 ble advantages to cause it to be compared with the neat and methodical section of the bone according to the plan of Dr. Barton. It would be rather more easy to divide the femur below the tro- chanter, but by this measure an all-important object would be lost—that of obtaining a new and solid articulation upon the pelvic bones, so as to re-establish the functions of the limb with the least possible shortening. 3. Removal of a wedge-shaped portion of bone, for straightening a bent and anchylosed knee joint. (Process of Barton, PL XXI. fig. 6.)—In bony anchylosis of the knee joint, when there is so much angular deformity as to render the leg a mere incumbrance to the patient, it was not till recently that any measure of relief had been proposed, save that of amputation. To Dr. John Rhea Barton* we are indebted for the introduction of a new pro- cess for the relief of this deformity, which in 1835 was success- fully employed by him in the case of a young physician from the south. The process is as follows:—the object being to expose a portion of the anterior surface of the os femoris just above the condyles, and as low down as within half an inch of the patella, which will be found firmly adherent on the face of the joint. Two incisions are to be made across the femur, just above the patella; one commencing at a point opposite the upper end of the internal condyle, and the other two and a half inches higher and on the same side; both are to be extended over the bone till they meet on the opposite side, forming a soft of tongue-shaped trian- gular flap. This flap, consisting of the integuments, the tendon of the extensor muscles of the leg at its place of insertion, some of the fibres of the rectus and cruralis muscles, and a greater part of the vastus externus, is to be dissected up, with the fascia and muscles, from the sides and front of the bone, and turned over upon the leg. This flap in some instances will be found stiff and * Vide Atner. Journ. Med. Sciences for 1838. resisting, in consequence of the deposit of new bony matter in the sub-aponeurotic cellular tissue. The soft parts are next to be detached at the outer side of the femur, from the base of the flap towards the ham, bypassing a knife over the circumference of the bone, so as to admit the use of the saw. A wedge-shaped piece is then to be removed from the spongy tissue of the head of the femur, by two sections with a saw, sloped so as to meet within a few lines of the posterior face of the bone, but not so as to divide it entirely across, for fear of injuring the vessels in the ham. The base of the wedge on the front part of the thigh must have a width proportioned to the degree of deformity that is to be remedied— say from two to two and a half inches. The leg is then to be pressed backwards, so as to cause a rupture of the undivided portion of the bone without disconnecting the fragments. No blood-vessel is likely to be wounded that will require a ligature. The wound is to be lightly dressed, and the limb supported on a splint having an angle corresponding to that of the knee previous to the operation. When sufficient time has been allowed for the asperities of the ruptured fibres on the back portion of the bone to become smoothed by softening and absorption, so that the pres- sure backwards cannot cause ulceration of the artery, the limb is to be somewhat straightened by substituting for the first splint an- other with an angle less obtuse. By thus varying every fewr days the angle of the splint, the limb is brought by degrees into a posi- tion nearly straight. To protect the popliteal vessels from all chance of pressure, two long bran bags are laid lengthwise on the splint, with a vacancy of four or five inches between them, (which is to be filled with carded cotton,) opposite the lesion of the bone. Protracted suppuration and constitutional irritation, such as are attendant on compound fractures, (to which the wound of the operation may be compared,) must necessarily be expected to follow, and during the treatment particular care should be ob- (Fig. 5.) EXTRACTION OF A SEQUESTRUM, OR NECROSED PIECE OF THE CLAVICLE. A quadrilateral flap has been turned down from over the bone. The shell of new bone, or involucrum, has been opened with the cutting pliers, so as to allow the loosened sequestrum to be grasped with the forceps and withdrawn. (Fig. 6, 7 and 8.) REMOVAL OF A WEDGE-SHAPED PIECE OF BONE FOR TRUE ANCHYLOSIS OF THE KNEE JOINT. (Process of Barton.) a. Patella, adhering to the face of the condyles. b. Tendon of the extensor muscles, cut off near its insertion on the patella. c. Lower end of the femur; the two black lines crossing the bone meet together a little short of the posterior surface of the bone, and indicate the two tracks of the saw by which the wedge-shaped piece is removed. d. The tongue-shaped flap of integument, muscle, and tendon, raised by two semi-oval incisions, and reverted on the inner side of the knee. Fig. 7 is a sketch illustrating the manner in which the limb is made straight, by gradually bringing up the leg, so as to throw the knee upwards till it effaces the space made by the removal of the wedge-shaped portion. a. Femur. b. External condyle. c. Adherent patella. d. Head of the tibia. e. Fibula. Fig. 8 represents the limb in its state of angular deformity. g. Is the outline of the wedge of bone removed. The other references correspond to the same parts as in fig. 7. 92 served, that in straightening the limb the lower fragment be not allowed to slide backwards, so as to shorten the leg, and render it nearly impossible to give the extremity the requisite degree of straightness. Four months after the operation, the patient of Dr. Barton was able to stand erect, with his feet in their natural position; at the end of eight, he could mount his horse with facility and walk with ease, notwithstanding the loss of motion at the knee, from forty to fifty miles a day. The same procedure has been repeated by Professor Gibson on a patient in the Philadelphia Hospital; this, and the former case, constitute the only instances, within my knowledge, for which this truly valuable American method for the treatment of anchylosis has yet been employed. In fifty-six days after the operation in the second case, there was firm union at the place of section; and though the thigh was shortened about an inch, the limb was ncarlv straight, and the patient could sustain himself upon it with ease. COMPLICATED FRACTURES AND LUXATIONS. Occasionally, these affections call for the performance of some specific operation. 1. I?i extensive laceration of the flesh and skin, with projection of the bone, occurring either in comminuted fractures, or compound fractures and luxations. In such cases, if the projecting fragment or the head of a protruding bone cannot be easily reduced, the wound should be enlarged by an incision, and a subsequent effort made to replace it. If this fail, the end of the bone is to be cut off with a saw, or a pair of strong-cutting forceps. The bones are then to be adjusted, and the wound treated so as to reduce it as much as possible to the state of simple fracture. 2. Where the fracture is attended with the separation of splinters or scales from the bone.—If the fragments are completely or nearly loosened from the bone and driven off into the soft parts, so as to be readily observed from without, an operation is required for their removal. An incision should be made opposite the irritating body, at the point where the bone is most superficial, selecting the intermuscular spaces when it is possible, and avoiding the side upon which the great vessels are located. The fragments are then to be removed with the forceps. Sometimes the splinters or scales are firmly attached to the periosteum by one end, while the other is lodged in the muscles, and will require to be loosened with the knife before they can be twisted out with the forceps. Sim- ple fissures or splintering of the bone, without displacement of parts, call for no operation, as they readily become consolidated by the subsequent effusion of callus, under the ordinary plan of treatment for fracture. 3. Where there is laceration of the vessels and nerves.—When the vessels are lacerated, the different means of arresting hemor- rhage suited to the peculiarities of each case, already noticed, have to be put in requisition. If the branches of the nerves be partially torn and exposed, they should be divided completely across with the bistoury. But extensive injuries of this description indicate the necessity of immediate amputation, a subject which will be hereafter considered. GENERAL OPERATIONS. PSEUDOARTHROSIS.—FALSE JOINT.—UNUNITED FRACTURE. Varieties.—Fractures in which no bony union has taken place, may from the facts revealed by dissection, with propriety be di- vided into three classes. 1. Those in which the ends of the frag- ments, rounded and thinned by the action of the absorbents, are connected by an intermediate fibro-ligamentous tissue. This con- stitutes by far the largest class. 2. Where the end of one of the fragments has become rounded into a head, and the other con- verted by the constant motion of the parts, and the thickening and condensation of the surrounding tissues, into a cup or socket; both portions being surrounded by an adventitious capsular mem- brane, and lined by a new-formed synovial tissue. 3. Where the fragments have not been brought into opposition, but are kept separate by a portion of muscle, or a detached or necrosed piece of bone. Causes.—The cause of the non-union in regard to the third variety, is sufficiently obvious. In respect to the first and second, it depends upon a number of circumstances very different in their character; and in some cases the accident occurs in despite of the most judicious treatment, and where no apparent cause can be assigned for the want of bony union. Among the most common causes, may be placed a mal-adjustment of the ends of the bones, imperfect support from the splints or other dressings applied, in- docility on the part of the patient in keeping the limb at rest, meddlesome interference of the surgeon by too frequently chang- ing the dressings without cause when they have once been properly adjusted, some morbid alteration of the bone, as that of caries or necrosis, the development of hydatids in its cavity, advanced age, or an impaired or exhausted state of the constitution. Sometimes, even after the bony matter has been deposited so as to unite the bones, it has been removed by absorption, leaving only a flexible cartilaginous bond of union. Remarks.—The period within which we may expect a perfect consolidation of a broken bone to take place by the usual method of treatment, varies so much in regard to different individuals, as to be scarcely subject to any general rule. Nevertheless, we may ordinarily consider that a false joint has been formed, when, after the lapse of six months from the occurrence of the fracture, the fragments still remain movable at the point of injury. False articulations have been observed in most of the bones; but they are more frequently met with in those which are most movable, as the humerus and the lower jaw. In fracture of the neck of the thigh bone within the capsule, where bony union in general is not to be expected, a false joint near the former centre of motion may be viewed as the best result that can follow. In most other instances, the integrity of the bone, by which it serves as a lever for the muscles to act with, is destroyed ; and the limb to which it belongs (if it occur on an extremity), becomes nearly- useless. But cases may occur, as rare exceptions to the general rule, especially where two bones are associated in nearly similar offices, as in the forearm and leg, in which an attempt on the part of the surgeon to solidify the false joint would be most injudi- cious. One of this description occurred in my service two winters ago at the Philadelphia Hospital. A man from the west had received in a fall a shock on the forearm, which dislocated the radius and carried it upwards on the humerus, and at the same time produced a fracture of the ulna about two inches and OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 93 a half below the joint, with considerable angular displacement; the lower fragment being brought up in close contact with the radius. No attempt at reduction was made; the limb in its deformed condition being merely put up in splints. The conse- quence was that bony union took place between the ulna and radius at the point where they come in contact, and a false ball and socket joint formed between the broken ends of the ulna. In flexion and extension, both bones moved together as far as they were permitted by the end of the radius resting on the humerus. In pronation and supination, which was very well performed, the radius and lower fragment of the ulna moved together, the latter rotating in the new formed articulation. Under such cir- cumstances, the solidification of the false joint would have im- paired to a great extent the utility of the limb; and the result here accidentally produced indicates the propriety of attempting to effect some analogous artificial means of relief in certain states of deformity and loss of use of the forearm, that occasionally arise from ill-treated fractures. Treatment.—The general as well as the local measures of treat- ment, must vary according to the causes which have led to the defect. 1. Of the local measures.—It is here only necessary to note briefly the more important of the multitude that have been de- vised. No one of these in all cases being entirely sufficient to accomplish the object desired, it becomes advantageous to com- bine them, or try them in succession, according to the degree of action which they are capable Of exciting in each case. 2. Friction of the ends of the bones.—This process, which is as old as the time of Celsus, consists in rubbing forcibly together the two fragments in order to excite a degree of inflammatory action that may lead to the deposit of earthy matter in the new tissue. This procedure is only applicable where the ends of the bones do not overlap, when there has been a mere transverse fracture, and when it is attempted at so early a period,—say six, eight to ten weeks after the injury,—that the false joint cannot be considered as fairly formed. The limb is then to be done up in splints, or what answers admirably well, the immovable appa- ratus prepared with dextrine or starch, and kept perfectly at rest for two or three weeks. After this period it is to be re-examined, and the measure, if it has been at all successful, repeated as before. If not, some of the succeeding processes are to be applied. Compression.—A method somewhat analogous to the above was introduced by White, and has been occasionally found very advantageous. It consists in applying round the fractured limb a strong support,—such as that of an envelop of stout leather, well padded, and firmly secured with straps and buckles,—the patient to use the limb as much as possible, and if it be the lower extremity, even to move about upon it. As soon as a sufficient degree of action is provoked at the place of injury, as manifested by soreness and swelling, the limb is to be kept completely at rest, as directed after friction of the ends. Simple compression of the ends of the bones together, by the fracture apparatus, while the limb was kept at rest, has succeeded in two cases in my hands, as late as the third and fourth months after the reception of the injury. 3. Cutaneous irritants.—The application of blisters frequently renewed, of caustic potash, tinct. iodine, and analogous substances 24 immediately over the point of fracture, has been much praised by Wardrop and others. It may be considered a useful process where the work of ossification proceeds slowly, and the bones lie superficial, as in the forearm and leg; but according to my own observation, has little effect, even in these cases, if not em- ployed within six or eight weeks after the injury. 4. Seton. (Process of Physick. PL XXI. fig. 2.)—The use of the seton, for which we are indebted to the practical wisdom of the late Dr. Physick, is a measure which may be relied on with considerable certainty for the cure of false joint in the jaw and upper extremity. In the lower extremity, the results of its employment have not been equally successful. Extension and counter-extension having been made upon the limb, so as to cause a separation of the fragments, Dr. Physick passed the ordinary seton needle through the limb, traversing the interval between the bones—cautiously avoiding the track of the principal blood- vessels and nerves, and selecting the points at which the bone was least covered with flesh. A stout cord or a skein of silk, which has been previously attached to the eye of the needle, is then to be drawn through after the instrument. The wound is to be simply dressed, and the limb, after suppuration is estab- lished, placed in an appropriate fracture apparatus. The seton is then to be daily moved in the wound, and retained even for a year or more, if so long a time be required for the limb to become sufficiently stiffened by the deposition of callus to admit of its executing its usual movements. If the necessary degree of irri- tation is not maintained by the simple seton, it may be smeared from time to time with some stimulating ointment. The first case of Dr. Physick was an ununited fracture of the humerus. At the end of twelve weeks the consolidation began, and at the termination of five months and a half, the cure was complete. Professor Horner, of this city, has employed the sail- maker's needle in place of the ordinary instrument for carrying the seton. This is less liable to divide important parts, and I have found it to answer well, particularly in fracture of the lower jaw. In the latter affection, it should be carried from the cavity of the mouth, downwards and outwards, through the integuments covering the base of the jaw. Modification of Wardrop.—This gentleman has proposed to modify the method of introducing the seton where the bone is deeply seated, as in the upper third of the thigh, by previously dividing with a bistoury the soft parts over it, and introducing the needle inclosed in a sheath down to the bottom of the wound, when it is to be passed through as in the process of Physick. Modification of Oppenheim.—This consists in the introduction of two setons, so that one shall come in contact with each of the ends of the bones. Both may be introduced at the same time, or the second a few days after the first. When suppuration is fully established they are to be withdrawn. By such means, this sur- geon believes a sufficient degree of inflammation will be exeited to insure a bony union without incurring the same risk of erysipe- las and abscess, w-hich have in some cases carried off the patient, when the seton has been maintained a long time in the wound. He does not consider it absolutely necessary that the seton should traverse the tissue between the bones, the same advantageous effects being produced when they are placed merely in proximity or contact with the periosteal covering of the ends of the bones. 94 GENERAL OPERATIONS. The value of this opinion has not perhaps been as yet sufficiently attested in practice. In some instances, it is found exceedingly difficult, if not im- possible, to pass the seton, either in consequence of the obliquity or overlapping of the fragments, or from the risk of injury of important parts ; and under such circumstances, Professor Fergu- son observes, he has seen a needle or probe left sticking in the fissure between the bones, followed by all the benefit that could have been expected if a cord had been carried through in the usual manner. In those cases where the fragments are held asunder by a necrosed portion of bone or a piece of muscle, the use of the seton would probably be attended with no benefit. SommVs modification. Section of the fibro-ligamentous union by means of a wire.—In an ununited fracture of the femur, this surgeon pierced the limb from within outwards, with a long delicate trocar, grazing the inner surface of the end of the lower and the front portion of the upper fragment. The stilet was with- drawn and a silver wire passed through the canula, and left in the wound, after the canula was taken away. A second puncture was made with the trocar, but in the opposite direction, from without inwards and forwards, and brought out at the place of the first puncture. The end of the wire, which had previously passed through the limbj was again carried through the canula; this instrument was then drawn through at the inner side of the limb and removed. The loop of the ligature thus surrounded the false joint, including the bridge of muscle and skin between the two posterior punctures, which was divided across with the bistoury to let the wire down to the bones; the lips of the incision were then brought together so as to unite by first intention. By gradually tightening from time to time the loop which embraced the liga- mentous tissue, this was by degrees divided, and an effusion of callus followed, consolidaling the fracture at the end of six weeks, so far as to justify the removal of the wire. Tbree months after the operation, the patient was able to walk. 5\ Acupuncturation.—M. Malgaigne has suggested, in place of the seton, to introduce a number of acupuncture needles through the fibrous tissue between the ends of the bones. The trials which have been made of this process do not, however, prove it to have been very efficacious. 6. Cauterization of the ends of the bones. (Process of Green.) —An incision through the soft parts having been made so as to expose the ends of the fragments, the fibrous tissue uniting them is to be divided with the knife, and each end rubbed with a cylin- der of caustic potash, till it becomes of a black hue. Especial care must be taken to protect the surroundingparts from the action of the caustic, which is to be applied in the depth and without turning out the bones through the wound. Earl has advised, in order to render the process more efficient, to previously scrape off the fibro-cartilaginous, or fibro-ligamentous covering of the ends of the bones, and apply the caustic directly upon the osseous tis- sue. Some operators have satisfied themselves with merely cut- ting down and scraping the ends of the bone. Numerous in- stances of the successful application of the caustic are recorded. The process is not, however, unattended with danger, as the frac- ture is rendered compound by the incision through the soft parts ; and though rather less likely to produce severe constitutional PLATE XXIL—OPERATIONS ON THE BONES. (Fig. 1.) REMOVAL OF AN EXOSTOSIS, OF THE EBURNATED SOLID KIND, FROM OVER THE LAMBDOIDAL SUTURE. The tumour was of a globular form, and projected for about an inch above the bone. It was divided vertically in two lines by the saw, so as to render its removal with Hey's saw more easy in three separate portions. One portion has been removed, and the saw is shown in the act of dividing the middle part. (Fig. 2.) REMOVAL OF A TUMOUR OF THE SAME DESCRIPTION FROM THE UPPER THIRD OF THE HUMERUS. a. A triangular flap of the whole thickness of the deltoid has been raised between two incisions which run down parallel with the fibres of the muscles. The flap is reverted toward the shoulder so as to expose the diseased surface of the humerus. b. A wooden ruler, which is placed on the inner side of the tumour so as to press inwards the biceps muscle and the brachial vessels out of the way of Hey's saw, with which the tumour is divided at its connection with the arm bone. (Fig. 4.) FORMATION OF AN ARTIFICIAL JOINT, FOR ANCHYLOSIS OF THE ARTICULATION OF THE HIP. (Process of Barton.) The patient is laid upon the sound side. A crucial incision has been made, with its centre over the trochanter major. The four flaps are dissected up and reverted. The bone, after being denuded in its circumference with the knife, has been divided nearly across with the saw, the section being made partly through the trochanter and partly through the lower end of the neck of the bone. The figure represents the last stao-e of the operation, when, after the section of the bone,.the limb has been swung inwards in order to snap the°thin portion left unsevered by the saw. Plate ZZ h'u, / /•■/./ On •>'.'.>r< br $ Cichowski Pfntaitelp/ii.t. Pu film.',.-./ by Cir.i■•..■ H.li rs />,,,.,; /...?,, /•»,,/■' f OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 95 symptoms, it is not in general so certain a means of effecting a cure, (the fragments often overlapping so that the caustic cannot be made to act on the proper point,) as resection of the ends. 7. Resection. (PL XXL fig. 1.)—The ends of the fragments are to be exposed as in the last process, by a longitudinal incision through the soft parts, and the intervening fibrous tissue divided across. The two extremities are then to be luxated, as it were, and made to project one at a time through the external wound, separating the adhering soft parts with the knife so far only as is absolutely necessary. The arteries are to be tied as they are cut. It will be found most convenient to protrude first the inferior frag- ment. The rounded ends of the bones are then to be removed with the saw or cutting forceps, after the manner of White. The bones are then to be replaced with their raw extremities exactly in contact. The subsequent treatment becomes precisely the same as in ordinary compound fractures, and the risk following the operation may be considered even greater than that attendant upon these affections; hence, when the thigh forms the seat of injury, it is so very dangerous that it should not be lightly under- taken. Sometimes, when the fragments are deeply placed, one is found so short and so little movable, that it is impossible to cause them both to protrude. Under such circumstances, Dupuytren has found that the resection of the end of one of the bones suffices for the cure, if the extremity is put immediately in contact with the other fragment, which may at the same time be rasped or shaved, or irritated with caustic potash. When the fracture has been very oblique, it is necessary to remove a sufficient portion of the bev- eled extremities, to prevent any unnatural lengthening of the limb, which would, in the thigh or leg, be productive of considerable inconvenience. M. Flaubert, of Rouen, has proposed after resec- tion to unite the ends of the bones by passing a wire in the man- ner of a suture through the fragments themselves. But the risk of necrosis, caries or abscess round the bone, and the constitu- tional disturbance consequent upon this process, would, it appears to me from what I have observed in one case, be so great as to render the measure as dangerous as it is unneeded. This propo- sition of uniting the ends of the bone in an ununited fracture by a wire suture is by no means new; the author having witnessed its performance many years ago in the Pennsylvania Hospital. In the fore arm and leg, we select for the purpose of exposing the ends of the bones, the surface which is nearest the skin. In the thigh and arm, the longitudinal incision is made on the outer side of the limb, for the purpose of avoiding the vessels and nerves. In the arm, the incision is made in the intermuscular space, sepa- rating the outer margin of the biceps from the muscles on the fore part of the limb. At the middle part of the arm, the musculo-spi- ral nerve is found on the outer side of the limb, and between the triceps and biceps; it pierces subsequently the septum between these muscles, and must be carefully avoided by keeping it behind the line of incision. Its division, as shown in a case from the country, recently under my charge for resection of the ends of the bones, may be attended by permanent palsy of the extensor and supina- tor muscles of the hand. The previous operation, which had failed in this instance, consisted of the application of caustic pot- ash to the ends of the bones. In the thigh, the opening should be made between the biceps flexor cruris and the margin of the vastus externus, where we may reach the bone, by following the intermuscular septum, without dividing a single muscular fibre. For the purpose of introducing a seton betwreen the ends of the bones, Wardrop cut down along the external border of the rectus femoris, and brought out the needle at the external border of the vastus externus. The method of resection for ununited fracture of the humerus is shown at Plate XXI, and fully explained in all its details. By the use of Heines' saw (see PL XXXI.) the resection of the ends might readily be made without dislocating either fragment from its bed, and consequently diminishing the risk attendant on the operation. The section of the lower fragment, when protruded, is readily effected by the ordinary saw, as the limb can be rotated during its action, so as to make the division complete without disturbing the muscles on the other side. A strong pair of pliers, or a stout pair of dentist forceps I have found convenient in re- moving the pieces in cases where it was not deemed expedient to complete, the section with the saw. A few touches of the knife may also be at times required to detach the adhering ligamentous shreds. In the arm, it is more difficult to make the complete sec- tion of the upper fragment with the saw without doing violence to the surrounding parts, in consequence of the resistance made by the muscles of the armpit, even when these muscles have been relaxed by carrying the arm upon the chest for the purpose of turning out the end of the bone. The bone, however, may be always deeply notched on its surface with a narrow saw, and the section may then be finished with Liston's cutting forceps, acting in the track of the former instrument. The wound should be carefully closed with adhesive strips covered with a compress, and the limb surrounded with a roller bandage, so as to effect, if possible, union of the lips of the incision by first intention. The limb should be kept perfectly at rest in a well adjusted fracture apparatus, and all pressure of the resected ends of the bones for several weeks carefully avoided, for fear of producing inflamma- tion and suppuration in the cellular tissue of the bone. Within a few months I have performed an operation of this de- scription before the class of the Jefferson Medical College, in a case where, from causes wholly unconnected with the operation, death took place at the end of the fourth week, when the patient was about preparing to leave the city. The wound had healed completely by first intention, and no more pain or suffering had been experi- enced from the limb than occurs in ordinary fracture. The ex- amination of the parts which I now have in my cabinet, shows a rigid thickening of the cellular tissue, aponeurotic layers, and neighbouring muscular fibres, about the place of fracture, which had given a considerable degree of solidity to the limb. The two ends of the bones were already coated over with a layer of tough gray matter, and adhered to each other by a tenacious filamentous lymph, which parted as the fragments were forced asunder. DEFORMITIES FROM THE IRREGULAR UNION OF FRACTURED BONES.-VICIOUS OR DEFORMED CALLUS. It is not unusual to meet with cases in which, from accident or mismanagement, the consolidation of a fracture has taken place, with shortening of the limb from the fragments riding over each other, or with a deformity in its direction owing to a mal-adjust- OPERATIONS. 96 GENERAL ( ment of the ends of the bones during the progress of the cure, or from its becoming bent or curved by a premature use of the limb while the callus was yet soft and yielding. Without going into detail in reference to the different theories of the formation of callus, it will suffice to state that it passes through different stages of development, from that of fibro-carti- lage to bone ; that it forms a temporary connection for holding the bones together, which, even when most consolidated, does not attain to the density of solid bone ; and that the permanent callus, which is formed between the surfaces of the divided bone and when it becomes solidified forms the true bond of union, is the last portion developed. The period requisite for these pro- gressive changes varies in different bones, but does not even in the larger consist of more than sixty or ninety days, beyond which period we may, under favourable circumstances, regard the union by permanent callus as having taken place. The longer, therefore, the callus has been in forming, the greater will be the difficulty of correcting the defects in the position of the bones. In general the temporary callus does not, before the fiftieth or sixtieth day, acquire so much solidity but that it may be readily made to yield by pressure and extension; but it is most desirable that all deformities should be corrected as early as possible after they become known. Dupuytren has, however, furnished in- stances where the deformity has been removed by such measures, as late as one hundred and twenty days after the occurrence of the injury. Cases will present themselves that have been ne- glected for periods much longer than this, in which relief can only be afforded by other means more severe and hazardous, but which are nevertheless perfectly justifiable, when the use and symmetry of an important part are destroyed. There are three principal methods for cure of the deformities referred to under this head. 1. Pressure and permanent extension.—If not more than a few weeks have elapsed from the time of the injury, we may be able at once to straighten simple angular deformities by the hands with- out the aid of machinery, especially if they are found in the fore arm or leg, the operator using his knee as the point of resistance ; but if there be shortening from oblique fracture, it will in addi- tion be necessary to bring down the bones by extension and coun- ter-extension. Having once got the limb straight, the treatment is to be continued as in ordinary cases of fracture. But if a longer period has passed—thirty, forty, fifty, or sixty days—pressure and extension must be made gradually with an appropriate fracture or orthopedic apparatus, and repeated every second or third day, strict care being observed to retain, by the steady use of the in- strument, what has been gained by the force applied. If the callus has become too solid to yield to these measures, it has been proposed to soften it previously by passing a seton through it so as to provoke a sudden inflammation, which is commonly attended with some softening of the new structure. Use of the seton. (Process of Weinhold.)—In a case of frac- tured thigh of three months' standing, firmly consolidated with a great exuberance of callus, and with a shortening of two inches, this surgeon was so successful as to ultimately restore the limb to within two lines of its natural length. With a sort of trepan needle, mounted on a joiner's brace, entered through the soft parts an inch to the outer side of the femoral artery, he perfo- rated the mass of callus. The needle was then carried out through the opposite side of the limb, dragging after it the ordi- nary seton. At the end of seven weeks the callus began to yield ; and the common extension apparatus was applied. 2. Rupture of the callus.—This may sometimes be effected by straining the limb over the knee, and rupturing the new union as we would break a stick. Velpeau has proposed to place the de- formed limb with its concavity upon a solid plane, while pressure is made suddenly and forcibly with the knee or hands on its con- vex surface. There is, however, always more or less danger of splintering the bone, or fracturing it at a new point, so that this plan, where much resistance is offered, is but little followed^ It is considered better surgery under such circumstances, especially where there is a mere angular deformity, to endeavour to effect the object by the aid of machinery, properly padded and braced, so that the force shall be applied only over the new-formed union. A double inclined plane, truncated at the top, and opening with a joint at a similar angle with the limb it supports, answers the purpose nearly or quite as well as the complicated apparatus of CEsterlen, in which a pad, attached to a solid piece of board, is forced downwards with a screw, so as to press on the convex sur- face of the callus. GCsterlen has reported forty cases of success by this method of treatment. 3. Section of the callus.—This is the only means left for reme- dying a deformity that has resisted the judicious application ofthe preceding measures, or for the treatment of a thoroughly consoli- dated fracture. It consists in laying bare the surface of the callus, by incisions, and, instead of breaking, dividing it across with a saw, or the gouge and mallet. It is the only method left for managing the confused solidification which sometimes takes place after fracture of the bones ofthe fore arm. It converts the deform- ity into the state of a compound fracture, and is attended by the same risk to the patient, and requires subsequently similar treat- ment with that affection. A judicious surgeon would not, there- fore, attempt a cure by this means, except in cases where it was urgently indicated. Process of Wasserfuhr.—For a fracture, in a child of five years, of the upper third of the femur of three weeks' standing with a salient angle at the outer side of the thigh and great shortening of the limb, this surgeon made a transverse incision over the promi- nent point, equal to one-fourth the circumference of the limb. The callus, exposed by the retraction ofthe divided muscles, was cut nearly through with a fine saw, and the separation completed by fracture.* The limb was then placed in an extension appara- tus, and complete success is said to have followed the operation. In many instances the American method of cure for anchylosis, by removing a wedge-shaped portion of bone, and subsequently straightening the limb, will be found available in relieving this class of deformities. This principle has been several times suc- cessfully employed; in one instance in a case of great deformity of the leg by Professor Mutter, f If in treating injuries of this description, the muscles on the concave surface of the limb have so shortened themselves as to refuse to yield readily on distension, * The solid state ofthe callus at this early period is to be explained by the youth of the patient—the process of bony reunion taking place more rapidly in children than in adults. f American Journ. Med. Sciences, April, 1842. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 97 a section of their tendons, especially in the lower extremities, made as described in this work under the head of subcutaneous operations, may occasionally be attended with advantage. EXOSTOSIS. (PL. XXII.) The tumours bearing this name may be distinguished : 1. Ac- cording to their original seat, which may be either between the periosteum and the surface of the bone, or between the medul- lary lining membrane and the cancellated structure. 2. Accord- ing to their nature—as they are cartilaginous, eburnated, porous, or osteo-sarcomatous. 3. According to their form and size, whether they are styloid, rounded, pediculated, circumscribed, diffused, etc. The proper periosteal exostosis, formed on the free surface of the periosteal membrane (periostosis), as shown by Professors Albers and Rognetta, are first formed like epiphysis, though they become ultimately solidly attached to the bone on which they rest. To all of these varieties, surgical operations for their re- moval are by no means applicable. If they are in their forming state, fibrous, or cartilaginous, they need not be interfered with except they produce great deformity. If they have degenerated so as to become soft and spongy, as in growths from the walls of the antrum maxillare, nothing short of resection of the bones involved, or amputation of the member will suffice. Simple ob- long enlargements on the surface of a bone are ordinary occur- rences ; and if no other inconvenience than slight deformity results from their presence, they should not be interfered with. Nothing in fact justifies their removal by operation, except that the tumour, from its great size or vicious direction, interferes with the functions of surrounding organs. Such as arise from syphilis, from scrofula (as is so common in children), and other constitu- tional affections, are curable usually by appropriate general and local treatment; and, if touched at all, cannot be taken away with safety till after the removal of the constitutional disorder. Modes of operation.—The application of the actual cautery and caustic articles so much in use among the ancients, and still em- ployed for a like purpose in farriery, is now abandoned in the treatment of these affections—surgeons limiting themselves almost exclusively to the employment of mechanical measures, and using the cautery only as a means of arresting hemorrhage after the operation, or destroying a portion which cannot be readily extir- pated. If the exostosis is entirely cartilaginous, intermixed with plates of bone, and periosteal in its origin, it does not adhere at first very firmly to the bone, and may be prized off from it after having been exposed by incisions through the soft parts covering it. Large tumours of this description I have found readily remov- ed from round the base and ramus of the lower jaw. If the tu- mour has become ossified, making a continuous structure with the bone below, it may, if pediculated, be detached by section with the saw, forceps, or chisel. If adherent by a large base, it must be separated in portions, either by several applications of the tre- phine, or divided perpendicularly in various directions with the saw, and the portions detached at their base with the cutting forceps, or the mallet and chisel. If the bone below be merely inflamed, vascular, and expanded in its areolae, it may be left to the influence of general and local therapeutic measures, on the same principle that we would treat similar affections in the soft parts, when the offending cause had been removed. If there are 25 grounds for suspecting its degeneration, an exploratory perfora- tion maybe made with a trephine, after the manner of Dupuytren, ift order to decide whether it will be necessary to proceed to re- section or amputation. If the seat ofthe tumour be in the medul- lary cavity of a long bone, the soft parts are to be dissected off, the expanded shell ofthe bone laid open with the trephine, the mallet and chisel, a Hey's saw, or the cutting forceps, (the last answer- ing well to enlarge the space after the opening has once been effected)—and the nucleus turned out from the cavity it occupies. The soft parts are then to be brought together, and a slip of linen interposed at the depending portion ofthe wound, so as to permit a free escape ofthe purulent secretion, and allow of the introduc- tion of detersive fluid injections. In the after treatment I have derived great benefit from compression applied by the means of a roller, or of adhesive straps, as in Baynton's method for the cure of ulcers, which, though acting directly on the soft parts, exercise considerable influence on the bone. Remarks. The mode of proceeding in the removal of exos- tosis will be more or less varied, not only by the nature and form ofthe tumour, but also by the character and peculiar arrangement of the parts which surround or support it. As these difficulties, as well as the means of surmounting them, cannot be subjected positively to any general rules, and as the latter must be founded upon the exigencies of each individual case, it will not be neces- sary to describe the process for the removal of these tumours in the various portions of the body. By reference to Plate XXII, the general method of proceeding will be well understood. The saw and the trephine will be found most appropriate in the removal of cranial exostosis, as the concussion attending the use of the mallet and chisel might injuriously affect the brain. In the removal of tumours deeply situated, the obvious necessity of protecting the neighbouring parts increases the dif- ficulty of the operation; and it is in these cases when w7e act in a narrow space, that great advantage may be obtained from the use of a chain saw, or the different steotomes that have been devised, the best of which is that of Heine. In laying bare the tumour, the rules generally laid down for avoiding the vessels and nerves are to be carefully followed. In many respects the method of incision can be advantageously modified so as to spare more or less important parts, according to the nature of the case and the ingenuity of the surgeon. In an exostosis with a narrow base seated below the deltoid, M. Roux made two parallel incisions in the direction of the fibres of the muscle, isolated the tumour below the bridge formed between the two incisions, and detached it at its base with a saw, without any transverse division of the muscle. In some cases where the excision of the exostosis is dano-erous or impracticable, and the tumour is neither large nor attached by a broad base, it has been recommended to lay it bare and strip off its periosteum, in order to deprive the external part of its nourish- ment from the periosteal vessels, and cause the surface and the subjacent parts to slough away. The result of such a method would necessarily be tedious and more or less uncertain; and it is hardly likely that any instances can arise in which its applica- tion would be advisable. OYSTS IN THE BONES. This peculiar form of degeneration has been frequently ob- 98 GENERAL OPERATIONS. served in the upper and lower maxilla?. It has also been occa- sionally met with in the extremities of the long bones and the bodies ofthe vertebrae. Tbe cavity ofthe cyst is most commonly filled with a mass of fibro-cellular matter, but sometimes its place is supplied by serum, pus, hydatid vesicles, gelatinous or colloid masses, etc. etc. Tbe fibro-cellular cysts of Dupuytren may be considered the same affection as that ranged by Sir Astley Cooper under the head of cartilaginous medullary exostosis. The cysts in the bones vary in size from that of a musket bullet to that of the fist. The peculiar nature of the substance they contain it is exceedingly difficult to discover, except by an exploratory puncture, or during the progress of an operation for their removal. This, however, is not a matter of great import- ance, as the indications of treatment are nearly the same in all. That which is more easy, however, and more important, is to distinguish the cystic from the cancerous degeneration of the bones called osteo-sarcoma, in which the operation for the re- moval of the disease is nearly as unpromising as it is successful in the case of cysts. Osteo-sarcoma is characterized shortly after its commencement by a varicose tumour, and by a simultaneous affection of the surrounding soft and hard parts disposed to take on the character of fungoid degeneration, and by irregularities over the surface of the swelling. Qsteo-sarcomatous tumours grow with great rapidity, and are traversed in their interior by fragments of bones, which are never observed in the cysts. These latter are slowly developed, smooth on the surface, and never involve the surrounding parts in disease, unless the contained substance has in the end degenerated into cancer. Their walls, which appear to be formed by a separation of the compact por- tions of the bone, grow thin in consequence of their expansion, and yield to pressure of the finger like a piece of parchment, followed in many instances by a crackling or crepitating sound, which, according to Dupuytren, is pathognomonic of this affec- tion.* Four principal methods have been employed in the treatment of these bony tumours. 1. By compression.—-This has been attempted, but the trial has not been attended with any permanent advantage. 2. By incision.-^—The mere laying open of the cysts, and evacu- ating their Contents, even when these are of a fluid nature so as to admit of the process, has not succeeded in effecting a cure. It is necessary to destroy or change the nature of the membrane lining the cyst, without which the orifice will close, and the con- tents accumulate anew. 3. By the seton.—A seton passed through the centre of the cavity, offers ih the serous cyst a somewhat better prospect of a cure, by producing suppuration of its walls, and the elimination * Lecons Orale de Clinique Chirurgicale, t. iii. PLATE XXIIL—OPERATIONS ON THE BONES FOR NECROSIS. (Fig. 1.) EXTRACTION OF A SEQUESTRUM FROM THE OS.HUMERI. An incision is made down to the bone, on the outer part of the arm, between the brachialis anticus and triceps muscles. The muscles have been dissected off from the bone, and the fore arm somewhat flexed so as to admit a wide separation ofthe lips of the wound. Two perforations have been made with the trephine through the new shell of bone, or involucrum, so as to expose the sequestrum or dead piece of bone inclosed by the involucrum. In the plate, the surgeon with his left hand supports the limb, and draws away the inner lip of the wound, (the external supposed to be drawn outwards by an assistant,) while, with a Hey's saw in his ri,, S(.,„, l,y .V (iclioif A i /'.vOmui Lith ri,,i I'hilndr/ph,., PubUshcn hy ,.,.■■ y '■' 11.i,/ OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 103 and injuries of the head, not only as a means of cure for the symptoms of irritation or compression to which they might give rise, but as a means of protection before they were developed. The gross abuse of the application of the trephine, to which such indications would lead, has been vigorously opposed, espe- cially by Desault, Abernethy, Langenbeck, Physick, Gama, Coo- per, and others, who restricted its use to cases in which the secondary symptoms of irritation and compression were strongly manifested, waiting always as regards the operation until these should appear. This doctrine was founded chiefly upon the serious nature of the operation, and upon the well-known fact that effused blood may be completely removed by absorption under the influence of appropriate treatment, and that even the depression of a piece of bone will frequently be borne without injurious consequences. The reaction thus produced mainly by the influence of Desault and his school,* established on the other hand an excessive repugnance to the operation, and trephining came to be considered as a desperate resource, which, if used at all, was apt to be applied too late. But the careful opening of the walls of the cranium, where no inflammatory symptoms prevail, is not of itself an operation of very serious danger; and the suc- * Saviard, more than one hundred years ago, found that most of the patients trephined at the Hotel Dieu, (when many surgeons, not yet having learned the value of saving the integuments to cover the wound, cut away the scalp from over the place of operation,) died soon afterward, in that unhealthy institution, of what was called the fever ofthe hospital. He objected to the use ofthe trephine. Desault followed more warmly on the same side, rejecting it almost in toto. Abernethy took up the subject on a different ground, and, without abandoning the operation, endeavoured to distinguish the cases suited for it; and laid down the rule, that the surgeon was not to trephine merely because there was fracture, depression, etc., but only for the consequences that these had produced. This has since been the ruling doctrine among British and American surgeons. Sir A. Cooper, Sir B. Brodie, and others, have receded slightly from the ground taken by Abernethy, and admit the immediate use ofthe trephine in cases where there are fracture and depression complicated with external wound. So little a matter, however, is the existence or the non-existence of an external wound in so serious an affection, that the admission would seem to imply that a more frequent use of the trephine would be found advantageous; and Velpeau, in a more decided tone, advocates its employment. The subject, however, requires to be studied anew, with careful reference to the statistics of the operation, before full and precise indications can be laid down for the various cases that occur; for as yet some consider it doubtful whether indiscriminate trephining immediately after fracture and depression, would not be attended with nearly as good results as the modern-practice of Abernethy and Desault. cess which the older surgeons met with after its employment, compared with the almost constant fatality which has followed its use in later times, goes to show that the cause of death in the latter instances is to be found in the restriction of the opera- tion to the worst class of cases, and partly perhaps in the fact that the affection of the brain and membranes consequent to the injury had been allowed to develop itself previous to resorting to the operation. Though in every respect opposed to the prodi- gal use made of the trephine by the older surgeons for the purpose of preventing inflammation, I believe, from what I have myself witnessed, that it would be well, (notwithstanding the exceptional cases reported, of musket bullets and splinters of bone becoming encysted within the cranium without producing serious results,) if the attention of the profession in this country was brought to a less unfavourable view of the operation early after the occurrence of the injury, when, according to the principles established by Pott, it would enable us to get rid of an obvious cause of irrita- tion, whether that be a foreign body, a depressed bone, a splinter from the internal table, or a mass of effused blood. I cannot but recall cases to mind, and every surgeon of experience in all pro- bability can do the same, where the early use of the trephine might have saved life—such, for instance, as that of a depressed bone with a splinter from the external table sticking into the sub- stance of the brain, and exciting abscess; the crista galli of the ethmoid driven by a blow on the forehead into the anterior lobe of the brain; various fissures of the skull from external violence, leading to effusion, compression, and meningeal inflammation ; and ruptures of the middle artery of the dura mater, by a blow even with the fist, and without fracture of the bones. The ad- mirable cures effected by Larrey in many cases of injury of the head, are well known; and the counsel left by that experienced surgeon is, if we are called in within the first twenty-four hours after the reception of the injury, to proceed at once to the removal of such foreign bodies, splinters, or extravasated fluids, as the case may render necessary; but if not summoned until after the inflammatory symptoms are set in, to defer an operation till they have been abated by treatment. If, however, the removal of an irregular-shaped fragment sunken in the brain cannot be made without inflicting much additional irritation, it will be better for the surgeon to desist and trust the case to the efforts of nature, after having obtained a free outlet for the fluids which may form. where the depression is greatest. A third application of the trephine was then made at c, and the fragment taken away without difficulty, its removal being necessary in consequence of the complete insulation of the piece and its pressing by its rough edge on the dura mater. This is the only place at which the perforation should have been made. The two former perforations were not only unnecessary, but contributed to enlarge the gap in the bone, and increased the risk of hernia cerebri, which in a case analogous to this, described by Sir C. Bell, actually occurred and destroyed the patient. Fig. 5.—A portion of bone, which exfoliated after the use ofthe trephine in consequence ofthe dura mater having been detached from its under surface by injury. Fig. 6 and 7.—Two portions of different skulls, removed from the same site in each, showing the variable degree of thickness of the bone in different individuals, and the necessity of always proceeding cautiously in the use of the trephine, lest the dura mater should be injured. Fig. 8.—A circular piece of bone, showing the two tables and the intervening diploic structure. The last four figures are taken without alteration from Bell. Fig. 9.—The perforator. This is frequently a very useful instrument in enlarging a fissure where small fragments are depressed. It may be attached to the handle of a trephine. OPERATIONS. 104 GENERAL < Sir P. Crampton* was obliged to give over an attempt of this sort, where the fragment of bone was lodged in the substance of the brain in consequence ofthe convulsive movements and moanings excited ; the fragment in this case was subsequently discharged by suppuration. Fractures of the bone, with or without depression, it is fre- quently by no means easy to discover, when there has been no opening in the scalp. In such cases, it is well to follow the advice of Cooper, Brodie and others, and not, unless the symptoms are of such a nature as fairly to indicate it, proceed from mere surgical curiosity to lay open the scalp, as the incision would necessarily be attended with an increased risk of erysipelatous inflammation. A proper distinction should be made as to the effects of depression, in reference to the age of the patient; for in children the skull is more yielding, more readily depressed without fracture, than in the adult, and has a greater natural tendency to restore itself to its previous state. The following are the indications for the use of the trephine in recent injuries, as given by M. Bourgery, one ofthe latest writers on the subject,—though his first division, as it would appear to most surgeons,.should be accepted with much qualification. 1. In all fractures of the cranium, with or without depression. 2. Whenever the tissue of the bone is much broken up. 3. In every case where the dura mater has been involved in a pene- trating or punctured wound. 4. In gunshot wounds, complicated with the presence of foreign bodies. 5. When coma and com- pression come on in a few hours after the injury, especially after a blow over the temple. 6. When epilepsy follows in a case where there is a prominently depressed portion of bone, attributable, without chance of mistake, to the injury which the bone has suffered.! In many of the indications included in this cate- gory, the application of the trephine may not be needed, if the offending portions of bone are so loose as to be readily removed with the elevator, or the male branch of a pair of scissors ; or if the wound ofthe bone is sufficiently large to permit the extraction of any foreign body lodged in it, or to give issue to the products of hemorrhage and suppuration. Instruments required for the operation.—1. The common En- glish hand trephine, seen at fig. 4, Plate XXIII; or the instrument of Hildanus, known by the name of the French trepan, fig. 1, which is worked like a joiners brace. 2. A tirefond or bone screw, like the tooth screw of the dentist. 3. A strong lenticular knife, with different sorts of elevators. 4, Dressing and cutting forceps. 5. A small brush to clean out from time to time the circular groove made by the trephine, and a piece of quill or ivory to measure occasionally its depth. 6. A straight Hey's saw and some bis- touries. To these might be added, at the will of the operator, the osteotome of Heine or Martin, which are particularly useful here, as well as in trephining other portions of the bony structures for abscess or necrosis. It will also be found advantageous te have at hand an oblong piece of sole leather or cork with a crevice ©ut in it, if we expect to use the Hey's saw, or a circular opening for the crown of the trephine, if we are disposed to apply this * Dublin Journal of Med*. Sciences, vol. i'i. p. 42. \ Vide a valuable paper on injuries of the head, by Prof. Dudley, in the 1st No. of Transylvan. Journ. of Med.; and (among others) a case by Dr. D. L. Rogers, New York Med. and Phys. Journ., vol. v. instrument on any point where the use of the pyramid would not be considered prudent. Points of application.—Authors in general direct the operator not to apply the trephine over the frontal sinuses, where the sepa- ration of the two tables of tbe bones renders the operation more difficult; nor at the anterior and inferior angle ofthe parietal bone, which lodges in a groove or canal formed in its inner table, the middle artery of the dura mater; nor upon the track of the sagittal suture, for fear of bounding the longitudinal sinus; nor upon the middle of the temporal fossa, where several vessels and a large muscle are found ; nor over the common junction of the sinuses at the occipital protuberance. These rules are good, and should always be respected, unless a well-founded indication exists for their vio- lation ; for the accidents liable to accrue from the operation at these excepted points may be easily guarded against. Hemorrhage from the artery of the dura mater maybe arrested by a ligature, as was done by Dorsey; if lodged in a canal, by plugging, as prac- tised by Physick ; or by cauterization with a heated stilet, in imita- tion of Larrey. The slightest pressure with a piece of lint suffices to check hemorrhage from the sinuses. By using the precaution of Sir C. Bell, to open the anterior wall of the frontal sinus with a large trephine, and the inner with a smaller, depressing the handle of the latter so as to act square on the bone, we may cut in the supra-orbital region with nearly as much safety, as regards the dura mater, as any other portion of the cranium. The separate removal of the external table is not, however, in all cases practi- cable, in consequence of the incomplete development of the sinus in young persons. The selection of the point for operation will depend upon the location ofthe injury, and the object we have in view; for some- times it has been found necessary to apply the -trephine upon the side opposite to the external injury, when, from the effect of coun- ter stroke, an effusion of blood or a gradual accumulation of pus or serum has occurred there. In simple fracture, we should apply the instrument with the pyramid resting near one margin of the fissure, so that the section may extend upon both its sides. In fractures with depression, care must be taken that the crown of the trephine does not act upon a loosened bone, for fear of causing irritation or laceration of the parts below. When a foreign body is wedged in the wound of the bone, and the fracture is but limit- ed, the crown of the trephine should embrace the whole sobjftioiv- of continuity. If a musket or rifle bullet penetrate the cavity of the skull, the smallness of the aperture which it leaves will lead the inexperienced to doubt the fact of its passage. The osseous fibres, yielding to the impulsive force ofthe ball, diverge many of them without breaking, and rebounding after it has passed, nearly close the aperture. In young subjects, where the bones are most elastic, this is particularly the case. In old indi- viduals, the fibres are more disposed to break, and the ball takes out a portion of the bone at least equal to one-half its diameter. A ball or similar foreign body, when its direction is such as to keep it between the bone and dura mater, may lodge at a spot a little remote from its place of penetration, without the extraction of it being thereby rendered impossible, or the case entirely hope- less.* In such instances, it has been advised, in order to ascertain the location of the foreign body, (when its presence gives rise to * Vide Campagne de Constantine, 1837, by Sedillot. 4 OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 105 symptoms of pain or compression, so as to render surgical inter- ference justifiable,) to introduce a caoutchouc probe along its track, the contact of which with the foreign body, will be made known by the feeling of resistance and roughness communicated. With- drawing then the probe, and measuring the distance in the same direction on the outside, we find the place for the application of the trephine. In cases of extravasated fluids, we operate imme- diately over the supposed seat of effusion, and sometimes more than one perforation at the distance of an inch or more apart will be required. When the effusion exists over each of the hemi- spheres, it has in some cases been deemed proper to make an opening on the two sides of the skull, but the chance of relief under such circumstances is nearly hopeless. In caries and ne- crosis, it is usually deemed most prudent to let the diseased por- tions separate of themselves, until they can be seized with the forceps and extracted. But if there should be such an accumula- tion of pus (which usually, however, flows without difficulty, by some external opening), as to give rise to symptoms of compres- sion, a few applications of a small trephine maybe made, and the interspaces divided with a Hey's saw or the ordinary cutting forceps. Operation. (PL XXIV. fig. 1, 2, 3.)—The point of the cra- nium upon which wre are about to operate having been shaved, and the head supported on an inclined plane, and well secured by assistants, we proceed to the 1st step ofthe operation, which con- sists in— 1. The denudation of the bone.—No fixed rules can well be given for the division of the soft parts for the purpose of exposing the bone. If there already exists a wound of the scalp, this is to be enlarged in such a way as to admit the application of the tre- phine, by forming a V, A, T, or oval-shaped opening. Where there has been no external wound, the V shaped incision of Phy- sick, with the point downwards, the flap dissected up towards its base and reverted, will uncover the bone with the least division of the vessels in operations over the temporal region. In other portions of the head, I have found the crucial or semilunar incision most appropriate. In making these incisions, the scalp should be divided at once by a single cut down to the bone, care being observed in case of fracture, that the knife does not penetrate below its surface. If the bone be. much comminuted, it would be most judicious to make first a slight incision of the scalp, and open it subsequently to the requisite extent on a grooved di- rector- The flaps are then to be dissected up, reverted, wrapped with fine linen, and held out ofthe way by an assistant. Former- ly, it was directed to detach the periosteum for a space equal in size to the crown of tbe trephine, with the rasparatory, a practice now justly abandoned. If the divided vessels bleed freely, and do not shortly contract under the astringent action ofthe air and sponging with cold water, they are to be pinched, twisted or tied, as in other parts of the body. 2. Perforation of the bone.—This is to be accomplished either with the hand or English trephine, or the trepan instrument of Hildanus, which may be made to revolve either with a brace, or like a drill by means of a how* The operation is the same with all. The hand trephine is usually preferred in this country and in England, and no possible objection can be urged against its use, except the slowness with which it cuts when the bone is solid. 27 The pyramid or centre bit is to be protruded beyond the level of the crown of the instrument, and firmly secured with the screw attached upon the side for the purpose. T he point is then to be entered into the bone with a semicircular motion of the hand, made by alternate pronation and supination, the arm being held immovably fixed. This motion is to be continued till the teeth of the crown come in contact with tbe bone, and furrow for them- selves a groove in the external table sufficiently deep for the in- strument to run in securely. The pyramid, as it is no longer of any use, is now to be retracted, lest it should injure the dura mater by perforating the bone in advance of the teeth of the crown ; and the operation is to be continued with the crown alone. This must be kept perpendicularly applied, in order that it may act at an equal depth on all the points of its circumference. The di- vision of the diploe can be recognized by the ease with which the trephine cuts, rather than by the bloody detritus rempved, usually given as the sign of this stage of the operation by writers. For on the living subject, blood constantly flows in sufficient amount to redden all the particles loosened by the saw. In old subjects and in children, the diploic structure ofthe bone is deficient, and the crown of the trephine must be withdrawn from time to time in order to clean the teeth with the brush, and furnish an opportunity to sound the depth of the groove, to see if it be equal in all its parts. We then resume the use of the trephine, remitting it after every third or fourth turn to sound the depth afresh, as we sup- pose we are approaching the under surface of the bone, which is very variable in its thickness in different individuals. If the motion of the crown be impeded in one direction, we make a half turn backward, and continue the operation with slighter pressure. If, on examination, the bone is perforated partially, but the piece still immovable, we are to continue the use of the trephine, inclin- ing it on the adherent side, and avoiding carefully all pressure on the divided point, for fear of injuring the dura mater. When the furrow is cut through at several points, the finger nail or an elevator introduced into the groove, will serve to effect the sepa- ration of the remaining portion of the internal table, which takes place with a crackling sound. If, however, the depressed frag- ment is found to run somewhat shelving under the edge of the trephine, so much motion of it might be caused by the turns of the instrument as to lacerate with its rough edges the dura mater. As soon as this fact is ascertained, the trephine is to be laid aside, and the disk detached by two elevators applied upon opposite sides, to prevent the tilting of the fragment on the membrane. If the trephine has to be applied so as to cover a small frac- tured portion, or a ball or other foreign body lodged in the bone, the centre pin or perforator cannot be used to start the crown. A piece of sole leather or cork, with a hole of the proper size cut in its centre, and firmly held by an assistant, will serve to retain the crown until it cuts a groove deep enough for its own support. Use of the Hey^s saw—Cranial saw—Bridge saw of Grcefe.— In fractures with depression, where the margin of one bone slides over the other, or in depression without fracture, which I have observed in children when a bone has been driven in at the sutures, or when the mere enlargement of an angular fissure becomes necessary, an opening may be made with this instrument more quickly and more conveniently than with the trephine. It 106 GENERAL OPERATIONS. is also applicable to cases where a large piece is to be cut out, the trephine being applied at the two angles, and the bridge be- tween the perforations divided with the saw. A piece of leather or cork, with a crevice cut in it, is to be placed on the skull, within which the straight edge of the saw is to play, till it cuts a groove sufficiently deep to lodge itself. As the instrument ap- proaches the inner surface of the bone, the circular edge of the saw alone is to be used, as less likely, from the rounded shape of the cranium, to inflict injury on the dura mater. The same pre- cautions as to sounding from time to time, above given, must be attended to, and it will be found better to break the last points of union, than to divide them completely with the saw. Rasparatory, or rugine.—Rasping or scraping a point of bone with this instrument, or at need with a piece of glass, until the bone is so thinned that an aperture may be formed large enough to admit the point of a lever or a pair of forceps, so as to break out a piece, was formerly recommended, especially in injuries of the head in children. But the practice has justly gone out of use. When it becomes necessary, (which is more rare by far in children than in adults,) to interfere by operation, the trephine is to be preferred if complete ossification has taken place; and in case it has not, the point of the knife or a pair of scissors may supply the place of any other instrument by opening one of the sutures. 3. Removal ofthe detached piece of bone.—It is directed to fasten the bone-screw into the orifice made by the centre pin, and by a few lateral motions loosen and detach the piece. The plan, how- ever, generally preferred, is to apply the elevators on the opposite sides of the piece, so as to detach and lift it out. Occasionally it will be brought away with the trephine. If the edges of the opening left be sharp and rough, they are to be smoothed off with the lenticular knife, or, which answers better, as having less tendency to disturb the dura mater, the point of the common elevator. If there exist the necessity of applying several times the crown of the trephine, (PL XXIV. fig. 1,) it should be so disposed as to cut into the space from which a piece had been previously removed, in order to leave but a small osseous angle, which can readily be divided by a Hey's saw or the cutting pliers. 4. Removal of the cause of compression.—If there is fracture with depression, the end of the common elevator, or the hook- shaped lever of Grzefe, is to be introduced below the sunken piece, which is to be gradually elevated by using the opposite margin of the opening, as a fulcrum for the instrument, or if this be not firm, the finger placed as a bridge across it. To prevent a too sudden elevation, which might detach the piece, it is well to make a little counter pressure on its outer face. If we cannot thus succeed in elevating the fragment, or the inner table is found shattered, it may be removed altogether with a Hey's saw, or another application of the trephine. Loose portions of the bone are to be picked away with the fingers or forceps. But in case one should be imbedded in the brain, and any disturbance of it attended by pain and convulsion, we might imitate the conduct of Sir P. Crampton, and leave it to be detached by suppuration through the external orifice. If the operation has been early done for extravasation or effusion, the fluid, if it lay on the outer side of the dura mater, will usually come away of itself. But if it be coagulated blood, it will require to be broken up with the finger or probe, and it has even been directed to wash it out with a syringe and warm water. If the*dura mater rise as the fluid is discharged it is a happy circumstance. But in none of these cases is the prognosis favourable. If the extravasation extend too far for this rising to be effected, it has been recommended by Sabatier to apply the trephine on another point, on the principle of a counter opening. If the effused fluid lay below the dura mater, this membrane will be found detached from the bone, and of a livid or brownish hue, and in most instances shares less than is natural in the pulsatile heavings of the brain. It is apt also to bulge in the opening and present a feeling of fluctuation below; but this is a sign which might lead into error, for the soft cerebral substance in the healthy state gives on pressure of the membrane a somewhat similar sensation. The presence of the effusion having been detected below the dura mater, this is to be opened, by pushing a straight sharp pointed bistoury obliquely through it; then depressing the handle so as to raise the point of the in- strument, the membrane is to be divided in a direction parallel with its vessels. Another parallel puncture, or a cross cut, is usually required. If the operator find the seat of the fluid not on the inner surface of the meninges, but in the substance of the brain—the result usually of a contusion that has terminated in abscess—he may, if, from the change of colour and consistence of the brain and a sense of fluctuation, there be unequivocal evidence of its existence, be justified in following the example of Dupuytren and Begin, and pass a bistoury for an inch even into the cerebral substance, if the fluid lie so deep. The punc- tures of these surgeons, however, were ultimately followed by death. In a case of this description, on which I operated during the winter of 1843-4 before the class of the Jefferson Medical Col- lege at the Philadelphia Hospital, the altered dura mater puffed up through the opening made by the trephine. On incising this, the softened pultaceous cerebral substance pouted through the orifice, and gave to the finger a distinct feeling of fluctuation below. The wound was lightly dressed, and all proceeding suspended for the time, as life was not immediately in danger, in the hope that the abscess would spontaneously open, which it did on the following day, so as to relieve at once to a consider- able extent the coma under which the patient laboured. More or less purulent discharge continued for sixteen days, during which time the patient improved so as to be able to walk about the wards and converse rationally on most subjects. At the end of this period it ceased entirely, and the cessation was followed by a return of delirium, succeeded by coma, of which the patient sunk. On dissection, the orifice in the dura mater, which had not been made sufficiently large, was found blocked up with fungous granu- lations from its margins, and the cavity of the abscess filling up with pus had opened into the posterior horn of the lateral ventri- cle, opposite to which the injury had been received and the per- foration had been made with the trephine. 5. Dressing and after treatment.—The dressing must be light and unirritating. A cribriform piece of linen spread with cerate is to be placed over the opening in the bone, with its angles doubled in, to maintain elevated the flaps of the soft parts, and form a sort of channel for the discharge of the secretions. A pledget of lint or charpie is laid above this, and secured with a OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 107 few turns of the roller or couvre chef bandage, or even a close fit- ting cap. The stuffing of the aperture with lint, and the use of thick tight bandages, are to be particularly avoided. Cold fomen- tations are to be applied to the head, and a rigid antiphlogistic treatment instituted. It is well not to remove the first dressing till it becomes loosened by suppuration. Subsequently the wound should be twice dressed daily. If after the extraction of a frag- ment, or the evacuation of an effused fluid, the symptoms of com- pression immediately cease, the parts may be closed with adhesive straps as in ordinary wounds, and reopened again if the symptoms return so as to render it necessary. If the operation has been done on a young subject, it may happen that a layer of new substance is secreted by the dura mater, which will ossify and supply the place of the removed portion of bone. But in the greater number of cases there is a very limited reproduction of bone, a tough resisting membrane sup- plying its place, through which the movements of the brain may be felt. It has been recommended to wear subsequently over the part, as a protection against external injury, a leather or metal covering. The trephine has also been employed with advantage in some cases of abscess in the mediastinum, accompanied with caries or necrosis of the sternum. It has also been four times resorted to in injuries of the spine—by Cline, Tyrrel, and Barton. But the result in all save the last case was unsuccessful, and the method can hardly be considered one of legitimate application. In the bones of the extremities the trephine and the Hey's saw become most useful adjuvants in several forms of disease, but particularly for the removal of sequestra in cases of necrosis. RESECTION OF THE BONES. The resection of a bone consists of its partial amputation. It is an operation done without destruction to the soft parts, so as to enable us to preserve, to a greater or less degree, the form and usefulness of the part from which the piece of bone is taken. It is in many cases the only alternative against amputation. Though not of particularly recent origin, it has mainly been brought into favour by the address and ingenuity with which it has been prac- tised by modern surgeons. It is an interesting and fruitful de- partment of the art, and under many circumstances becomes the means of saving not only the limb, but even the life of the patient. Operations of this class cannot, however, on account of the varying nature of the causes which render them necessary, and the necessity of their performance at the diseased point, be sub- jected to the same definite and prescribed regulations as are given for amputation, and ligature of the arteries. The immedi- ate method of proceeding in very many cases must be left to the judgment and ingenuity ofthe surgeon, and should be adjusted to the character and extent of the pathological changes in the parts surrounding the bone. The operations for resection maybe arranged into three groups. 1. Those which are practised in the continuity of the bones; that is, at some point between their articular extremities. 2. Those in the contiguity, or at the articular extremities of the bones. 3. Those in which a bone is extracted in its whole extent. Indications.—The causes for which resection is practised are very various. 1. Caries ofthe articular extremities ofthe limbs, and of some of the bones of the trunk, when all other means have proved in- sufficient for its cure, and life is endangered by the progress it is making. 2. Osteo-sarcoma, spina ventosa, medullary fungus, and other affections of a malignant character, when they involve parts, as the upper and lower jaw bones, to which amputation cannot be applied. 3. Compound or-comminuted fractures, in which a fragment has been driven through the skin, and cannot otherwise be replaced in consequence of the obliquity of the fracture, the retraction of the muscles, or the inflammatory engorgement of the surrounding parts; or when a portion denuded of its periosteum has been exposed for some days to the air, and menaced with necrosis. The rule of treatment in such cases is both simple and easy—to enlarge the wound if it be necessary, glide a piece of card or some other means of protecting the soft parts below the bone, and remove the protruding portion with the saw or cutting forceps. 4. Gunshot injuries near the heads of the bones, and especially those ofthe upper extremities. These accidents, even when there has been extensive injury of the soft parts, have furnished again and again, occasion for the most gratifying and successful employ- ment of the resection of the shattered portion, with preservation of the limb. 5. Compound luxations; when the period which has elapsed from the occurrence ofthe injury, or the engorgement and inflam- mation of the soft parts, or other causes, present an insurmounta- ble obstacle to reduction of the protruded head of the bone. In cases of this sort resection has been many times done with success on most of the bones of the upper extremity. The end of a bone projecting beyond the margin of a stump after amputation, necrosis, some" forms of exostosis, or foreign bodies lodged in a bone, are all causes for which resection can frequently be practised with advantage. Counter indications and prognosis.—The resection of bones, especially when done for a chronic affection of the joints, consti- tutes nearly always a long, difficult, painful and complicated ope- ration, in consequence of the anatomical derangement of the parts, the enlargement and preternatural adhesion of the bones, and the thickened and callous nature of the surrounding structures, all which render it difficult to distinguish the vessels and nerves, and produces a greater risk of tetanus, protracted suppuration, fistulous sinuses, purulent absorption, erysipelas, gangrene, and necrosis, than ordinarily follows amputation. In regard to the fitness or unfitness of each particular case for the operation, no precise rules can be laid down. The many and various circum- stances of the case, the age of the patient and his powers of endurance, and the particular joint affected, must all be duly con- sidered by the surgeon. Though cases seemingly very unpromis- ing may eventuate well after resection, still not even the hope of saving a limb should lead the surgeon to prefer it to the more simple, easy, and rapid process of amputation, when the patient suffers from one of the cachexia?, possesses unusual nervous sus- ceptibility, or is in an advanced state of marasmus. Time of performance.—The time when resection could be prac- 10S GENERAL OPERATIONS. tised with the greatest certainty of success is most frequently al- lowed to pass by, before the ordinary resources of the art have been satisfactorily tested. As soon, however, as the prospective loss of limb or life becomes apparent to the surgeon, it should be undertaken, for fear that the soft parts should become too exten- sively involved to subserve the purpose of flaps. Nevertheless it is important to know, that if the tissues be indurated, larda- ceous, or even perforated with fistulous openings, they will often, in consequence of the removal of the source of disease and the establishment of healthy suppuration, be afterwards restored to a healthy condition. The elder Moreau believed such a restoration possible, if they possessed even the lowest degree of vitality. But such has not been always the result. The chances of suc- cess will vary much according to the condition of the soft parts, as well as to the seat of operation. In the continuity of the long bones, and in the thin or flat, as the shoulder blade, the consecutive inflammation is usually moderate and the cure rapid. In the spongy tissue of the heads of the long bones, and in the bodies of the short or thick, the results of the operation are more to be dreaded, and in a degree proportioned to the extent of struc- ture removed. Instruments and apparatus.—Besides the ordinary scalpel, there should be at hand a sharp-pointed and a probe-pointed bistoury, a double-edged amputation knife for the larger joints, the common dissecting and torsion forceps, saws of various descriptions, the bone-cutting forceps of Liston and Muller, blunt hooks, a tre- phine, the mallet and gouge or chisel, rollers, compresses, and strips of leather or flexible splints of wood, card, or metal, to glide between the bone and soft parts in order to protect them against the action of the saw.—with sponges, ligatures, and the other necessary appurtenances for ordinary surgical operations. Tbe tourniquet is not usually needed, as the large vessels are to be cautiously avoided, since their division would seriously com- promise the success of the operation. GENERAL RULES FOR RESECTION. The operation is divided into three stages. 1. The incision to expose the bone.—Two objects are to be kept in view—to expose the bone freely with the least injury to the muscles and tendons—and to avoid the route of the great vessels and nerves. For this reason, in operations on the arm and thigh, and over the orbicular joints, the incision is made on the outer aspect of the limb. In the hinge joints two lateral incisions are made, as the vessels and nerves are always found either on the anterior or posterior face of the joint. The incisions, however, must frequently be varied in regards number, form and extent, according to the size and depth of the bone, and the peculiar anatomy of the region. Considerable difficulty will often be en- countered in dissecting the soft parts from the bone, and in iso- lating the vessels and nerves, in consequence of the thickening induration, and even partial ossification of the surrounding cellu- lar tissue. If an articular extremity is to be removed, the direc- tion of Professor Syme, (which I find usually the most convenient in practice,) is to penetrate at once into the joint, by dividing at the same time the superficial covering and the ligaments with the knife. 2. Section of the bone.—The soft parts are to be separated with blunt hooks, and the diseased heads of the bones loosened with the knife, turned out between the lips of the wound, and divided with the saw or cutting forceps; or if there be a diffi- culty in turning them out, they may be cut in their bed with the rotary saw of Heine or Charriere, or the chain saw of Jeffrey. In the removal of the detached extremities, the bone screw of the trephine case fastened into the spongy tissue, will furnish a convenient command of the fragments. All the cartilaginous structure of the joint must be carefully removed. If the caries is found to extend beyond the place of division, another portion may be removed, or the advice of Jager followed, which is to apply the actual cautery to the end, in order to arrest the caries by producing necrosis. It will seldom, however, be found neces- sary, in cases of caries, to remove more than the epiphysis. But if the case be one of caries of the body, or necrosis of the shaft of a bone, the proceeding must be different. The extent of the caries will be determined in a great measure by the separation of the periosteum, which is to be opened, with the overlaying soft parts, by the probe-pointed bistoury, and the bone divided at the height at which the membrane is detached. If the caries involves but a part merely of the spongy structure, it is to be cut away with the gouge and mallet; but it is a law of the first importance when the operation is once commenced, to remove completely all the part actually carious, preserving as far as possible the periosteum. If the case be one of necrosis, the trephine, per- forator, or gouge may require to be used, according to the indi- cations already given. In resection of the bones of the fore arm and leg at the ankle and wrist, it will be best in most cases to re- move both at the same level, to prevent the subsequent deviation of the limb. 3. Dressing.—Union by first intention is seldom effected to much extent. In one instance, however, in which I had resected the elbow joint, it took place except at one point throughout the whole extent ofthe external wound, and the cure was proportion- ally rapid and satisfactory. An attempt, therefore, should always be made to accomplish it by closing the wound neatly with the interrupted suture, (to which I give the preference,) or the twisted suture—aided by adhesive straps, compresses, and bandages. The limb is to be steadied in addition with the apparatus for fracture and placed at rest on a bolster or pillow. In the lower extremity, where we desire a solid union, the limb is to be laid out in the straight or extended position. In the upper, the elbow must be flexed, as a position less constraining to the patient, and likely to leave a more serviceable limb in case the operation, if it be at a joint, should be followed by anchylosis. The first dressing should not be disturbed till the purulent discharge ren- ders it necessary. The after treatment must be apportioned to the symptoms that arise. I have derived, it appears to me, very great advantage by keeping the wound steadily wetted for the first week with cold water merely, or a strong lotion of lead water and laudanum, placing the patient during this time under the sustaining influence of opium ; thus limiting the amount of constitutional irritation by keeping down inflammation, and ob- viating one of the chief sources of danger—the development of tetanus. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 109 RESECTION OF THE BONES OF THE TRUNK. The resection of the bones of the cranium, whatever be the cause that renders the operation necessary,—tumours, caries, or necrosis,—must be practised according to the methods which have been detailed under the head of trephining. RESECTION OF THE BONES OF THE FACE IN GENERAL; The upper and lower maxillary bones are.far more subject than any others of the pile which constitutes the frame-work of the face, to structural degenerations which render their removal wholly or in part necessary. From the size and complicated structure of these bones, the disease, whether it consists of caries, cancer, medullary fungus, osteo-sarcoma, or tumours of a less malignant character, is very often, even after it has attained great development, comprised within the limits of the lower or upper maxilla. Definite and fixed rules have, therefore, been given for the separate resection of these bones. But in many instances the other bones of the face,—particularly those forming the walls of the orbit and nose, as the malar, the unguis, the palatine, and the lateral portions ofthe ethmoid,—if not primarily affected, become so involved in the progress of the disease as to require removal. But the intimate connection of these bones, their comparatively small size, and the varying degree of alteration to which they are subjected, renders it impossible to fix any general rule for their removal; the surgeon finding it necessary to modify the set rules or improvise, as it were, a plan suited to the exigencies of each particular case. Instances may occur where the tumour, espe- cially if it have its origin in the upper part of the antrum, will be found developing itself in the upward direction (in which it meets with less resistance), obstructing the cavity of the nostril and push- ing the eye from its socket without materially impairing the integ- rity of the palatine and alveolar processes. In these instances, the outer wall of the antrum has been opened, the contents of its cavity scooped or dissected out, and such parts merely of the bones above and around it as were affected taken away, leaving a part of the upper maxilla to preserve the proportions, and to a considerable degree the. usefulness of the jaw. Tumours of a fibro-cellular character may even grow from the periosteum on the outer wall of the antrum, producing great de- formity ofthe face, without altering the shape or specifically affect- ing the bones, which require no method more severe for their removal, as has been shown by Dupuytren and Dieffenbach, than simply stretching the commissure of the mouth with hooks, or if necessary widening the opening by an incision, dividing the buccal mucous membrane, drawing down the tumour with a hook and removing it from over the face ofthe bone. Frequently, moreover, we meet with instances where the tumour, as in epulis, has had its origin in the gums, or the sock- ets of the teeth, in which it suffices merely to remove with the saw, or better still with the cutting forceps, the parts immediately involved, not interfering to any great degree with the bony contour of the face, or leaving a greater breach on the side of the mouth than can be hidden by the mechanism of the dentist. OF THE UrPER JAW. (PL. XXV.) In m ost instances, patients afflicted with malignant tumours 28 of the jaws are unwilling to submit to an operation apparently so fearful as resection, until the upper maxilla of one side has become so much involved, as to require to be wholly taken away, and the other bones of the face so extensively implicated in the affection, that the saw and the bistoury will not alone suffice—the cutting forceps, the gouge and mallet, or the incandescent iron, being required to complete the extirpation, without regard to the anatomi- cal connections ofthe bones. General Rules. There are, however, certain general rules for resection, as ap- plied to any portion of the bones ofthe face, which must be con- stantly observed, as far as the nature of the lesion will allow. 1. To avoid injuring the parotid duct, or the branches of the portia dura nerve which give motion to the muscles of the face, by open- ing the soft parts in a direction as much as possible parallel with their course. 2. To protect from unnecessary injury the facial artery and the infra-orbital and mental nerves. 3. To carry the line of incision or amputation in a part of the bone which is per- fectly free from enlargement or other indication of unhealthy action. 4. To tie the arteries, which are commonly small, as they are divided and come into view, arresting the hemorrhage if it be profuse by pressure on the common carotid or the tem- poral artery, until the ligature can be applied, and using the actual cautery to suppress capillary bleeding as well as to destroy any diseased portion that cannot be reached by cutting instru- ments. The great improvement of modern surgery, in reference to un- doubted malignant growths of the upper maxillary bone, consists in its amputation entire at its points of articulation, instead of attempting to cut out with saws, forceps and gouges, the diseased mass alone, which process is too apt to leave behind some germ for the future reproduction ofthe evil. If, by the removal of the maxillary bone, we get rid of the whole site of the disease, the prospect of the return is infinitely less than when we have to attack in addition the palate, unguis and malar bones. Surgical anatomy.—The upper maxillary is united with the other bones ofthe face at four separate points, which, though well calculated to support pressure in mastication, may nevertheless be readily separated. But three of these, however, as has been ob- served by Gensoul, merit the particular notice ofthe surgeon. 1. Above and in front, where the nasal process ofthe maxillary joins with the frontal, nasal, lachrymal and ethmoid bones. 2. Upwards and outwards, where it unites with the malar bone, and through this is connected with the zygoma and with the external angular pro- cess of the os frontis. 3. In front and below, where it comes in contact with the corresponding maxillary and palate bones. The fourth, where it unites behind with the pterygoid process and the palate bone, presents no obstacle to the separation, yielding readily when the maxillary bone is depressed toward the cavity of the mouth. The arteries divided are small, and consist of the branches of the internal maxillary and the facial. The trunk of the former is not usually injured, but if cut can readily be tied after the removal of the bone. But one important nervous trunk is necessarily involved—the superior maxillary—and the division of this may be readily made, so as to prevent traction upon it, previous to the luxation of the bones. 110 GENERAL OPERATIONS. Methods in general.—Various methods have been employed for laying bare the bone, when the soft parts have not been so in- volved in the lesion as to determine necessarily a particular mode of incision. If the alveolar margin of the bone only requires to be removed, it will suffice in many cases to draw the lip upwards and outwards, and divide the mucous membrane which attaches it to the bone; and if more space is required in order that the saw or forceps should work with advantage, the mouth may be widen- ed by division of the commissure: or, which is usually to be pre- ferred, the upper lip divided near its middle by a vertical incision extended as far as necessary along the outer margin of the ala, the triangular flap being subsequently dissected off from the bone. It has been advised, if the portion of bone affected be between the incisor and third or fourth molar tooth, and extends upwards to- wards the orbit, to expose it by dividing the cheek in the direction ofthe inner border of the zygomaticus major, from near the angle ofthe mouth upwards and outwards to the margin ofthe masseter w-ithout injury to the duct of the parotid. If the tumour be broad and the dissection of the soft parts in either direction do not sufficiently expose its surface, a vertical incision through the lip and by the side of the ala nasi may be added so as to form a sort of V shaped flap, which is to be dissect- ed up towards its base. If the disease is located behind the third or fourth molar tooth, the outer incision, instead of pass.ng along the course of the zygomatic muscle, should run out transversely to the masseter, leaving the duct ofthe parotid on the upper flap. PLATE XXV.—RESECTION OF THE UPPER JAW. (Process as employed by Warren, and modified by Velpeau.) Fig. 1 and 2.—A semilunar incision has been made from the commissure of the lips to the middle of the space between the external canthus of the eye and the point of the ear, as shown in fig. 3, and the flap rapidly dissected off from the bones, and reverted with the undivided upper lip upon the forehead, where it is held by the two hands of an assistant (d and e). The zygomatic process, the external angle of the orbit, the nasal process of the upper maxillary, and the palatine arch between the second incisor and canine teeth, have all been successively divided, and the fat of the orbit carefully detached from the floor of the orbit without injury to the ball. The next stage of the operation is that shown in the figure, in which the surgeon loosens the bone with his left hand, while with a knife in his right he detaches from above downwards the soft parts from the bone on the side of the zygomatic fossa. f Section of the zygomatic arch. g. Section of the external orbital process. h. Section of the nasal process of the upper maxillary bone. i. Section of the palatine arch. j. Eyeball, surrounded with its mass of fat. k. Maxillary bone, moved by the left hand of the surgeon (/) for the purpose of shaking it from its remaining attachments, while it is detached with the knife (m) from its connection with the soft parts in the zygomatic fossa. In fig. 2, the surface of the wound is exhibited after the removal of the bone. The space from n to o shows the portion of undivided lip reflected upwards with the flap. p. Section of the upper maxillary bone. q. Palatine arch. r. Nasal septum, above which are seen the middle turbinated bone and the os planum of the ethmoid. s. Posterior opening of the nasal fossa, comprised between the septum within, and the zygomatic process without. t. Border of the temporal muscle. u. Section of the zygomatic attachment of the masseter. v. Surface of the tongue. Fig-. 3.—Wound closed after the preceding operation. Fig. 4.—Closure of the wound, after the removal of the bone by incisions made according to the process of Gensoul. Fig. 5.—Excision of upper jaw bone, as practised by Lizars, Syme, Liston, and others. a, b, b. Line of incision of the upper lip, extended from the nostril through the ala of the nose. Liston prefers to make the incision from the margin of the nostril along the line of junction of the ala with the cheek. d. Horizontal incision from the corner of the mouth. The triangular flap thus formed is to be dissected up rapidly from the face of the bone, and reflected upwards and outwards. Fig. 6.—View of the parts after the elevation of the flap, formed as seen in fig. 5. a, b, b. Vertical line of incision in the lip and side of the nose. d. Horizontal incision. c, e, i. Flap reflected off from the tumour of the maxillary bone (g). h. Nasal process of the upper maxillary bone sawn or cut across with the forceps. k. Palatine portion of the upper jaw bone, cut through into the nostril after the removal of the canine tooth. r. The facial artery, divided in the horizontal incision, and secured with a ligature. Flate Z< Fiff. / • StoK, by ■ J f t ibt,s/,c. /,, .;,,,, j,u.. PS !)„,:>. /.U/l OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. Ill M. Gensoul recommends, especially where the entire bone is to be removed, the formation of a square flap as detailed in the pro- cess below. Mr. Ferguson* advises the V shaped flap above described, with the addition of an incision extended from the external angular process ofthe frontal bone, towards the neck ofthe lower jaw, so as to form an outline of this description N. Velpeau has proposed to substitute for the complicated incision of Gensoul a simple division of the cheek, (see PL XXV. fig. 3,) extended from the corner of the mouth to the external canthus of the eye, or the re- gion ofthe temple immediately behind it, leaving the duct of the parotid in the lower flap. The cicatrix following this process is more regular and less deforming than that following the process of Gensoul. Dieffenbach* has proposed a new method of turning off the soft parts, which he has applied to the resection of the bones of the face in general. Let the seat of the disease be where it may, even if it be in the posterior region of the cheek, he dissects up and throws back a large flap, which is marked out above, by a hori- zontal incision passing from one canthus to the other, leaving en- tire the lower eyelid, and on the median line by a vertical incision through the middle of the upper lip and over the back of the nose, through both skin and cartilage, so as to divide the nose into two equal parts. Care must be observed to preserve the conjunctiva with the upper lid; and, in dissecting at the internal canthus, to separate the tissues from the bone, in a way to avoid all injury of the lachrymal passages. In dissecting back the flap, the infra- orbital nerve is the only part of importance divided ; but although the facial nerve, the duct of the parotid, and the facial artery, are preserved uninjured in the thickness of the flap, it is very ques- tionable whether, from the risk of injury to the eye, and of the chance of deformity in reconstructing the nose, it will ever be much employed by any other surgeon. Process of Gensoul. (PL XXV. fig. 4.)—The patient is to be seated on a low chair, with his head thrown back and sustained against the breast of an assistant. A vertical incision is to be dropped from near the inner canthus of the eye, so as to divide the upper lip completely through over the dens caninus. A second transverse incision is to be carried outwards from this, commenc- ing on a level with the nostril, and terminating a third of an inch in front of the lobe of the ear. To the outer end of this incision a third is carried down nearly vertically, beginning at a point about half an inch to the outer side of the external canthus. The whole side of the face is thus divided into two flaps; the upper one, which is square, is to be dissected and turned over the forehead, and the lower, somewhat triangular in shape, reversed merely upon the angle of the jaw. The bone is now fully ex- posed. If a portion only is to be taken away, it may be done with a knife if the bone be soft, or by the use of a Hey's or a narrow- bladed saw, the strong cutting forceps, or, if need be, the mallet and chisel. But if it requires to be taken away entire, it will be necessary to detach it with five blows with the mallet and chisel, or as many applications with the cutting forceps, which will usu- ally be found to answer the purpose as effectually and with less shock to the brain. First, we divide the union ofthe malar bone * Practical Surgery, Amer. edit., p. 520. t La Chirurgie de Dieffenbach, par Ch. Phillips, Berlin, part. I. p. 122, 1840. to the external orbital process ofthe os frontis. Secondly, the zy- gomatic process of the malar bone. Thirdly, the os unguis and the nasal process of the upper maxillary. Fourthly, all the soft parts uniting the ala of the nose to the bone ; removing the first incisor tooth of the same side, and entering a chisel at this point, but in the direction of the eye, of the affected side, so as to separate the diseased bone from the place of junction with the one of the other side. (The maxilla is now loosened at its three principal points of attachment, and is held by no other bones than the pala- tine and the pterygoid process of the sphenoid.) Fifthly, the chisel is to be directed obliquely upon the floor of the orbit from above downwards and before backwards, in order to destroy its connec- tions with the pterygoid process, to divide the upper maxillary nerve, and at the same time gain a point of support, so as to poise the loosened bone over in front. The surgeon has then only td divide with the curved scissors or bistoury the soft parts connected with the bone, and especially the attachments of the velum palati to its lower and back part, as the velum should be left entire. The mass of bone, which now readily comes away, consists ofthe upper maxillary and the malar bone, and a part of the unguis, ethmoid, and palatine. A large excavation is left, (PL XXV. fig. 2,) limited within by the septum of the nose, without by the buc- cinator muscle, above by the inferior rectus muscle of the eye, (the origin of which has been divided,) and the fat of the orbit, communicating below with the mouth, and behind with the pha- rynx, above the velum palati. This operation, formidable as it appears, may nevertheless be quickly done. Gensoul has ope- rated in eight cases without losing a patient; and in one instance the removal of the bones was effected in two minutes and a half. It is seldom that more than one or two small arterial branches require to be tied. Necrosed portions of bones will be frequently thrown off' for some time after the operation. More or less para- lysis of the face follows, a result which can only be avoided by opening the soft parts after the manner of Dieffenbach. Dressing. (PL XXV. fig. 4.)—The wound is kept open for half an hour or an hour, in order to allow the capillary bleeding to cease, and to facilitate, according to Dieffenbach, union by first intention. If there is any morbid or even suspicious tissue left after the removal of the bones, the actual cautery is to be used to destroy it. If it be found even on the under surface of the flaps, Dieffenbach does not hesitate, when it can be removed by this means, to pass the cautery rapidly over it, in preference to removing any portion which would increase the amount of the deformity. The flaps are to be brought together with the twisted suture, and the parts supported according to the direction of Velpeau, by a retaining bandage. Cold applications are to be made over the face. The bones left, will gradually approximate during the progress of the cure, and the deformity following the operation will be much less than would be previously supposed. A troublesome incident during the operation is the fall of blood into the throat, and it is for the purpose of obviating this as much as possible, that the patient is placed in the sitting posture, and that the detachment ofthe bone is commenced on the si le of the cheek. The cavity between the tongue and the eyeball is to be lightly filled with lint or charpie, (to prevent the latter sinking too low,) and withdrawn at subsequent dressings ihough the orifice of the mouth. 11: GENERAL OPERATIONS. Process of Lizars. (PL XXV. fios. 5 and 6.)—The surface of the bone is exposed up to the margin of the orbit, by the eleva- tion of the triangular flap, referred to at page 110, formed by a horizontal incision from the mouth and a vertical one through the side of the nose and the upper lip. The soft covering of the bone is then to be divided at the parts where it is to be sawed, by ap- plying the knife—first, upon the floor of the nostril; secondly, over the nasal process; thirdly, upon the gum and mucous mem- brane of the mouth near the palatine suture, keeping in view the preservation of the palatine plate of the palate bone ; and lastly, round the bone on the side of the pterygoid fossa. The nasal, the malar, and palatine processes, are now to he notched with a saw. One blade of a large pair of cutting forceps is introduced into the nose, and the other into the orbit, so as to divide the nasal process of the maxillary bone. The connection of the maxillary with the malar bone is then separated in the same way; and finally, after having removed one of the incisor teeth, (pro- vided it had not previously come away,) the alveolar process and PLATE XXVL—RESECTION OF THE LOWER JAW. (Fig. 1.) RESECTION OF THE CHIN. This portion of the bone alone being diseased, the middle of the lip has been divided in the middle line, and the section continued down to the os hyoides. The flaps have been dissecfed off and reverted, and the two canine teeth extracted, to give passage to the saw with which the jaw is divided vertically on either side of the chin. Previous to detaching the piece, a fine silver wire has been passed through the substance of the genio-hyo- glossus muscles, in >rder to prevent the convulsive retraction of the tongue backwards. In the stage of the operation shown, an assistant holds the wire thread (a), while the surgeon draws downward with the left hand (6), the fragment of the jawT, and with the bistoury (c), is about to divide the insertions of the genio-hyoglossus, and genio and mylo-hyoid muscles. (Fig. 2.) RESECTION OF THZ BODY OF THE LOWER JAW ON THE LEFT SIDE. The points for dividing the bone being at the canine tooth of the same side, and at the origin of the ramus, a vertical incision (a) has been made through the lip to the base of the chin. Another incision (6), starting from the middle of the posterior part of the ramus of the jaw, is carried first down to the angle, and then along the base of the jaw to the vertical incision at the chin. The flap (c) has been dissected off from the bone, and reflected upward upon the cheek. The first molar tooth has been removed to give room to the saw in dividing the bone. The bone has next been separated by dissection from the soft parts on its inner face, and a guttered instrument (e) passed below the bone, on the groove of which the chain saw of Jeffrey has been passed, as seen in the drawing, for the purpose of making the last section of the bone. (Fig. 3.) RESECTION OF THE WHOLE LOWER JAW. A single incision, commenced below the lobule of the ear at the posterior part of the ramus of the jaw of one side (a), has been carried first down to the base of the jaw of the same side, then around the base (b, c), and ascending on the ramus of the opposite side, to a height corresponding with its place of commencement. The facial artery will be divided in this incision, and must be secured with a ligature. The immense flap (d) thus circumscribed, is dissected from below upwards off from the bone, loosening it first in its middle portion, and then on its sides, by cutting the attachments of the masseters (e). The flap is then reversed upon the face, so that the edge ofthe lower lip (f) becomes inverted. The jaw is next isolated below and within by dividing the platysma muscles (b, c), and the mylo-hyoid (g). Then, before cutting the attachments of the tongue, a well annealed silver wire is passed through the substance of the genio-hyoglossus muscle, brought out between the lips, and given in charge to an assistant; after which the attachments of the tongue may be divided with impunity. The jaw thus isolated on its inner side, is sawed through at the symphysis, to facilitate the disarticulation of each branch. In the drawing, the left half has been already removed, and the right, forced outwards, displays the gutter (e) from which the jaw has been removed, the under surface of the tongue (m), the sides of the tongue (n), placed within the upper dental arch, and the section of the left pterygoid muscles (o). Between these muscles the trunk of the internal maxillary artery has been tied, so as to prevent hemorrhage from its various branches—the inferior dental, the masseter and pterygoid, which have been cut in the operation. The assistant, who holds with his hands (p, p) the flap, is to make pressure previously on the trunk of the carotid artery till the stage of the operation arrives in which the internal maxillary can be secured. In the last step of the operation, as represented in the drawing, the surgeon, after having isolated the coronoid process, forces out the right half of the jaw with one hand, while he divides with the knife in the other, the insertion of the internal pterygoid near the condyle, which presents the last obstacle to the disarticulation of the bone. t'tar-e ?.',. /<'/W.*-.' 'K P/ftti' Z8 Fig J /■'/,, - Fll( / %££" \ ■;\ l'h.l.,,1. //,/,,.. . I ■„ I./,,'...{ !.,. I ,,,;■„ A- //„,/ PS. /)„*„/. Hlh.TUil' OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 121 is to be opened transversely, and the insertions of the four articu- lar muscles carefully cut with a probe or button-pointed bistoury, rolling the bone so as to bring them successively under the action of the knife. The long tendon of the biceps may usually be saved, though its division if necessary may be made without much disad- vantage. The elbow is then to be forced inwards and upwards, in order to luxate the head of the humerus and make it protrude at the wound, and the knife carried behind the head so as to separate the soft parts on its inner face. A compress or a piece of card or wood is to be passed between the humerus and soft parts, and the diseased portion cut off' with a saw. This process is the most simple and the most ancient, but at the same time one of the most difficult, except in cases where the joint has been previously opened, or the head separated from the body of the bone as in a gunshot wound. To facilitate the division of the tendons, and the protrusion of the head,—the most difficult step of the operation,—M. Baudeus has proposed to divide the deltoid across, at each angle of the vertical cut, below the skin and without cutting the latter. Textor modified this process so as to give to the external wound the shape of the letter L, or that of a {-, the longitudinal incision passing down on the outer side of the biceps, and the transverse across the deltoid. Bromfield crossed the lower end of the longitudinal incision of White, with a transverse incision through the deltoid, forming a _L reversed. Bent made a short transverse incision over the acromion a1 the top ofthe longitudinal, |~; this, when the triangular flaps are dis- sected off, exposes largely the joint, and serves particularly well when it is necessary to remove in addition a part of the acromion process or cervix scapula. The process of Sabatier as modified by Goyraud consists in raising up and turning over the acromion, a V shaped flap of the deltoid from the anterior and superior part of the shoulder. Moreau and Manne formed a quadrilateral flap by means of two vertical incisions; one passing down from the acromion and the other from the coracoid process. These were united by Moreau by a transverse cut immediately below the acromion ; by Manne at their lower extremities. Bell and Morell formed a semilunar flap with the base upwards. Buzaires adds to the longitudinal incision of White, in cases where this does not yield room enough to effect the extraction of the head of the bone, a transverse cut made from the acromion either along the spine of'the scapula or in the direction of the clavicle; or in both directions, if it be necessary at the same time to resect a portion of the scapula. Malgaigns proposes to modify the longitudinal incision of White, by commencing higher up and a little more to the inner side: viz., at the top ofthe coraco-clavicular triangle. He extends the incision downwards for five inches, dividing at one stroke the skin, the deltoid, and the capsule. This exposes the joint freely on its inner and upper surface, and gives great facility in the ex- traction of the head. Roberts commences the longitudinal incision from the anterior margin of the clavicle, two fingers' breadth from the acromio- clavicular articulation, and carries it down through the deltoid between the coracoid and acromion processes. 31 Syme (PL XXVIII. fig. 1), adds to the longitudinal incision of White, another which passes from its inferior termination back- wards and a little upwards, so as to divide transversely the ex- ternal part of the muscle. The raising of this quadrilateral flap exposes well the structure of the joint. The capsule is to be divided across, the finger, introduced into the joint to serve as a guide to the knife in the section of the articular tendons, and the operation completed as has already been described. The only artery requiring to be tied is the posterior circumflex. Process of Bourgery. (PL XXVIII. figs. 3, 4, and 5.)—The patient is to be seated upon a chair, with his head held over to the opposite side by an assistant, who at the same time with one hand compresses the subclavian artery over the first rib. 1st Step.—The surgeon, standing on the outside, gia~ps 'he arm (which is to be slightly drawn out from the trunk), with the left hand, and enters a catling at the back part of the articulation an inch and a half above the posterior fold of the armpit. Cir- cumscribing the bone and the capsule with the point, the knife is to be next passed out below the acromion, as in Lisfranc's operation for disarticulation at the shoulder joint. The knife is now to be carried down close on the outer face of the bone, to- wards the insertion of the deltoid, so as to form two vertical incisions each three inches long—the upper terminations of which are found at the places of the entry and exit of the point of the knife already mentioned. The knife is then to be withdrawn; a compress is to be passed through the wound for the purpose of raising the bridge formed between the incisions, which will con- sist of the greater part of the mass of the deltoid, 2d Step.—An assistant raises the arm in order to relax the mus- cle, and at the same time lifts the bridge ; the surgeon then with a common scalpel separates the attachment of the biceps round the neck of the humerus, so as to be able with the aid of a spatula to pass a compress below it, the two ends of which are to be drawn downwards and backwards, in order to carry out of the way of the instrument the muscles, vessels, and nerves that occupy the armpit. The, capsule and the tendons ofthe articular muscles are now to be cut across; a chain saw is next to be carried round the neck of the bone, so as to divide it from within outwards. The loosened fragment is then removed by dividing the attachments of the capsule on its posterior face, and luxating it through the anterior incision.- The glenoid cavity and the adjoining parts of the scapula are next to be examined, and any part found diseased should be removed with the saw or cutting forceps. If, on sound- ing with the probe, the neck of the scapula appear much involved in the affection, or if extensive fistulous sinuses have formed, am- putation at the joint will be preferable to resection. Dressing.—Whatever process is adopted, the incisions are to be closed by the interrupted suture, after the introduction of a mesh at the depending point of the wound for the purpose of affording exit to the purulent discharges. The divided osseous surfaces are to be brought gently together, and the arm kept per- fectly at rest in the apparatus for fractured clavicle. .Appreciation.—Of the various processes above' described, those with longitudinal incisions merely, are to be preferred, whenever the state of the bone or the soft parts admits of their application. These inflict Jess injury on the deltoid muscle ; this is a mat'er of some importance, as one of the consequences to be dreaded, where 12. GENERAL OPERATIONS. a flap has been formed by a transverse section of its fibies, is such a retraction ofthe ends as will prevent their coming together and rendering the muscle again capable of acting on the arm. Of the longitudinal incisions, I prefer those of Bourgery and Mal- gaigne; of the flap operations, those of Syme and Bent. But they may all occasionally be found applicable—the greater or less size of the head of the bone, or the peculiar injury of the soft parts, often rendering some one more particularly indicated than the rest. RESECTION OF THE ELBOW JOINT. (PL. XXIX.) The elbow joint, next to that of the shoulder, is considered as offering the most favourable indications for resection ; for even in PLATE XXIX.-RESECTION OF THE ELBOW JOINT- (Fig. 1.) RESECTION OF THE LOWER END OF THE HUMERUS. (Process of Moreau.) The patient is laid upon the abdomen, and the left arm, carried a little outwards from the trunk by an assistant, presents its posterior surface upwards. With his other hand, the assistant may compress the trunk of the brachial artery. The drawing represents the state of the wound at the end of the operation, when a few fibrous attachments alone remain to be cut. The portion represented as removed is far greater than will be required, unless the whole head of the bone should be found carious. a. Flap, formed ofthe integument and the inferior end ofthe triceps muscle, dissected from the bone and turned upwards towards the shoulder. b. Upper border of the wound, formed by the cut through the triceps. c. Inferior border of the wound, formed by the supinator radii longus and the radial extensors. d. Bottom ofthe wound after the resection ofthe bone, formed by the posterior surface ofthe brachialis anticus the fibres of which have been cut obliquely at their attachment to the bone. The white line indicates the position of the ulnar nerve. e. Section of the os humeri. /. Olecranon process of the ulna; below this is seen the articular cavity on the end of the radius. The ends of these bones are supposed to be healthy, so as not to require removal. g. Left hand of the operator holding the resected piece, while with the other hand he detaches it with the bistoury (h). (Fig. 2.) RESECTION OF THE ENTIRE JOINT, AS EMPLOYED SUCCESSFULLY BY THE AUTHOR. The patient is represented as lying on the abdomen, and the right arm resting over the side of the bed, with its back uppermost. IVo longitudinal incisions have been made, as shown in fig. 3, and one transverse, uniting the former over the back of the joint, the cavity of which it opens; the two quadrangular flaps (a, b) have been dissected up from the bone and reverted. The end ofthe olecranon process was first removed, then the condyles of the humerus, and lastly, the heads of the two bones of the forearm. c, c. Ulnar nerve winding round the inner condyle to get to the forearm. d. The articular head of the radius. "' «wTXtrCmKy-0f Vhen'na' , ^ °leCran°" P'°CeSS h8S bee" de,acl,ed at its base ™«> 'he ordinary amputating he u na Z nTtf , „T ' "eXed f°r ,he PUrp0SC' T"e Uack line indiMt- "" P*™ "bJJLd of tne ulna was notched with the saw. /, g. Outer and inner condyles of the os humeri *" relle exdrpatn °" TwT T't ™\™ ^ ^P08^' bUt "* CaH°US °r °therwise ^™* - » to require extirpation. Two sections have been made with a short straight saw from either tuberosity of the bone, meeting at an angle in the sigmoid fossa tuberosity ot the this bone " "aS subse1»™% W'^ i» 'he same manner „„ the opposite margin of *' cSomPk.:adge'ShaPed CUSeI' ^ "hiCh With ' fe" 'apS °f "» ™""> «"» -.ion of the head of the „,„a was "* ^ziiL",:^:;:^ af,et,,h^opera,ion'with se™ai **■*> -*«■ - *—»*- %- equallyas well ' ^ "^ "* Pa"S ^ lhicke"ed a"d hard> a°d ™™° "» P-Pose Fai. / rt■ I'm ? ,!,, S/.-u. "•■/. H,::l... /■/,,/..,„-,„/,,.,, /'„/,/,,.<-,,.., ,.,- ,:,,..,■(.//,,,., f.V /■)■„,..,/. I.,//. /■/,,/ OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 123 case anchylosis should succeed to the operation, the patient will still retain in a good degree the uses of the hand and limb. It was first practised by Moreau, (in 1728,) and since that time has been done by a number of surgeons, for caries, gunshot wounds, and comminuted fractures complicated with opening of the joint. Velpeau has collected sixty cases, in forty of which the operation was successfully performed. In a majority of instances, the condyles of the humerus will be found the part most extensively affected. The necessity of resect- ing the condyles merely, or of extending the operation at the same time to the olecranon and the head of the radius, will depend upon the degree of pathological alteration in the joint. The brachial artery, and the median and radial nerves lying on the front of the arm, separated from the bone by the brachialis anticus muscle, are not liable to be injured; but the ulnar nerve is much endangered on account of its position, and must, when it is necessary to take away a large portion of bone, be carefully detached from the fibrous sheath between the olecranon and the adjacent tuberosity ofthe humerus in which it is contained. But in cases where the articular facets of the humerus only require to be removed, I have not found it necessary to disturb the nerve from its bed. The thickness of the muscles and the position of the vessels on the front part of the limb, render it necessary to attack the articulation from behind. Various processes have been employed by different surgeons in resection of these bones. Longitudinal incision.—Park made a longitudinal incision four inches long over the back part ofthe elbow joint, separated the soft parts from the bone, divided the lateral ligaments, sawed off the olecranon process, dislocated the humerus backwards, and subse- quently divided the bones. This process is attended with diffi- culty, from the little space it allows even when a transverse incision is made in addition over the olecranon, and has, therefore, been abandoned. Simpson improved this method by crossing the ends ofthe lon- gitudinal incision by two transverse ones _C, so as to form two lateral flaps. The objection to this, is the increased risk of injury to the ulnar nerve. Incision in |—. Jaeger, assuring himself of the position of the ulnar nerve by pressure with the finger, makes an incision directly over it two inches and a half long, the centre of which rests on the internal condyle. The ulnar nerve is then to be separated from its sheath, and drawn by an assistant with a blunt hook over the internal condyle. The operator, strongly flexing the forearm so as to render the tendon of the triceps tense, next enters a strong bistoury at the back part of the joint, and opens it transversely by one cut, which divides the tendon of the triceps, the skin, and the posterior part of the capsule—turning subsequently the edge of the knife inwards and outwards so as to divide the lateral liga- ments. The two flaps thus formed are to be dissected up, and the joint resected in whole or part, according to the extent of the pathological alteration. Roux and Liston employ this form of incision. Roux makes, however, the longitudinal incision over the external condyle, and dissects off the two triangular flaps towards the internal condyle, so as to expose the inner and pos- terior face of the joint. In cases where the resection is only to extend to the. articular facets of the humerus, the reflection of the flaps inwards enables the surgeon to accomplish his object with- out disturbance of the ulnar nerve. This is a neat process, and leaves a wound which cicatrizes readily after the operation; but under many circumstances,—as where the bones are much en- larged, and the subcutaneous tissues are thickened and hardened, —does not sufficiently expose the joint to render the operation easy. Semilunar incision.—Sedillot has proposed, in cases where we wish to remove only the inferior extremity of the humerus, to make a semilunar incision convex downwards, which should cross the point of the olecranon. The arm remaining flexed at a right angle, the tendon of the triceps is to be cut, and the flap reflected upwards, the lateral ligaments divided, the ulnar nerve separated from the olecranon, and the end of the humerus luxated back- wards, so as to be divided with the saw. If all the bones of the joint require to be removed, he advises two lateral semilunar in- cisions, the arches of which should meet on the centre of the olecranon, and the extremities rest upon the condyles of the humerus. After dividing the ligaments, opening the joint, and sawing off the olecranon, he proceeds to the resection of the end of the humerus. These processes of Sedillot I find easy of execution on the dead body; they might answer well in cases of traumatic injuries ofthe joint, but they have no particular advantages over the incision in I—, and are liable to the same objections. Incision in |—i.—The process of Moreau and Syme, which con- sists of two longitudinal incisions, united by one drawn trans- versely over the joint, has been generally adopted, as the most easy of execution, and fulfilling best the indications, whether the end of the humerus is to be removed alone, or in conjunction with those of the two bones ofthe forearm. The greater dimen- sion of the wound occasioned by this process, is of little import- ance compared with the greater facility it affords for protecting the surrounding parts, for determining the extent of the disease, and finishing more speedily the operation. The" author employed this process (PL XXIX. fig. 2), in the following manner, in a case of fungus of the joint with caries of the articular surface of the three bones forming its structure, for which, from the constitutional irritation the patient had suffered, and the repeated formation of phlegmonous abscess above the joint, it had been proposed to amputate at the arm. As this operation has but in a few instances been practised in this country, the de- tails will be given somewhat at length. I was assisted in the operation by Drs. Peace, Davis, Huston, and others. The patient was placed with his face downwards on a bed, over the side of which his arm was extended and supported by an assistant. Another assistant steadied the shoulder, and restrained the movements of the patient. A bistoury was now- entered perpendicularly into the joint, on a level with the top of the olecranon, with its back almost in contact with the ulnar nerve, as directed by Syme, and the integuments, triceps tendon, and capsule, divided with a sawing motion completely across to the external tuberosity ofthe arm. From either end of this transverse incision, the integuments were divided through to the bone, up- wards as well as downwards for an inch and a half along the opposite margins of the arm, so as to give'the wound the shape of the letter H, and form the two square longitudinal flaps of 124 GENERAL OPERATIONS. Murcau. The ascending incision, on the ulnar side of the arm, was inclined at its commencement a little towards the radius, for the purpose of more surely avoiding the course of the ulnar nerve. The flaps were dissected from the surface of the bone, and reflected upwards. The upper one was so loosened by suppuration from the end of the humerus, as to be readily stripped off. Its reflec- tion upwards was more difficult in consequence of the great effu- sion of ossific matter in the cellular tissue on the side next the bone. The olecranon process was then sawed off at its base, in a direction slightly sloping towards the joint. The surfaces of the bones forming the joint were now well exposed to view ; the ends of the humerus and ulna were found extensively affected with caries, and the synovial membrane of the interior of the joint, as well as that of the lesser sigmoid cavity, was soft and pulpy. The caries had not, however, extended beyond the articular epiphysis ofthe bone, though each bone at a considerable distance from the joint was thickened, and rough, and reddened by granulations in the process of formation. The ligamentous structures on the sides ofthe articulation were now cut through with the knife; care being taken in dividing the internal lateral ligament to loosen previously the ulnar nerve from its bed, and press it inwards with the left thumb, while the bistoury was introduced between it and the ligament with which it lies in contact. The arm was then bent and the radius twisted forward, so as to expose completely the external condyle. This was divided with a Barton's saw from a point just below the tuberosity nearly into PLATE XXX.—RESECTION OF THE BONES OF THE FOREARM. (Fig. 1.) RESECTION OR EXTIRPATION OF THE METACARPAL BONE OF THE THUMB. A quadrilateral flap has been raised from the radial side of the bone and reflected on the back of the hand. The bone (a) has been denuded on its dorsal surface, and disarticulated from the first phalanx with the knife. It is represented as held by the left hand of the operator, at the moment at which he is about to sever its last ligamentous connections at the carpal joint with the bistoury (b). At the palmar margin of the wound, is seen the muscles belonging to the ball of the thumb, and at the dorsal, the extensor tendons, which have been carefully separated from the bone. (Fig. 2.) RESECTION OF THE CARPAL EXTREMITY OF THE RADIUS. A longitudinal incision has been made along the outer margin of the radius, the lower end of which is crossed by another at a right angle, so as to form a sort of ~f incision. The flaps have been dissected up, the bone isolated so as to admit of a compress being passed below it; and over this passed a chain saw, with which tbe bone has been divided. The operator then raises the fragment, as shown in the drawing, after having opened the radial articulation, and completes the resection by dividing the remains of the ligamentous connection on the inner side of the bone with the knife (c). A hook draws outwards the aponeurosis, the cephalic vein of the thumb, the radial nerves and vessels, and the extensor tendons of the thumb as well as those of the two carpal radial extensors. On the inner or dorsal side of the wound are seen the extensor tendons of the fingers. At the bottom of the wound are seen the fibres of the pronator quadratus muscle. (Fig. 3.) RESECTION OF THE CARPAL EXTREMITY OF THE RADIUS. A longitudinal incision has been made as in the process of Roux, from the lower end of which a short incision was made in the direction of the head of the radius. The flap has been reverted, the bone isolated, and a band passed below, with which the soft parts are partly drawn away from the bone. Over the band a chain saw- has been passed, with which the bone is about to be divided, c, d, are the tendons of the extensor and flexor carpi ulnaris muscles. (Fig. 4.) RESECTION OF THE RADIO-CARPAL ARTICULATION ENTIRE. (Process of Bourgery.) The soft parts are separated entire in two masses, anterior and posterior, so that the different tissues, vessels, nerves and tendons, are undisturbed in their relations with each other. The sheaths of tbe tendons that glide over the bones are necessarily opened. By this process, the carpal extremity of the radius and ulna alone, or the whole articulation may be removed, according to circumstances. A longitudinal incision has been made on either side of the joint, and the soft parts carefully separated from the anterior and posterior surfaces of the bones, so as to admit of the introduction of two linen bands, by which they have been lifted from the bone; this has given room for the action ofthe chain saw with which the lower ends of the radius and ulna have been divided. The same process as shown in the drawing, is repeated in the section with the saw of the first range of earpal bones, in order to remove the joint entire. Plate 30 rhihidtJfjtua . Published- by Carey ••'// /• ,/■■ Sl,.„, ij. I. 13, r,/l.' •■nil.t*,lf,l,,* l;,hli..hn/ i, -Carer* H, f S /).,.„/. l,,tl, // AMPUTATIONS. 143 AMPUTATION OF THE METACARPAL BONES SEPARATELY IN THEIR CONTINUITY. Of the metacarpal bone of the thumb.—The anterior extremity of this bone may be very readily.removed by the common circular process described at page 135, dividing the skin at the level of the metacarpo-phalangeal joint. If it be necessary to remove a larger portion, the oval process will be found preferable to any other. The apex of the oval or V shaped incision should in this case rest upon the radial side of the metacarpal bone, and its base circumscribe the palmar fold of the thumb. The soft parts are then to be loosened on the palmar face of the bone, and the latter divided obliquely across from above downwards and inwards with the saw. Ofthe second or fifth metacarpal bone. Either of these may be amputated in its course in a similar manner by the oval process, with the exception that the bone should be divided obliquely in a direction opposite to that recommended for the thumb. For the removal of the third and fourth metacarpal bones, (PL XXXVI. fig. 1), the oval process may also be applied with advan- tage. I have twice employed it with success, and the division ofthe bone, wdiich is the more difficult part ofthe operation, was readily effected with the cutting forceps of Liston. This process enables us to avoid the division of the vessels, nerves and ten- dons, in the palm of the hand,—an object of very serious conside- ration. The following, however, is the process more generally recom- mended. The hand held in pronation is to be transfixed from the dorsal to the palmar face with a narrow, sharp pointed bis- toury, which is to enter just above the diseased part, and shave down the sides of the bone till it cuts through at the correspond- ing commissure of the fingers. The skin on the back of the bone to be amputated, is to be drawn as far as possible under the edge of the knife, so that the surface of the bone may be exposed after the incision. The skin and soft parts are then to be drawn to the opposite side away from the untouched surface of the bone ; along this surface the bistoury is again to be entered, falling into the former line of incision, so as to separate the bone from its remaining connections without any new division of the skin, except at the place of the commissure on the other side of the finger. A short V shaped wound is thus formed, with its base towards the phalanges. A small piece of w-ood, card, or a compress, is to be introduced on one side of the finger, and a narrow saw at the other, with which the bone is to be divided obliquely across, and the finger with the anterior part ofthe bone removed. If the palmar arches are divided or the digital arteries before their subdivision, they will require to be tied ; but if the vessels are only cut near the commissures, simple coaptation of the sides of the wound, and gentle compression with a roller, will alone suffice to arrest the bleeding. AMPUTATIONS IN THE METACARPO-CARPAL JOINTS. The five bones of the metacarpus may be disarticulated in a mass from the inferior row of carpal bones, or any one may be removed by itself. But it is seldom that any but the two first and the fifth require to be taken away separately. AT THE METACARPO-CARPAL JOINT OF THE THUMB. Surgical anatomy.—The superior extremity of the first meta- carpal bone is slightly convex and triangular in shape, and is attached by a loose capsule in its articulation with the trapezius, where it is separated only by a space of one or two lines from the base ofthe metacarpal bone ofthe fore finger, which rests against the trapezoides and the inner face of the trapezium. On the back surface, the bone of the thumb is coated only by the skin and extensor tendon ; on its palmar surface, it is covered thickly by the mass of muscles. Its junction with the trapezius may in the healthy state of the joint be readily ascertained by pressing the thumb towards the indicator and running a finger back along its dorsal edge, till we feel the tubercle formed by its head, imme- diately behind which is the joint. More or less motion may also be felt at this joint in flexing and extending the metacarpal bone. Care must be observed, however, not to confound the tubercle ofthe metacarpal bone with the projection ofthe scaphoid, which will be found nearer the wrist. In cases where there is so much tumefaction as to completely mask the joint, its position will be found to correspond very nearly with a point an inch below the styloid process of the radius. The line of articulation between the trapezius and metacarpal bone, along which the knife is to pass, is directed obliquely downwards and inwards toward the root of the little finger. The radial artery dips down into the palm between the bases ofthe metacarpal bones ofthe thumb and index finger, and is sometimes divided in the operation. Remarks.—The great object of the operation is to fill up well with a flap the space from which the bone is removed, and avoid a cicatrix in the palm, which is apt subsequently to become pain- ful upon pressure. These results are much better obtained by the oval method than the flap ; to the former, therefore, I give the preference. Oval method. (PL XXXV. fig. 1.)—In operating on the right side, the hand should be placed in pronation, and the incision commenced on the radial border a line or two above the joint. For the left, on the contrary, the hand is to be placed in supina- tion. The wrist supported and the fingers abducted by an assist- ant, the surgeon, taking hold of the point of the thumb, carries a sweeping incision with a long straight bistoury over the back of the metacarpal bone, down to the line which indicates the junction of the first phalanx with the palm ; turns his knife round this line so as to form two-thirds of a circle, dividing all the parts as deeply as possible, and carries another incision up to the point at which he started, forming with the two an angle of about thirty degrees. Detaching rapidly the covering from the back of the bone, the surgeon divides the extensor tendons at the angle ofthe wound, opens the dorsal surface of the joint, depresses the lower end ofthe bone, and completes the division ofthe ligaments with the point of the bistoury ; the blade of the knife is then to be passed through the joint behind the bone, so as to detach it com- pletely by shaving its'palmar face down to the base of the oval. In order to prevent the liability to projection of the end of the trapezius through the back ofthe wound, Malgaigne has proposed to modify the operation by first making a linear vertical incision over the back of the joint, and beginning the two incisions to form the oval half an inch below the joint. Flap operation. (PL XXXV. fig. 2. Common process.)^- 144 GENERAL OPERATIONS. The hand held as above described, and an assistant drawing the integuments to the radial border of the thumb to give as great di- mensions as possible to the flap, the bistoury is placed vertically at the angle of the commissure between the thumb and the fore fin- ger, and carried by the surgeon up at once to the metacarpo-carpal joint, (where it is arrested by the internal projection of the tra- pezius,) shaving the whole ulnar side of the bone in its course. Arrived at this point, the edge of the knife is to be turned out- wards towards the bone, in order to prevent its passing between the trapezius and the second metacarpal bone. With a sawing motion, it now passes into the joint. The surgeon next luxates the bone backwards by inclining forwards its ulnar edge, and draws upon it so as to stretch the capsule, in order that he may carry the bistoury round the convex head of the bone. The ope- ration is then completed by shaving downwards the radial edge of the bone, cutting out a little beyond the metacarpo-phalangeal joint, in order to obtain a flap sufficiently long to cover the wound. To form the flap as large and fleshy as possible, it is well in mak- ing the first incision, to incline the handle of the bistoury toward the little finger. The dressing, in either mode of operation, is very simple. The blood-vessels are to be tied, or well twisted, and the wound closed by adhesive straps, supported by a few turns of a roller. OF THE METACARPAL BONE OF THE LITTLE FINGER. Surgical anatomy.—The internal border of the fifth metacarpal bone does not form the margin of the hand. It is overlapped by the mass of muscles, which renders easy the formation of a lateral flap. The oval method is, however, in this, as in the operation last described, the preferable method. By carrying the finger along the edge of the metacarpal bone, we feel a prominent tu- bercle at its posterior extremity. Immediately behind this is the joint, (marked by a little depression,) by which it is articulated with the unciform bone. The outline of the articulation is somewhat curved, but is found nearly in the direction of a line drawn from the ulnar side ofthe joint to the middle of the second metacarpal bone. It forms also another-small articulation, by a lateral facet which meets with another on the adjoining metacarpal bone. Oval method.—This process for the disarticulation of the fifth metacarpal bone, is so similar to the first, that it needs to be but briefly described. The hand turned prone, and the fingers con- veniently secured, the oval incision is to be commenced a line or two above the joint, brought around the commissure of the finger, and carried back again to the starting point, so as to form there an acute angle. The bone is then to be loosened from the soft parts, or its sides disarticulated from the unciform bone, and separated by a sweep of the bistoury on its palmar face. PLATE XXXV.—AMPUTATIONS THROUGH THE METACARPO-CARPAL JOINTS. (Fig. 1.) OVAL AMPUTATION THROUGH THE CARPO-METACARPAL JOINT OF THE THUMB OF .THE RIGHT HAND. The incision of the skin and muscles having been completed, the operation is shown as the surgeon is about to complete the disarticulation of the bone. a, b. Hands of an assistant sustaining that of the patient. c. Left hand of the surgeon sustaining the thumb, while he cuts the ligaments of the joint with the knife (d) in his right. (Fig. 2.) FLAP AMPUTATION OF THE THUMB. The bistoury (h) has been passed up on the ulnar side of the metacarpal bone, carried through the joint, and is brought down on the opposite side of the bone so as to form the flap. e,f. Hands of an assistant. g. Left hand of the surgeon. (Fig. 3.) AMPUTATION THROUGH THE METACARPO-CARPALJOINT OF THE LITTLE FINGER. (Process of Lisfranc.) The internal or palmar flap having een cut by puncture, or dissection, from the ulnar border of the hand, the knife is shown in the act of being passed into the joint. i. Hand of an assistant. I. Left hand of the surgeon grasping the finger to be removed, while he employs the knife with his right hand ( m. (Fig. 4.) AMPUTATION OF THE THIRD METACARPAL BONE. The bone has been isolated by two lateral incisions, forming a V with the base towards the fingers. The knife (a) is shown as applied to complete the section of its ligamentous attachments. n. Left hand of an assistant. p. Left hand of the surgeon. /7///V 33 Fuj p Cllttn.l,(/•!,,* . /'..*/,y/.,rf i,- C„,,, jt. H..rl I >,',,. I /,,//, /•/,,/' AMPUTAr Flap operation. (Process of Lisfranc.)—The hand is to be pronated. An assistant, or the surgeon himself with the left hand, draws the soft parts on the back and palm to the ulnar side, so as to allow the formation of as large and fleshy a flap as possible. The bistoury is passed from the back to the palm, perpendicularly through, on the inner side of the bone, exactly opposite the me- tacarpo-carpal joint, and is carried downwards, shaving the ulnar edge of the bone, so as to finish the flap a little below the commis- sure with the adjoining finger. The flap is then to be drawn up- wards by an assistant, and the bistoury carried along so as to free the radial side of the bone. This may be done by drawing away the little finger from the one next to it, and cutting from the commis- sure upwards—or by carrying the integuments and extensor tendon towards the thumb, passing the knife between them and the bone, and cutting from above downwards to the commissure, between the ring and the little finger. The lateral ligaments are then to be cut, and the joint opened on the back or palm; the bone is then to be removed by cutting the interosseous ligament, which will be facilitated by rocking the bone at the same time a little outwards. Palmer flap. (PL XXXV. fig. 3.)—This bone may also readily be removed by a palmer flap formed by dissection, as shown in the drawing. The oval method will, however, of all, be found the most appropriate. OF THE METACARPAL BONES OF THE SECOND, THIRD, AND FOURTH FINGERS, AT THEIR JUNCTION WITH THE CARPUS. The flap and oval methods have both been employed for the separate removal of these bones; and the processes are nearly the same as those for the removal of the first and fifth metacarpal. The chief embarrassment in these operations consists in the dis- articulation, and arises partly from the form and number of the articular surfaces, and partly from the difficulty of attacking the joints upon their sides. The second metacarpal, the removal of which is most difficult, forms a triple articulation—a sort of mortise and tenon joint—the middle part of its base uniting with the trapezoid bone ; and the two projecting processes at its side uniting one on the radial side with the trapezius, and the other on the ulnar with the os mag- num and the third metacarpal. These articular surfaces are all connected by ligaments, and a strong interosseous ligament unites the second and third metacarpal bones. But the key of this compound joint is an anterior or palmar ligament, fastening the process on the inner side of the head of the bone to the os mag- num and the third metacarpal, without the previous division of which, disarticulation is almost impossible. We may mark out the line of articulation as follows:—carry the finger along the ra- dial margin of the second metacarpal bone, till it is arrested by a prominence. This is formed by the head of that bone, and immediately behind it is the inner side of the joint, distant about an inch and a quarter from the styloid process of the radius. The third metacarpal forms a single line of articulation obliquely downwards and inwards. That of the fourth metacarpal is nearly transverse. From the size of the vessels likely to be divided, a tourniquet should be applied to the arm; or what is more con- venient, pressure made by an assistant on the radial and ulnar arteries. 37 LTONS. 145 Oval method.—The hand is to be placed in pronation, and the bistoury, starting from a point a little above the middle ofthe articu- lation, is to be carried obliquely downwards and across the bone to one of the commissures, thence round the digito-palmar groove, and up again over the dorsum to the place of commencement, so as to form an oval-shaped incision with an acute angle above. The lips of the wound are now to be separated by an assistant; the surgeon cuts with the front of the bistoury the dorsal and inter- osseous ligaments, luxates the head of the bone by pressing its anterior extremity into the palm, and, gliding the knife under its palmar face, detaches the bone in its whole extent. In disarticulating the second metacarpal, it is necessary in dividing the ligaments to follow particularly the angular lines of the joint; and in severing the strong anterior ligaments, it is directed by Sedillot to carry the point of the bistoury four lines behind the union of this metacarpal bone with the third, and cut upon the bone at the same time that its anterior extremity is pressed downwards, in order to effect the luxation. Flap method. (PL XXXV. fig. 4.)—The bistoury is to be car- ried vertically, so as to divide one of the interosseous spaces from the commissure of the fingers up to the carpal bones, prolonging the incision in the skin a little above the joint both on the dorsal and palmarfaces. Drawing upon the finger about to be removed, while the adjoining one is held separate by an assistant, the sur- geon passes the bistoury a second time from the back to the palm at the upper angle of the wound and on the opposite side of the bone, and brings it downwards, shaving the bone, so as to cut a second flap, emerging at the commissure on the other side of the finger. In making this second incision, the skin and soft parts are to be drawn to the opposite side, so as to diminish the amount of the structures removed. The bone is next to be disarticulated as in the oval process. It is occasionally in our power, by removing two or more of the metacarpal bones together, to retain a portion of the hand that ultimately becomes very useful. I have removed, in a case of gunshot injury, the os magnum with the corresponding meta- carpal bone and finger, and the hand has been preserved with its uses but little impaired. Benahen has taken away the first two metacarpal bones with the trapezium, trapezoides, and scaphoides; and M. Sully the last two metacarpal bones with the unciform, pisiform and cuneiform. No distinct formula, however, can be given for such irregular operations. Dressing.—The vessels, which are numerous and important in the palm, must be carefully tied. The removal of the fourth metacarpal bone, by the flap operation especially, is attended with a division of the terminal branch of the ulnar arterial arch and the second radial interosseal artery ;■—the middle finger, with that of the ulnar and radial arches or their digital branches. The parts are to be closed by adhesive straps and bandages, and kept constantly irrigated with cold water or some cooling lotion, in order to keep down inflammatory action. AMPUTATION OF THE FOUR METACARPAL BONES OF THE FIN- GERS TOGETHER AT THEIR METACARPO-CARPAL JOINTS. (PI. XXXIV. Fig.4.) The amputation of these bones in a mass is attended with less difficulty than the disarticulation of a single bone. It is necessary, 146 GENERAL OPERATIONS. however, for the surgeon to have a precise knowledge of the posi- tion, structure, and zigzag direction of the line of articulation, else he will become embarrassed, or be compelled, as I have had occasion more than once to observe, to use the saw in their sepa- ration. An outline of this articulation is seen at PL XXXIV. fig. 5. It is most essential to ascertain at the commencement of the operation the terminal points of the line, and for which the directions have already been given in the process for the disarticu- lation of the second and fifth metacarpal bones. The course of the line in the main is strictly convex, with an inclination down- wards and inwards. The articular heads ofthe second and fourth metacarpal 'bones are nearly on the same level. The articular surface of the third is about a line in front of these ; that of the fifth, on the contrary, is about half a line nearer to the wrist. The space between the metacarpal bones of the thumb and index finger is large, and these bones may be said to be at their bases merely in juxtaposition. By examining the outline drawing above referred to, it will be seen that the metacarpo-carpal joint of the thumb is directed obliquely forwards and inwards, and is found at its inner edge about the sixth of an inch lower than that of the fore finger. All the metacarpal bones of the fingers are united together by dorsal and palmar ligaments. Their joints are con- nected, by an extension of the synovial membranes, with those ofthe proper carpal bones, the inflammation of which, if it should follow amputation, might be attended with serious consequences. Operation.—An assistant presses on the radial and ulnar arte- ries so as to command these vessels. The surgeon with the left hand applied over the dorsal surface, which should be uppermost, grasps the fingers and makes a semilunar incision convex downwards a little more than half an inch in front of the articulation, commenc- ing at the joint of the fore finger if it be.the left hand, or at that of the little finger if it be the right, and ending at the opposite margin of the articular line. The skin is then to be retracted by an assistant, and the extensor tendons divided by another incision on a line with the joints. The operator is now to raise the knife nearly to a vertical position and run the point along the line of articulation, following exactly the zigzag direction above described, so as to cut the dorsal ligaments, but without attempting to pene- trate into the joints. When they are all divided, he presses the end of the metacarpal bones downwTards so as to luxate them at their base. He next passes his knife into the gaping joints so as to complete the division of the ligaments, and insinuating the blade flatwise under the heads of the bones, shaves their anterior surfaces, and cuts outwards into the palm, so as to form a flap an inch to an inch and a half in length. This process may, at the will of the surgeon, be reversed, first cutting the palmar flap, then the dorsal, and luxating the bones in the manner described. In cases of necessity, the metacarpal bone of the thumb may be removed with those of the fingers. The operation terminated, it only remains to tie the trunks of the radial and ulnar arteries, and bring the flaps together with adhesive straps and a roller bandage. PLATE XXXVL—AMPUTATIONS OF THE WRIST, AND OF THE THIRD METACARPAL BONE. (Fig. 1.) AMPUTATION IN THE CONTINUITY OF THE THIRD METACARPAL BONE. An incision has been made on either side of the metacarpal bone, so as to form a V. The hand of the patient is sustained by that of an assistant (a), who at the same time grasps the little bands which have been applied to separate the soft parts from the bone and protect them from the action of the saw. The surgeon with his left hand (b) holds the end of the metacarpal bone, while he divides it with a narrow saw near its junction with the carpus. (Figs. 2, 3.) CIRCULAR AMPUTATION AT THE RADIO-CARPAL JOINT. Fig. 2.—The stage ofthe operation shown is that when, after the circular division of the skin, the knife has cut the extensor tendons and passed through the joint for the purpose of dividing the ligaments on the palmar side. a. Left hand of an assistant, sustaining the stump. b. Left hand of the surgeon holding that of the patient, while with his right (c) he finishes the disarticulation. Fig- 3.— This shows the surface ofthe stump after the operation in fig. 2. The surgeon has seized the mouth ofthe radial artery with the forceps (d), around which the hands of an assistant (e,f) are seen applying the ligature. The hand of another assistant (g) sustains the stump. Fig. 4.— Closure of the wound with three adhesive straps, after the amputation at the same joint by two flaps, the larger one being formed by incision over the dorsal surface. (Fig. 5.) DOUBLE FLAP AMPUTATION AT THE RADIO-CARPAL JOINT. (Process of Lisfranc.) The fore arm is sustained with the hand of an assistant (a); the left hand of the surgeon (b) grasps that of the patient. The palmar flap has been cut by puncture, with the hand in a state of supination, and the operation is shown at the moment the surgeon is about to finish cutting the dorsal flap with the hand in a state of semi-pronation. Plate 36 On j/<>"> If •>' Ciehatvski Philadelphia. Published by Carey t Hart I'i Uiiinl.Lilh Phil- AMPUTATIONS. 147 AMPUTATION IN THE RADIO-CARPAL ARTICULATION. This has latterly, notwithstandingthe amount of prejudice usually entertained against disarticulation, become a very common opera- tion. It te especially applicable in all such injuries or diseases of the hand as have spared the articulation of the wrist and its inte- guments ; and the great success which has attended its perform- ance, shows that it should always in such cases be resorted to in preference to amputation in the continuity of the forearm. Surgical anatomy.—Of the four bones of the upper carpal row, the three outer only enter into the structure ofthe joint—the sca- phoides, the lunare, and the cuneiform. The upper surfaces of these bones form together an oblong polished head, which is re- ceived into a corresponding shallow socket or depression on the conjoined extremities ofthe radius and ulna, the styloid processes of which may be readily distinguished through the skin bounding the two sides of the joint. The exact seat of the joint may be readily determined by the following indications. Draw a straight line from the point of one styloid process to the other, and the joint will be found in the direction of a curve, the highest point of which passes about a quarter of an inch above the middle of the straight line. This curvature in the direction of the articulation should be well un- derstood ; for if the disarticulation should be made directly across, the separation will be found to have taken place between the two ranges of carpal bones. The palmar face of the wrist in a state of flexion presents three lines, which may serve as a guide to the articulation. The one next the palm (the hand being held straight) corresponds to the joint between the two ranges of carpal bones. The middle one, half an inch above the former, indicates the position of the radio-carpal joint; and the third, which is an inch above the middle one, and sometimes very faintly marked, is on a line with the junction of the epiphyses with the shafts of the bones. When the hand is bent firmly back, the summit of the angle, as observed by Malgaigne, which it forms with the forearm, corresponds exactly with the position of the joint. It is well, also, to notice that the scaphoid bone projects a little higher up than the lunare or cuneiform, and that the pisiform ofthe lower row protrudes a little in front ofthe carpus, and that the knife of the surgeon during the operation must turn around these bones. The capsular ligament of the joint is in itself thin and mem- branous, but it is strengthened by lateral ligaments on its sides, and by the fibrous sheaths of the tendons on its dorsal and palmar faces. The circular method or the flap may either be employed in amputation at this joint, but in consequence of the absence of muscular tissue, and the liability of the styloid processes to become uncovered at the angles of the flaps, the former will be found to yield the most satisfactory results. Circular method. (PL XXXVI. figs. 2 and 3.)—An assistant retracts circularly the skin, and at the same time commands by pressure the circulation in the radial and ulnar arteries. The surgeon, grasping with his left hand the one about to be operated on, places it in semi-pronation, with the back turned towards him. With a small straight-edged knife, he then makes a circular in- cision through the integuments, which shaves the thenar and hypothenar eminences of the hand, following the lower of the three lines on the palmar surface of the wrist. The skin, which is alone to be divided, is then to be dissected up and reverted as high as the articulation, taking care not to loosen with it the pisi- form bone. By another circular cut carried round from the lower edge of one styloid process to the other, the tendons and lateral ligaments are divided completely across. All that sustains the articulation now, is the thin capsular ligament. This may be opened with a scalpel, either on the front, back or side, at the will of the operator, and the wrist luxated and detached by following with the blade of the instrument the curved line of the joint. By the formation of two flaps. (PL XXXVI. figs. 4 and 5.)— The hand placed and sustained as above described, the surgeon makes on the back a semilunar incision through the integuments, commencing half an inch below one styloid process, and termi- nating the same distance below7 the other,—the middle part of the curve being about two inches lower. The flap of skin thus formed, and loosened by one or two cuts ofthe knife, is to be raised and drawn back by an assistant. The surgeon then divides on a level with the joint tbe extensor and radial tendons, the posterior part ofthe capsular ligament, the lateral ligaments and the tendon of the carpal extensor. He next presses downwards the palm so as to luxate the carpus, and carrying his knife through the joint, detaches the extremity by cutting a flap on the anterior surface an inch or more in length. It has been directed to raise tbe handle of the knife in this last step, so as to avoid including the pisiform bone in the flap. But it is probable that little inconvenience could result from its being left with the skin, and we would thereby preserve the attachment of the flexor carpi radialis. This process may be often conveniently modified according to the peculiar seat and the extent of the lesion for which the ope- ration is performed ; and it is perfectly easy to cut either a dorsal or palmar flap of sufficient dimensions to cover the ends of the bones, if the integuments have been destroyed on one ofthe faces of the wrist. The process of Lisfranc, (fig. 5,) which is inferior in value to either of the others, consists in passing a catling or double-edged knife across the anterior face ofthe wrist, from a point just below one styloid process to the lower edge of the other, and shaving downwards the surface of the wrist bones, so as to form an an- terior flap. A semicircular incision is then made by puncture on the dorsum, and the flap thus formed dissected up. The knife is next passed under the styloid process of the radius, and swept along the curved line of the joint, so as to complete the disarticu- lation. Dressing. (Fig. 4.)—The radial and ulnar arteries are to be tied. It has happened, however, that these vessels have retracted so much that their orifices could not be found; and experience has shown that under such circumstances no secondary hemor- rhage is liable to follow. The integuments are to be closed by adhesive straps passed from the back of the arm ; and a roller bandage is to be carried from the elbow downwards, in order to overcome the excessive tendency to retraction of the skin and muscle. At the lower extremity of the forearm it is also well to apply some longitudinal compresses, in order to flatten the syno- vial sheaths and prevent suppuration of their cavities. 148 GENERAL OPERATIONS. 2. OF THE FORE ARM. AMPUTATION IN THE CONTINUITY OF THE FORE ARM. Surgical anatomy.—The fore arm, like the leg, is covered with muscles that degenerate in their inferior portion into tendons, which are enveloped by synovial sheaths more or less continuous with those of the palm. The presence of these tendons and their synovial sheaths, the liability to the propagation of inflammation upwards along the latter, and the fear that in the absence of the muscular structure the skin would cicatrize tightly over the ends of the bones, so as to make painful pressure on the extremities of the nerves, deterred the older surgeons from amputating in the lower half of the arm. But the experience of latter times has shown that the general rule of removing as small a portion as possible, is as applicable to the amputation of the fore arm as to any other part of the body, that the extenson of synovial inflam- mation maybe prevented by judicious treatment, and the tight adhesion of the cicatrix to the bone avoided, by giving a sufficient degree of extent to the cutaneous covering. In the amputations of the fore arm, the circular, oval, and flap methods are all occa- sionally employed. In a surgical point of view, the fore arm may be divided into three sections. The inferior, which is flattened somewhat like the palm, is well suited to the flap operation, provided care is ob- served to turn back the flaps so as to reverse a portion of the uncut skin above the angles ofthe wounds, in order to divide the bones higher up and prevent their edges subsequently protruding at these points. Either of the other methods may be employed at the will of the surgeon—but in my hands they have not served to form so neat a stump. In the middle region the arm is conical, and the flap is particularly appropriate here, in consequence of the diffi- culty of dissecting up and turning back towards the base of the cone the sleeve-like fold of skin. The upper third of the arm is round and muscular, and well suited for either form of amputa- tion, though the circular has been more generally employed. In the fore arm, where there are two bones to which the muscles are extensively connected, it has been' observed that the muscles retract but little after their division; and the surgeon must bear this in mind during the operation, so as to cut his covering of skin of sufficient length, and if necessary, as it usually is, dissect off' the muscles from the bones for a little space before applying the saw. Circular method. (PI. XXXVII. figs. 1, 2, 3.)—The patient is to be placed upon the edge of his bed, or seated on a chair. The brachial artery is to be compressed with a tourniquet, or the fingers of an assistant, and the fore arm partly flexed and put in the middle state between pronation and supination, and well sup- ported by assistants. The surgeon, placing himself at the inner side—a position that gives him a greater facility in dividing the bones—grasps with his left hand the fore arm above or below the point of operation, according to the limb upon which he acts. A straight-edged amputating knife is then carried, with the right hand well pronated, under the arm to the upper surface of the radius, and the integuments divided down to the fascia in a cir- cular sweep, the knife coming round to the point from which it PLATE XXXVII.—AMPUTATIONS OF THE FOREARM. (Figs. 1, 2, 3.) CIRCULAR AMPUTATION OF THE FOREARM OF THE LEFT SIDE. Fig. 1 represents the first stage of the operation. A circular incision has been made, and the integument is seen raised with the left hand of the surgeon (a), while it is detached from the aponeurosis with the knife in the right (b). Fig. 2 shows the face of the stump at the conclusion of this circular operation. The stump is supported by the left hand of an assistant (c). The three ligature threads (d) which have been applied to the radial, ulnar, and anterior interosseal arteries, are seen hanging from the side of the wound. Fig. 3 represents the appearance of the stump after the closing of the wound with four adhesive straps. (Fig. 4.) DOUBLE FLAP AMPUTATION OF THE FOREARM AS PRACTISED BY THE AUTHOR. The surface of the stump is shown after the completion of the operation. f Right hand of an assistant supporting the stump. g. Anterior flap reverted; which, in consequence of the greater thickness of the soft parts on this side, has nearly twice the length of the posterior flap (h). (Fig. 5.) CIRCULAR AMPUTATION AT THE ELBOW JOINT. (Process of Velpeau.) A circular section has been first made of the skin, and secondly one of the muscles, so as to give to the stump the appearance of a hollow cone, as in the modification of M. Cornuau. The operation is shown at the moment when the knife (m), which has been passed through the joint, is applied so as to divide the tendon of the triceps above the head of the olecranon process. The right hand (i) of an assistant compresses the humeral artery; the left hand of the surgeon (k) sustains the forearm. The sloping direction of the section of the muscles of the fore arm, which leaves the heads of the radius and ulna prominent, is seen at /. Plale 37. Fig. 3. On Stone by C.Kuchel rkiladd.-ph.ia,, Published by Carey &' Hart- F, v Du vol & Co.LUM.rhU? AMPUTATIONS. 149 started, by allowing the hand which holds it to turn during the circuit into a state of supination. The integuments are to be dis- sected from the fascia for an inch or more, according to the thick- ness ofthe limb, and reversed. If on account of the conical shape of the limb difficulty should occur in turning back the skin, it may be slit over the radial and ulnar bones. By another circular in- cision the muscles are divided down to the bone nearly on a line with the base of the reflected skin. When the tendons are strong, there is a difficulty in dividing them in the circular sweep, and it is well to follow then the practice of Cloquet, by running a cat- ling through on each face of the interosseous ligament, and cutting outwards. The cut muscles now retract; a narrow interosseous knife or catling is passed into the gap to divide the interosseous ligament and the interosseous muscles, both on the front and back ofthe bones. The retractor is next adjusted with the middle tail passed between the bones, and the. muscles and skin drawn back out ofthe way ofthe saw. The saw is now to be applied on the face of both the bones, the radius being held in the middle state between pronation and supination, in order that it may not be left too long; and the section of the ulna completed last, in conse- quence of this bone being most firmly connected with the humerus. The retractor is then removed; the radial and the ulnar arteries, and occasionally the interosseal, tied. The wound is to be closed with adhesive straps, and supported with a roller bandage, making the line of reunion correspond with that of the end of the bones. Malgaigne has lately proposed, as a modification ofthe circular operation, to form a flap of the muscles, about an inch long, on each side ofthe arm after the reflection ofthe skin, bypassing the catling flatwise on each face of the interosseous ligament. Flap method. Single flap.—Graefe, following the process of Verduin and Ruysch, passed the catling through from side to side in front of the bones and interosseous ligament, and cut out so as to form a semi-elliptical flap on the front part of the fore arm. The skin and soft parts on the back were then divided down to the bone by a semicircular incision. The remaining muscular fibres and the interosseous ligament were then divided, the soft parts retracted, and the bone sawed in the usual manner. Double flap. (PL XXXVII. fig. 4.)—This method is more fre- quently employed than the preceding, and is of very easy execu- tion. The fore arm placed in the middle state between pronation and supination, so as to render the two flaps of more equal size, the surgeon glides the knife across the arm either from the ulnar or radial edge, shaving the faces of the bones and the interosseous ligament, and cuts downwards and outwards so as to form an ante- rior flap two inches or more in length according to the size ofthe arm. The lips of the wound are then to be drawn backwards, and the knife carried over to the opposite side of the bones, and passed from tbe upper angle of the incision to the lower without making a new puncture in the skin, so as to form a posterior flap nearly of the same size as the anterior. An assistant then raises the flaps, the surgeon cuts the interosseous ligament and remain- ing muscular fibres, and divides the bones with a saw. To prevent any possibility of the subsequent exposure of the bones at the angle of the wounds, I am in the habit of further loosening the flaps at the base with the knife, but without dividing 3S the skin—an assistant at the same time drawing them strongly upwards—then applying the three-tailed retractor, and finally di» viding the bones so that after their section they shall be half an inch above the upper angles of the flaps. Sir Charles Bell preferred to cut the flaps with a common am- putating knife from without inwards, in order to avoid the irregu- lar division of the tendons and muscles, which will sometimes take place to such an extent by the opposite mode of cutting the flaps as to require subsequent trimming. He made his anterior flap much larger than the dorsal, and observed the precaution to divide the bones high up. I have employed this process, and found it to form a handsome and most serviceable stump. The only objection to it, which is not one of much moment, is, that the muscles recede to some extent into the interosseous hollow before the edge of the knife, leaving a considerable amount of fibres to be cut with the catling in the second step of the opera- tion. Mixed process.—M. Sedillot cuts a thin, short flap, on either side of the fore arm, elevates them, and divides the muscles cir- cularly, or with a slope upwards at their base, down to the bone, which he cuts in the usual manner with the saw. M. Baudens prefers, in the inferior two-thirds of the arm, to divide the skin circularly, to dissect and turn it upwards to the amount of three fingers' breadth, and then passing his knife through at the base of the fold on either surface of the bones, cut from within out- wards two short, thick muscular flaps an inch in length. These are to be drawn upwards by an assistant, while the operator iso- lates the bones and divides them in the usual manner with the saw. AMPUTATION AT THE ELBOW JOINT. The amputation at this joint, first executed by Ambrose Pare, has been revived and practised to a considerable extent in latter times. It has not, however, by any means, received the general sanction of the profession, though it has been warmly supported by Dupuytren and others, and is considered by Velpeau as less dan- gerous than the amputation of the arm, the only alternative when we reject the operation at the joint. It is, however, a great ad- vantage to the patient to be able to preserve the entire length of the arm, and it is at least certain that the disarticulation has been attended with a fair average of success. In cases of injury ofthe fore arm, when there is no chronic affection of the joint, and the structures about the humerus are uninjured, the surgeon might feel himself justified, in the hope of preserving a more useful member, to encounter the difficulties of disarticulation at this joint and the dangers attendant upon the extensive and slowly healing wound which it necessarily leaves. Surgical anatomy.—The exact position of the joint may be ascertained by the careful observance of the following rules. The lateral prominences or tuberosities at the lower extremity ofthe os humeri, too often considered by those deficient in anatomical know- ledge as being on a level with the joint, are placed at unequal distances above it. The internal one, which is most prominent, is nearly an inch above the junction of the ulna with the pully of the humerus; the external, about half an inch above the articula- tion of the radius with the condyle of the humerus. The tuberosi- 150 GENERAL OPERATIONS. ties are placed nearly on the same horizontal level; and in con- sequence, the articular line is directed from within obliquely outwards and upwards. The base of the anterior flap, therefore, should be cut obliquely, and never so high as the tuberosities, lest it should be found too short to cover the end of the bone. When the integuments are not diseased, the head of the radius may be felt rolling in its joint, so as to serve as a guide to the general articulation. The articular surfaces of the radius and ulna being nearly on the same level, and forming a line in front interrupted only by the slight elevation of the coronoid process, we are en- abled at once to carry a knife by a single cut directly into the anterior portion of the joint. Between the radius and the hume- rus, the knife may be readily passed from the outer side into the joint; but on the internal side, its entrance is resisted by the ole- cranon and coronoid processes. On its posterior face, the line of the articulation is of a shape like that ofthe letter j, reversed, the body of which is formed by the olecranon; the internal transverse branch, which is the shortest and highest of the two, by the in- ternal side of the coronoid process; and the external branch, by the condyle of the humerus which articulates with the radius. A strong lateral ligament is found on either side of the joint; in front and behind, the capsule is thin and membranous. After the ablation of the fore arm, the end of the humerus presents a large surface, which will require a considerable extent of skin or flap to cover it thoroughly, and prevent the exposure ofthe bone. The oval, circular and flap methods have all been employed for this disarticulation; and rank in regard to appropriateness in the order in which they are enumerated. In the circular, there will be but one artery to tie,—the brachial; in the flap operation, several ligatures will be required. Circular method. (Process of Velpeau. PI. XXXVII. fig. 5.)—The surgeon, standing at the outer side of the limb, divides the skin circularly in the ordinary manner, at the distance of three fingers' breadth below the line of the articulation, or'that of four fingers below the tuberosities of the humerus. He then dissects and turns back the skin to the level of the joint, and by a second circular incision, divides at this height the soft parts down to the bone. The fore arm is then to be strongly extended, and the anterior and lateral ligaments divided with the knife, rocking the joint from side to side as the latter are cut. Drawing downward upon the fore arm so as to separate the head of the two bones from the articular surface of the humerus, the knife is Carried backward so as to cut the tendon of the triceps at its insertion upon the olecra- non, divide the posterior ligamentous fibres, and thus complete the disarticulation. If found more convenient, the olecranon process may be divided at its base with the saw, and left adhe- rent to its tendon. Its removal, however, gives more regularity to the surface ofthe stump, and diminishes the extent ofthe wound ; it has moreover been ascertained that the triceps will contract new adhesions, so as to move the arm perfectly after it has been de- tached from this process. The covering of the stump will consist merely of the skin and subcutaneous cellular tissue, the edges of which are to be drawn together so as to form a linear wound from side to side. In order to leave some fleshy covering for the ends ofthe bones, M. Cornuau, who follows in other respects much the same process, PLATE XXXVIIL—AMPUTATIONS OF THE ARM, (Fig. 1.) FLAP AMPUTATION OF THE RIGHT ARM AT THE ELBOW JOINT. (Process of Dupuytren.) The anterior flap has been cut by puncture and reverted upon the arm, the soft parts divided on the back part of the joint, and the ligaments of the joint severed so as to effect the disarticulation of the arm. The saw is seen applied for the purpose of dividing the olecranon, which in this process is left attached to the tendon of the triceps. a. The hand of an assistant compressing the artery. b. The left hand of the, surgeon sustaining the fore arm. c. The saw with which the olecranon is cut. (Figs. 2, 3, 4.) CIRCULAR AMPUTATION AT THE MIDDLE OF THE ARM OF THE LEFT SIDE. Fig. 2. Section of the soft parts. A circular section has been made of the skin, and of the two layers of muscles, as described in the text. An assistant compresses the brachial artery with his right hand (d), while with his left (e), he sustains the upper part of the arm, and at the same time retracts the divided tissues. f Left hand ofthe surgeon supporting the lower end of the arm. The conical projection ofthe divided muscles on the inferior fragment is shown at (g). The conoidal hollow ofthe end ofthe upper fragment (h), is partly effaced by the retraction ofthe soft parts made by the assistant. The knife (i) is shown as it is brought round by the right hand of the surgeon, so as to complete the section of the layer of deep-seated muscles, over the bone. Fig. 3.—Surface of the stump raised by the hand of an assistant (k). It presents the appearance of a hollow cone, and shows the ligatures applied upon the divided arteries. Fig. 4.— Coap>tahon of the lips of the wound over the end of the bone, by means of four strips of adhesive plaster. The ends of the ligatures project from its inferior angle. P/aie 38 (l„ sli'ie by //. Ouere PL/Weie-iAia, PeS/eAe,/ ly Grey & //art. P.S/),„■«/ U/A PA,/' AMPUTATIONS. 151 cuts the muscles a little distance below the joint. The brachial artery will then be divided after its bifurcation into the radial and ulnar, and two ligatures will be required. Oval method. (Process of Baudens.)—The patient is seated on a chair, with the fore arm extended and turned so as to present its external face upwards; an oval-shaped line is marked round the arm with ink, commencing at the external border ofthe radius, four fingers' breadth below the outer tuberosity of the humerus, and carried so as to cross the ulna two fingers' breadth nearer the joint, in order to leave less skin on the ulnar side, and admit the escape of the watery discharges which occur during the progress ofthe cure. The integuments are to be divided along the traced line down to the fascia, and the internal semilunar flap dissected up and reverted as high as the internal margin of the oval. On a level with this point the superficial layer of muscles are to be cut with a circular sweep of the knife; then, drawing upwards the divided portions with the left hand, the knife is applied a second time so as to cut the remainder of the muscles on a line with the joint, and is entered at the termination of the sweep, between the head of the radius and the os humeri. The liga- ments are next divided, as in the circular operation, and the fore arm detached by sawing the olecranon at its base. At the bottom of the wound will be seen the end of the humerus, surrounded by the divided muscles, and bordered by a large external flap, which will abundantly suffice for the covering of the stump. A patient upon whom this process of disarticulation was performed, was perfectly cured at the end of a month. Flap method. (Process of Dupuytren slightly modified. PI. XXXVIII. fig. 1.)—The fore arm supinated, and one-third flexed, the operator, standing on the inner side, ascertains with the thumb and middle finger of the left hand the position of the two tuberosi- ties of the humerus, and grasping the soft parts immediately below, raises them so as to facilitate the passage of a double-edged knife or catling across the face of the bones, from the inner to the outer side, immediately over the line ofthe articulation. In order to get as large an anterior flap as possible, the handle of the knife should at first be depressed so as to enter the point through the integu- ments posterior to the front face of the ulna, then raised horizontally as the point crosses the joint, and again elevated as it emerges in order to pierce the skin as far back as possible on the outerface ofthe radius. The knife is to be carried downwards, shaving the face of the bones, so as to cut, according to the thickness of the limb, a flap three or. four inches long, which is to be drawn up- wards by an assistant. The knife is now shifted to the posterior part ofthe limb, in order to make a horizontal division ofthe soft parts there, on a level with the base of the flap. The fore arm is next to be extended, the anterior and lateral ligaments divided as above described, and tbe division of the limb effected either by cutting the tendon of the triceps or sawing the olecranon at its base. Brasdor began the operation by making a semicircular division of the skin, convex downwards, a few lines below the top of the olecranon. He then cut the tendon of the triceps, the lateral ligaments, and running the knife through on the face of the bones ofthe fore arm, cut a large anterior flap. Sedillot, holding the arm semiflexed, opens the integuments nearly in the same manner on the back, by making a semicircular incision which covers about one-third ofthe circumference of the limb, crossing it at its middle, an inch below the top of the ole- cranon. An assistant draws up the skin so as to allow the opera- tor to divide the tendon of the triceps and the posterior and lateral ligaments, and lay open the radio-humeral articulation by following the line ofthe joint. From the external extremity ofthe first in- cision, he then (before attempting to luxate the bones) drops a vertical cut two inches long. He now carries the fore arm, still flexed, backwards and inwards, and disarticulates it by dividing the remaining portions of the ligaments. A knife is then carried through the joint to the front of the bones, and the operation is termi- nated by cutting an anterior flap, which comprises the remaining two-thirds ofthe whole circumference of the limb. In operating on the left elbow, tbe vertical incision is to be made and the dis- articulation commenced on the internal side. The value of this process has not yet, however, been tested by its application to the living subject. Dressing.—In the flap operation there are always two arteries at least to tie, and occasionally the trunk ofthe brachialis injured by the puncture with the catling, so as to require a ligature. The flaps are to be drawn together, or the circular fold of skin closed with adhesive straps, in the manner which will most completely cover the end of the humerus. 3. OF THE ARM. AMPUTATION IN THE CONTINUITY OF THE ARM. Surgical anatomy.—The arm has but a single bone, which is everywhere completely enveloped with muscles, except in the neighbourhood of the elbow joint. These muscles may be ar- ranged into two classes—those which have for their chief office to move the fore arm, and those which move the arm. The first class consists of the two flexors on the front and inner part of the arm, the biceps flexor, and the brachialis anticus, and one exten- sor—the triceps extensor cubiti. The brachialis and the triceps are attached to the bone throughout their entire length, and are therefore susceptible of little secondary shortening after division in an amputation. But the biceps lays loose in its whole extent, and, like several muscles of the thigh, shortens itself to a great degree when cut. In amputation in the lower two-thirds of the arm, it is therefore advised to put the fore arm in a moderate state of flex- ion, and to cut the biceps a little lower than the other muscles. In the upper third the bone is surrounded with the second class of muscles, that consist, besides the articular—which are concern- ed only in the operation for disarticulation at the shoulder joint— of the powerful deltoid, the coraco-brachialis, and the muscles of the armpit—the great pectoral, the latissimus, and the teres major. In amputation in the upper third, the action of these mus- cles forms a subject for consideration. If the operation is per- formed so as to leave in part the insertion of the muscles of the armpit, the deltoid, coraco-brachialis, and biceps are cut off from their insertion, and are liable to retract so as to leave a conical stump, and by drawing up the integuments retard the healing of the wound. If the section be made above the insertion of the armpit muscles, the latter will retract upon the chest so as to leave the bone nearly naked, and the stump will occasionally be made 152 GENERAL OPERATIONS. to stand straight outwards by the unresisted action of the supra and infra-spinatus muscles. For these reasons Lafaye and Larrey preferred amputation at the shoulder joint to that through the up- per third of the arm. But this practice has been generally and justly rejected by most surgeons. It has been found that it is more dangerous than amputaiion through the arm; that every inch of the humerus that can be preserved consistent with the formation of a good stump becomes of great value to the patient; and more- over, that the two other articular muscles, the subscapularis and the teres minor, prevent most commonly the permanent elevation ofthe stump The operation through the bone,"with a single large external flap, is, therefore, when the case admits it, to be preferred to that through the joint. In cases where the amputation is made at the lower border or through a part of the insertions of the muscles of the armpit, we obviate much ofthe inconvenience above mentioned in reference to this operation, by raising the arm to the horizontal position, so as to shorten the deltoid before it is cut, and then dividing the bone at a height proportioned to the degree of retraction of the deltoid, the biceps, and coraco-brachialis, which will be found to vary in different cases according to the activity of the muscles. The circular and flap methods are both perfectly applicable to amputations of the arm in any part of its course, except near the elbow joint, where integument may be. gained to cover the bone by the circular process, though there would not be room for the flap without removal of a larger portion of the bone. The oval method has also been advantageously employed by Guthrie for amputation on a line with the armpit. AMPUTATION IN THE LOWER TWO-THIRDS OF THE ARM. A knife of middling length, a scalpel, saw, and a two-tailed retractor, with the ordinary apparatus for dressing, are all that are required in this operation. The patient is placed in a sitting posture, and, if possible, in a chair, to which he may if necessary be secured with a towel. The arm is to be extended at a right angle with the body, and the fore arm a little flexed if the nature of the lesion will allow it. The circulation in the brachial is to be commanded with a tourniquet, or by pressure with the fingers of a competent assistant in the armpit, who is at the same time to be charged with drawing upwards the soft parts after their di- vision. Another assistant supports the portion of the limb to be removed. The surgeon places himself at the right side of the limb, so as to be able to grasp with his left hand the parts above the place of operation. Circular method. (PL XXXVIII. figs. 2, 3, 4.)—1. An assistant drawing the skin upwards, the surgeon grasps the limb with his left hand, and carrying the knife below, begins the circular inci- sion on the edge of the biceps, dividing the skin and adipose membrane all round at a single cut down to the fascia. The integuments are then to be dissected from the fascia and turned backwards like a sleeve, for an inch or an inch and a half, ac- cording to the thickness of the arm. 2. The biceps may then be divided across separately, so as to allow it to contract; then placing the knife at the level of its shortening, divide circularly all the remaining muscles down to the bone. Tbe assistant draws the cut edge of the muscles upwards, wdiich then presents the appearance of an elongated cone. The point of the cone, con- sisting Of the deep-seated fibres, is now to be cut anew by a second circular incision down to the bone, and the deep-seated fibres subsequently separated from the bone for the space ofiialf an inch or an inch if the. arm be large, with the point of the knife. 3. The surgeon next runs his knife round the bone to divide the periosteum as well as the musculo-spiral nerve in its gutter, if this has not been previously cut, applies the retractor to draw the soft parts upward, and severs the bone with a saw at their base. Many surgeons do not deem it necessary to make the previous section ofthe biceps, but complete the circular division of all the muscles at the same ,time. In my own practice, I have found a better stump formed by first cutting the biceps with a single stroke of the knife about three-quarters of an inch below the point at which the general circular incision is to be made. On the dead subject, where the biceps cannot shorten itself, and must be pushed up to represent the actual operation on the living, the process will'not appear so neat as without the use of this pre- cautionary measure. Dressing.—The brachial artery, w?hich is found on the inner side ofthe bone between the biceps and triceps, is to be tied. If any of its branches-bleed, they are also to be secured with liga- tures. The muscles are to be pressed downward with the hand, in order to cover the end ofthe bone, and the wound closed with adhesive straps, so as to form a line from front to back. Some surgeons, however, prefer to unite the integuments in an oblique ; others in a, transverse direction. The roller is to be applied from above downwards in order to prevent the spasm of the muscles, and their subsequent retraction from the end of the bone. Flap method.—In amputation in the lower two-thirds of the arm, the operation with double flaps is very commonly preferred in Germany and England to the circular, and is employed by many of the surgeons of this country. It is more rapid, and at- tended with less pain during its performance, but has no other advantage over the method last described. As the bone of the arm is circularly surrounded with muscles, we may in particular instances of disease, cut the flaps with their base in any direction that will enable us to preserve the greatest length of the limb. The flaps are commonly cut by puncture and division from within outwards, but they maybe also well formed in the opposite direc- tion from without inwards. Common process.—The patient is to be placed in the sitting posture and the limb extended and well sustained by assistants. The surgeon grasps with his left hand the muscular mass formed by the biceps and brachialis .anticus, and passes the double-edged catling across the anterior face of the bone,—entering it at the internal side for the right arm, and the external for the left,—and cuts from above downwards an anterior flap two inches and a half long, which should appear regularly beveled from the centre to the circumference. The flap is now to be raised by an assistant. The lips of the wound are then to be drawn backwards with the left hand, and the knife passed behind the bone through the two angles of the wound in the skin, so as to cut a posterior flap of the same form and length as the first. Both flaps are now to be well drawn upwards, while the surgeon divides with a circular turn of the knife, the remaining fibres about the bone. When AMPUTA the bone is sufficiently isolated, the surgeon applies the saw close to the base of the flap. A doubled-tailed retractor may, if pre- ferred, be employed to draw back the flaps. Process of Langenbeck and Bell. Section from without inwards. —The integuments drawn strongly upwards by an assistant, the surgeon standing at the inner side of the arm, sustains with one hand the arm below the place of operation, and with the other applies the amputating knife upon the skin, so as to cut from below upwards and towrards the bone two flaps in succession, one on the internal and the other on the external side of the arm, each of which should be from two and a half to three and a half inches long. The assistant then raises the flaps, and the surgeon iso- lates and divides the bone at their base. By this process, the surgeon is required to-be ambidextrous. But if he has not prac- tised the use ofthe knife with his left hand, he may place himself at the outer side in operating on the left arm. One objection to this process by vertical flaps is, that it may allow the end of the bone to sink to the lower angle of the wound, so as to be exposed during the progress of cure. Mixed process of Sedillot.—This is analogous to the one of the same author described in reference to the forearm. Two small superficial flaps are cut by puncture with a double-edged knife ; the one on the external side of the limb is short, and consists but of little more than the skin and adipose tissue. The integuments are now drawn inwards, and the point of the knife carried through from the upper to the lower angle of the wound, so as to form a second flap like the first, but in which the brachial artery is not included. The flaps are next to be elevated, and the deep-seated muscles divided as in the process of Alanson,—obliquely upwards, —so as to form on the face of the stump a hollow cone, at the apex of which the bone is to be cut. This process leaves a wound very regular on its surface, and of but limited extent. It is more difficult of performance, and seems to be attended with no greater advantages than the circular method, which is remarkably well adapted to the amputation of the arm. AMPUTATION AT THE UPPER THIRD OF THE ARM. From the excessive tendency to shortening of the divided del- toid, and other reasons which have already been detailed, the common circular process is not so well suited as either the flap or the oval to amputations between the insertion ofthe deltoid on the arm and the head of the bone. The common causes that ren- der this operation necessary, are gunshot or other injuries which have directly involved the bone, the effect of which may be found, during the course of its performance, to have extended higher than was at first supposed, so as to make it necessary to remove the bone immediately below its head, or to detach it at the shoul- der joint. Under such circumstances either of the latter processes, but especially the flap, offers facilities for going above the intend- ed place of section of the bone, without rendering necessary a second general division of the soft parts. Process of Louis and Sabatier. (PL XXXIX. fig. 4.)—The arm is to be applied against the side ofthe body, so as to extend the deltoid and permit its being eut at its greatest length and ena- ble the surgeon to judge of the degree to which it will shorten itself, before he divides the soft parts on the inner side ofthe limb. 39 .TIONS. 153 The artery is to be compressed against the second rib above the clavicle, as in disarticulation at the shoulder joint. A transverse incision down to the bone is to be made immediately across the insertion of the deltoid, and a converging longitudinal one, two inches in length, along either border of the same muscle, joining at their lower end the two extremities of the first. The flap thus marked out is to be dissected loose and raised, and the remaining soft parts cut by a circular incision on a line with its base, the re- tractor applied, and the bone isolated and divided with the saw. From the uncertainty of the assistant's preserving the steady com- mand of the circulation by pressure above the clavicle, it would be safer to seize and tie the extremity of the axillary artery pre- vious to the division of the bone. The oval method has been employed by M. Guthrie for ampu- tation of the arm in its upper third. The mode of making his incision is precisely the same as in his operation for disarticula- tion of the shoulder joint, with the exception that the apex of the V is to be placed two fingers' breadth below the acromion. In fact most of the various processes for disarticulation might be employed for this amputation. The dressing of the wounds after amputation of the arm is so simple, as not to need description. To obviate the tendency of the muscles to shortening, the arm should be placed on the pillow in a state of half extension. AMPUTATION AT THE SHOULDER JOINT. Although the disarticulation of the arm at the shoulder joint was practised by Ledran more than a century ago, it is only within the last half century that it has been admitted as a regular process of the art, and chiefly through its very successful and frequent per- formance by the great School of Military Surgery, of which Baron Larrey was the head. Surgical anatomy.—In no amputation is a thorough knowledge of the structures concerned in the operation of greater importance, than in that of the shoulder joint. The articulation differs con- siderably as to form and arrangement, from all the other joints. The glenoid cavity of the scapula is an oval with a superficial hollow, an inch and three-eighths in length, and an inch broad at its widest part, which is at the inner and lower portion. The head of the humerus is nearly hemispherical, about an inch and three- quarters in diameter, and is rather applied against than fitted to the socket of the scapula, in which not more than one-third of the circumference of the head of the bone can be at one time received. The depth of the glenoid cavity in the recent state is about a quar- ter of an inch, and its face is presented outwards and slightly forwards and upwards. Half an inch above the top of the glenoid cavity is found a sort of arch or roof, formed by the acro- mion and coracoid processes, and the strong ligament which is stretched between them. This arch projects more than an inch and a quarter in front of the glenoid cavity, and protects the ante- rior and part of the lateral surfaces of the joint, covering as it does at least one-third of the circumference of the articulation, and pass- ing back about a quarter of an inch more on the posterior and external than on the opposite surface of the joint, in consequence of the sloping form of the base of the acromion process. The length or base of this arch is full two inches and a half. When 154 GENERAL OPERATIONS. the arm is close by the side, there is a distance of nearly an inch between the greater tuberosity of the humerus and the point of the acromion. When it is elevated, the tuberosity is brought up immediately under the acromion, close to the margin of the gle- noid cavity, and more than an inch of the articular surface of the humerus projects on the opposite side beyond the glenoid cavity, between the teres minor and subscapularis, pushing before it.the capsule which is there thin and weak. At the anterior and inter- nal side of the joint, between the tendons of the subscapularis and the supra-spinatus, the capsule is also thin and feeble. At the outer side the capsule does not descend lower than the upper margin of the tuberosities ; but on the inner it descends, or may readily be depressed, for a quarter of an inch below the line of the neck ofthe humerus. Above, the capsule is not only attached to the margin ofthe glenoid cavity, but also to the outer edge ofthe coracoid process, by a strong band of accessory fibres, called the coraco-humeral or accessory ligament. If we roll the arm out- wards we put these fibres on the stretch, and give them the ap- pearance of a band going to both the tuberosities, but especially to the outer. This renders the coracoid process really a part of the articulation. It will appear from this that the strength ofthe capsule is principally at its anterior and outer portion, the part upon PLATE XXXIX.—AMPUTATION AT THE SHOULDER JOINT—AT THE UPPER THIRD OF THE ARM. (Figs. 1, 2, 3.) AMPUTATION OF THE LEFT SHOULDER JOINT. (Process of Lisfranc.) Fig. 1.—a. Hand of an assistant compressing with the end of the middle finger the subclavian artery as it passes over the first rib,—the thumb taking a support at the same time from the posterior part of the shoulder, so as to steady the trunk of the patient. 6. Left hand ofthe surgeon grasping the arm so as to place it in. the requisite positions during the operation. c. Right hand ofthe surgeon passing the long double-edged catling in order to form the outer and posterior flap. The knife has been entered in front of 'the posterior angle of the armpit, and passed up between the head of the humerus and the belly of the deltoid. The point has then been lowered in order to open the capsule of the articulation, and again raised so as to be brought out through the triangular space formed at the top and front part of the shoulder, by the coracoid process, the acromion process, and the clavicle. The point and edge of the knife are subsequently to be brought downwards, so as to cut the outer and posterior flap, which is immediately to be raised by an assistant. (Fig. 2.) FORMATION OF THE INTERNAL AND POSTERIOR FLAP. The blade of the knife has been carried into the articulation through the wound in the capsule made by the puncture as shown in fig. 1, and brought round so as to divide the remains of the capsule, and shave the inner side of the neck of the bone. At this stage of the process, which is that shown in the drawing, an assistant grasps the axillary vessels between his thumb and fingers (d). The surgeon then completes the section of the flap with the knife (f), and with his left hand effects the necessary movements of the lim.b. (Fig. 3.) SURFACE OF THE WOUND SHOWN AFTER THE COMPLETION OF THE OPERATION. The glenoid cavity, with half of its capsule about it, is seen in the apex of the wound. The anterior flap is formed by the pectoral muscle, the heads of the biceps, the coraco-brachialis, the latissimus dorsi, the teres major, and the rotator muscles of the joint. The posterior and outer flap is formed by the deltoid alone. The arteries have been seized and tied. g. Axillary artery tied at the point at which it takes the name of brachial. h. Inferior scapular artery. i. Posterior circumflex. (Fig. 4.) AMPUTATION AT THE UPPER PART OF THE ARM. (Process of Sabatier.) The operation is shown near its completion. A flap has been cut at the external and upper part of the arm through the substance of the deltoid, the soft parts on the inner side have been divided by a section downwards and inwards, and the saw is shown applied upon the bone. a. Left hand of the surgeon sustaining the inferior part of the arm. b. Artery pad applied by an assistant to compress the subclavian artery over the first rib. c. The other hand of the same assistant, by the aid of a compress raising the flap out of the way of the saw (e). d. Line of the horizontal section of the soft parts downwards and inwards on the side of the axilla. h'ln C Plate .W i-'i/f /. &i' .ito„, 1-, .V i /;;,..,..;/ih.« -,,*,,.,,* /,, ,„,,. .(,-, AMPUTATIONS. 155 which the point of the knife is first to cut in the process for dis- articulation. The articular tendons also offer the greatest resist- ance in the same position; those of the supra and infra-spinatus and- the teres minor, occupying the outer semi-circumference of the joint, and which by rotating the arm strongly inwards may be brought forward so as to come readily under the action of the knife. In front there is but one tendon—that of the subscapularis ; —rotation in the opposite direction does not so much influence this tendon, and it is therefore usually found the most troublesome to divide. The projection of the acromio-clavicular,arch makes the prin- cipal difficulty of the articulation. In several of the processes, the point of the knife must be passed under this projection, as though it was going to pierce the scapula, in order that it may divide the external rotator tendons which are lodged below the arch. This arch, it must be recollected, forms an irregular osse- ous interval open in front, bounded by the coracoid process on its inner side, by the acromion on its outer, and the neck of the sca- pula behind; the interval, which is quadrangular and an inch in extent in all its directions, is occupied by the coraco-acromial ligament, which readily admits the passage of the point of the knife. It may be necessary to observe, that from the projection of this arch, unless'the integuments be divided at least three fingers' breadth below the pectoral border of the armpit, the sides of the section will not meet after the disarticulation so as to form a linear wound. The stump of the shoulder is more thickly covered with the muscular structure on the back surface than the front, and if two flaps are formed with the superior angle at the acromion, the posterior will consequently be much larger than the anterior. The acromion and coracoid processes remain for a long time unossified ;—a fact which is to be remembered, as it facilitates the disarticulation of the arm in young subjects. The circular, flap, and oval methods, have all been employed in amputation at this joint, and the processes have been so mul- tiplied, that more than twenty may be enumerated : those entitled to the most favour only will be given. In each case, pressure is to be made upon the subclavian artery above the clavicle with the thumb, the compressor of Bourgery, the handle of a large key, or a boot hook; but since, as has been before observed, it is ex- ceedingly difficult to maintain a thorough command ofthe circula- tion, an "intelligent assistant should always be prepared to seize the artery either before or at the moment of its division. Circular method. This method, which was employed by Alanson in 1744, has been advantageously modified by Greefe, Cornuau, and Sanson, and is well suited to cases where there is much emaciation, or the muscular system is but little developed. Process of Sanson. (PL XL. fig. I.)—The patient is to be put in a sitting posture. One assistant compresses the artery above the clavicle, and another, placed on the side opposite to the limb affected, passes one arm in front and one behind the trunk, so as to <*rasp the top of the shoulder with both hands, and draw back- wards the skin, especially that of the armpit, as strongly as possi- ble. The surgeon, standing in front of the patient if he operate on the right arm, and behind for the left, grasps the limb with the left hand, and raises it nearly to the horizontal position. He then passes his knife under the limb, so as to rest its edge over the tendons ofthe armpit, at the distance of an inch and a half below the point of the acromion, and divides with a single circular in- cision all the soft parts down to the bone; these are immediately to be separated from the head of the humerus so as to expose the joint. He next cuts with a semicircular incision the rotator, tendons and the capsule, draws the arm downwards, and carrying the knife through the joint, turns it around the head of the bone, which he detaches from its socket by dividing the posterior and lower portion of the capsule. This process is very rapid when well executed, but in fleshy subjects, does not leave sufficient inte- gument to cover well the point of the acromion ; and if the arm be raised too high during the first part of the operation, leaves a wotind too extensive on the side next the thorax. There is also great danger that excessive hemorrhage may occur from the divided vessels, in consequence of the difficulty of making effectual com- pression ofthe artery above the clavicle. The following process, though more tedious in the execution, is therefore entitled to a preference. Process of Cornuau.—The arm disposed as above directed, the surgeon divides the integuments by a circular cut four fingers' breadth below the point of the acromion. The skin being still further drawn upward by an assistant, he divides by a single cut the soft parts on the anterior, outer and back parts of the limb— from the coraco-brachialis muscle to the tendon of the latissimus dorsi, or from the latissimus to the coraco-brachialis, according as it be the left or right arm—leaving the axillary artery untouched. The divided muscular mass is then to be loosened and raised, the rotator tendons and the capsule cut, and the head of the humerus luxated backward. The knife is next carried round the head of the bone, so as to shave the inner side of its neck. An assistant passes his thumb or forefinger into the wound so as to grasp the artery between them, and the surgeon detaches the limb, by cut- ting out into the armpit so as to complete the circular incision. If difficulty should occur in opening the joint, in consequence ofthe length of the integuments below the acromion, they may be split up, as was originally directed by Alanson. Dressing.—The axillary, the posterior and anterior circumflex arteries, and the acromial, are to be tied in succession. The lips of the wound are to be brought together in a vertical line, and secured by adhesive straps and an appropriate bandage. Flap method. The processes by this method are the most numerous, and have been arranged by Velpeau into two classes, according as the flaps are cut from without inwards, or from within outwards. Process of Ledran. Single axillary flap.—The patient is to be seated in a chair, and the arm held horizontally. The surgeon divides transversely, two fingers' breadth below the acromion, the deltoid and the two heads of the biceps muscle ; then, lowering the arm, he continues the incision so as to cut the outer part of the capsule and the rotator tendons, and carries the knife through the articulation in order to bring it down on the posterior part of the neck of the bone. A temporary ligature is then passed with a needle round the bundle of vessels in the axilla, and the knife is brought down so as to detach the limb by cutting a flap three to four inches long on the posterior and internal side of the 156 GENERAL OPERATIONS. shoulder, in which are comprised the great vessels and nerves. It is difficult to retain the large internal flap sufficiently well ele- vated to cover the acromio-clavicular arch ; this process is there- fore justly abandoned, except in cases where, from the destruction of the soft parts on the exterior of the shoulder, no other could possibly be applied. Process of Lafaye. External and superior flap, formed from the deltoid.—A transverse incision down to the bone is made across the deltoid, five fingers' breadth below the acromion. Two other deep incisions nearly vertical, converging a little below like the margins of the deltoid, one on the internal and anterior sur- face, the other on the external and posterior, are dropped upon the extremities of the first. The flap is then to be dissected from the bone and raised by an assistant, the capsule opened, and the head of the bone luxated upwards. The axillary artery is next to be denuded and tied at the inner margin of the wound; the surgeon then brings down the knife so as to divide the soft parts on the interior of the bone upon a level with the fold ofthe arm- pit. Grosbois and Dupuytren modified this process by elevating the arm at a right angle with the trunk, raising the mass of the deltoid with the left hand, and pushing a double-edged knife between the head ofthe humerus and the acromio-clavicular arch, so as to cut from within outwards an external superior flap of sufficient length. The flap is to be raised by an assistant, so as to expose the joint, and the surgeon, grasping the arm with the left hand, approaches it to the trunk, and rolls the elbow inwards so as to extend the rotator tendons. These he divides with the knife, and enters the articulation under the acromion process. He then rolls the elbow so as to turn the head of the bone outwards, while the knife, pressed in the opposite direction, cuts the inner portion of the capsule and the tendon of the subscapularis. The head of the bone is now to be luxated outwards, and the knife slid down upon its neck. The surgeon then pauses for a moment, tillthe assistant, who has raised the flap with one hand, grasps the axillary artery with the thumb and fore finger of the other, introduced—one into the wound—and the other into the cavity of the axilla. The knife is finally carried downwards so as to cut outwards at the axillary borders, inclining it however a little forwards, in order to make the flap pointed in front, and leave the whole hollow of the armpit remaining on the stump. Langenbeck and Onsenoort perform the operation in a manner similar to that just described, with the exception that they cut the flap from without inwards, at a single sweep with a knife curved on the flat. Remarks.—The single flap formed out of the deltoid by these various processes, falls after the operation on the glenoid cavity, and effectually covers the arch above the socket. But the flap is thin at its base, and the muscular tissue of which it is composed is slow to unite with the subjacent parts; it wrinkles and con- PLATE XL.—AMPUTATION AT THE SHOULDER JOINT. (Fig. 1.) CIRCULAR AMPUTATION ON THE RIGHT SIDE. (Process of Sanson.) The integuments have been firmly drawn up by an assistant towards the joint, and the amputation knife, which has been applied over the insertion of the armpit tendons, is seen as it is brought round to finish the circular section of the skin and soft parts down to the bone. The right hand of an assistant (a) applies the artery pad upon the subclavian as it passes over the first rib." The hand of another (b) retracts the soft parts towards the shoulder. The surgeon sustains the limb with his left hand (c) while he makes the circular sweep with the knife (d). The head of the humerus is then to be separated from the surrounding muscles with the knife, and detached by the division of the ligaments of the joint. After the ligature of the vessels the margins of the skin are to be brought together with adhesive straps, so as to form a linear wound in a direction downwards and slightly inwards. (Fig. 2.) OVAL AMPUTATION. (Process of Baron Larrey.) _ The operation is shown near the period ofits completion. A vertical incision (a, b, b) has been dropped from the point ofthe acromion. From near the lower end of this, two oblique lateral incisions have been made to the opposite borders of the armpit. The operator has then separated the soft parts with the knife from over the bone (g), divided the capsular ligament, and carried his knife through the joint round upon the inner face of the neck ofthe bone. At this period ofthe operation, which is the one shown in the drawing, an assistant grasps the axillary vessel in the inner flap between his thumb and fingers (e). The operator, sustaining the arm with one hand (f), with the other (h) finishes the section by carrying the knife (e) from the angles of the two oblique incisions through at the inner side of the arm, dividing with the skin the vessels and nerves of the armpit. After the ligature of the divided vessels, the lips of the incision are brought together in a vertical line. Fig- 3.—Appearance of the wound after the oval operation of M. Guthrie, which is but a slight modification of the process of Larrey, and yields the same results. i. Glenoid cavity. j. Branch of the posterior circumflex artery. I. Inferior termination of the axillary, raised on the forceps by the surgeon while an assistant secures it with a ligature. Plate 40. On Stan, t>j tV liehoivski PhiloLdelphia. PubUsheJ. by Cirt.v *.iHeirt AMPUTATIONS. 157 tracts, and, from the difficulty with which it is maintained in contact with the inner and lower margin of the wound, the heal- ing process is rendered protracted. In certain cases, however, of injury of the structure on the axillary side of the joint, it is the method to be preferred. But in circumstances admitting of a choice, the process by a double flap will be found to form a better stump. Double flap. Process of Sir-Charles Bell. One superior and one inferior flap, which unite so as to form a transverse wound.— The artery compressed between the scaleni muscles above the clavicle, and the arm raised, the soft parts are to be divided by a circular incision down to the bone, three fingers' breadth below the point of the acromion. The arm is then to be lowered, and two vertical incisions are to be dropped from the level of the joint down upon the transverse cut—one on the anterior and one on the posterior part of the limb. The flap thus marked out upon the external part of the shoulder is to be dissected from the bone and raised, and the disarticulation accomplished in the usual man- ner. This process may be considered a good one—it forms regu- lar and well-shaped flaps ; but it is not so rapid in its performance as the following, which is commonly preferred to it, though, as it appears to me, upon no very satisfactory grounds. Process of Lisfranc. (PL XXXIX. figs. 1, 2.)—Posterior ex- ternal and posterior internal flaps. Left arm.—The patient is seated on a chair, and an assistant placed behind him, ready to raise the flap first formed, and com- press the orifice of the posterior circumflex artery with one hand, and the axillary with the other previous to tts division in the formation of the second or internal flap. To prevent still further the effusion of blood, the assistant may, during the formation of the first flap, compress with his middle finger the artery above the clavicle, steadying the shoulder with the same hand. 1. The arm is to be raised nearly horizontal. The surgeon standing behind the patient, embraces the stump of the shoulder with his left hand—the thumb resting on the posterior part ofthe head of the bone, and the ends of the two first fingers over the coraco-acromial triangle ; then taking in the other a narrow dou- ble-edged knife or catling, which should be eight inches long, and held parallel with the humerus, he enters the point just at the external side of the posterior fold of the armpit, in front of the tendons of the latissimus dorsi and teres major muscles, with the upper cutting edge a little turned in front, so that the flat of the blade shall lay nearly parallel with the broad surface of the ten- dons of the above muscles. The knife is then to be passed up along the outer and posterior surface ofthe humerus, till the point touches the head ofthe bone; the handle is now to be inclined a little downward to carry the point over the head, and then ele- vated again with a rocking motion so as to depress the point and open the capsule: now shifting the fingers of the left hand down the arm, he carries the point through in the centre of the space hetween the coracoid and acromion processes, with the handle raised the distance of two Or three inches from the arm. The most difficult part ofthe operation—the puncture—is now accom- plished. Holding the hand nearly immovable, the surgeon next cuts with the point of the knife, inclining it a little from within out- .wards and from below upwards, so as to disengage the edge from below the acromion, and turn it round the head of the bone. 40 The knife is now brought down along the external face of the bone, and subsequently inclined towards the skin, so as to cut a posterior external flap three inches long, which includes the ten- dons of the latissimus dorsi and the teres major. This flap is to be instantly raised by the assistant, and the stream of blood from the posterior circumflex artery, if not arrested by pressure above the clavicle, is to be checked with the thumb and finger of his left hand. 2. The articulation is already laid open, and the outer rotator tendons cut across, if the process as described has been exactly followed. The operator now carries the knife from the outer side through the joint, keeping the handle inclined low, so.as to cut from heel to point, and brings it round to the internal side of the head of the bone, which is to be luxated as the knife is slid be- hind it. The handle is then further depressed so as to become vertical,—the blade is brought down so as to shave the internal side of the bone,—and as soon as sufficient room is made above the knife, the assistant grasps the artery in the thickness of the flap, and the surgeon detaches the limb by cutting out at the level of the armpit, so as to divide the tendon of the pectoralis major and form an internal and posterior flap, of the same length as the preceding. Right arm.—In the operation for the right arm, some modifi- cation of the process is required, in order to enable the surgeon to employ the knife with the right hand. In forming the first flap, he may stand behind the patient and proceed as in the case last described. Then shifting his position to the side of the patient,' and holding the handle upwards, he carries the knife through the joint and forms the second flap. Or if he finds it more convenient, he may form the first flap by entering the knife between the cora- coid and acromion processes, and carry it down nearly parallel with the bone till the point emerges under the tendons at the pos- terior fold of the armpit, and finish the section of the flap by bringing the handle downwards. This process of Lisfranc is very rapid when skilfully performed ; the flaps are well disposed for reunion, and furnish a ready outlet below for the discharges that attend the progress of the cure. The acromion is not always, however, sufficiently well covered, and in young subjects, when the muscles are large and act with force, it is not easy to pass the knife in the space between that process and the coracoid. In the latter case, it might answer to make the puncture at the outer side ofthe acromion, and divide by a sepa- rate incision the external rotator tendons and the capsule, rolling the arm inwards so a's to bring them more readily under the action of the knife. But on the whole, this process is inferior to the oval method in regard to the neatness and regularity with which the flaps are formed. Oval method. Process of Baron Larrey. (PL XL. figs. 1, 2.) —The arm of the patient is to be placed nearly in contact with the side of the chest. The surgeon commencing at the point of the acromion, makes a vertical incision three inches long, splitting the deltoid in its middle down to the bone. The arm is now to be raised nearly horizontal. An assistant draws the integument well upward towards the top of the shoulder, and the operator makes two oblique cuts through the soft parts in the form of a \ reversed, commencing at the middle of the vertical incision;— —one, the anterior, is carried downwrards and forwards to the 15S GENERAL OPERATIONS. anterior fold of the armpit, so as to divide the pectoralis major very near its insertion upon the humerus ; the other—the poste- rior—downward and backward to the posterior fold of the armpit, cutting in like manner with one sweep of the knife the deltoid, and the insertion of the latissimus dorsi and teres major, leaving untouched the vessels, nerves and integuments of the axillary cavity. The two muscular flaps are then rapidly loosened from the bone and drawn upward by an assistant, who grasps one with each hand, and at the same time makes pressure on the bleeding orifices of the two circumflex arteries. The articulation is now laid bare. The surgeon rolls the arm a little inwards and divides the rotator tendons and the outer half of the capsule by a semi- circular cut; luxates outward the head ofthe bone ; glides around it the knife so as to shave the neck and divide the remaining half of the capsule ; and arrests the instrument on a line with the lower angles formed by the two oblique incisions. At this pause in the operation, another assistant introduces his thumb and fore finger—one into the wound, the other into the axilla, so as to com- press the axillary artery, the position of which will be manifested by its pulsations. The surgeon then completes the operation by cutting through towards the chest, so as to unite the two oblique incisions at their lower ends. The incision is not, however, to be made directly transverse as if we were to cut the base of a A, but sloped a little downward on the arm, in order to leave on the stump a little more than the whole integuments belonging to the axilla. By thus modifying the last step of the operation, we leave the two flaps united below, so that they come well together in the middle line ; for when the transverse incision is made in the more common mannej directly into the armpit, the integuments are too scant at the lower edge of the wound, and leave a space which has to be filled up by a cicatrix of new formation. In this process the surgeon stands at the outer side ofthe limb, and finds it difficult to make both oblique incisions with the right hand. It is better, therefore, as regards one of them, to shift the knife over to the left hand as directed by Baron Larrey. It is not difficult, however, if the surgeon is unpractised with the left hand, to make the second incision with the right—which may be an- terior or posterior according to the arm on which he acts—by dividing the parts from the skin to the bone and from below up- wards ; or by passing the knife over the face of the bone from above downwards, puncturing the skin under the tendons, and cutting outwards. In making the anterior oblique incision, the operator, if he is not sure of his hand, may pass his fingers into the axilla, to avoid all risk of a premature division of the great artery, which lies but a little distance from, the anterior tendons of the armpit. A slight modification of this process of Larrey has been made by Guthrie and Scoutetten. They both reject the vertical inci- sion. Guthrie begins the two oval incisions at the point of the acromion, cutting first only through the integuments, which are then to be drawn upwards, and the muscles divided by a second incision on a line with the retraction. Scoutetten begins tbe oval incision at the same point, cutting at once down upon the bone from the joint to the armpit tendons, and carrying the knife lightly across so as to divide merely the skin of the armpit, and unite the two oblique incisions below. The subsequent steps of the ope- ration in each case are the. same as in the process of Larrey. Of the various processes described, the oval and the circular are those unquestionably which offer the greatest facility in the performance, and afford tbe most satisfactory results. But the lesions requiring amputation of the arm at the joint are so very various, and so often accompanied with a destruction of the soft parts on one side of the limb, that cases frequently occur in which the single or double flap will be found the only ones admis- sible, and even these as given, wiU sometimes require to be varied by the ingenuity of the surgeon, in order to get for the stump the best covering possible out of the uninjured soft parts. The process of Barron Larrey, which has been the most era- ployed, has, according to Sedillot, been attended with success in ninety out of a hundred cases. Dressing.—For the prevention of hemorrhage the ligature en masse of the vessels previous to the operation, as practised by Ledran, is now utterly laid aside, the surgeon trusting to the plans already detailed for the stifling of the hemorrhage until the limb is removed and the surgeon can secure the bleeding orifices on the face of the stump. The axillary artery is to be" the first tied, next the circumflex and such other vessels as throw out blood in a jet. The ligatures are to be brought out at the lower angle of the wound, and the flaps approximated with adhesive straps;—occasionally the interrupted suture will be found useful in the adjustment of the flaps. Pressure should be made with a bandage from the trunk towards the stump, so as to prevent puru- lent accumulations. A particular bandage (fascia pro excisione humeri) will be found useful to effect this object. It is to be two yards and a half fcng and three quarters wide, slit open in the middle so as to receive the arm and come up to the shoulder of the opposite side, and then split into four tails which are to be brought round the stump. AMPUTATION OF THE SHOULDER BLADE WITH THE ARM. In cases of extensive traumatic injury, caries, or malignant diseases, it may occasionally be necessary to remove a part or even the whole of the shoulder blade with the arm. Parts ofthe shoulder, as the acromion process, the neck of the scapula, and the outer end of the clavicle, have been many times successfully removed ; and Cuming, of Jamaica, and Professor Mussey, of Cin- cinnati, have been equally fortunate jn removing the shoulder blade entire. But the success has been chiefly confined to instances of traumatic injury. The mode of operation must vary according to the nature of each particular case, and no general formulae can be established. There will be in fact two operations—one for the resection of the shoulder, and one for the disarticulation ofthe arm. The resection ofthe shoulder bones should in gene- ral precede the latter. The methods for resection which have already been given, will only require to^be so modified that the division of the soft parts shall be made in order to facilitate as .much as possible the subsequent operation upon the joint. OF THE LOWER EXTREMITIES. As in the upper extremities, amputation may be performed in the lower, either in the continuity of the bones or at the joints. AMPUTATIONS. 159 The importance, however, of preserving the greatest possible length of the limb, by operating under certain circumstances for this purpose thfBiigh the joints, is not so imperative in regard to the lower extremities as the upper, and must indeed be held as subsidiary to another object—that of affording the greatest facility for the adjustment of the means of artificial support. The shortness of the toes, their minor importance as compared with the fingers, and the risk of the stump becoming irritated against the boot, render it customary, with the exception of the first, to amputate them at their metatarso-phalangeal joints rather than between the phalanges. The great toe, which forms an im- portant point of support to the foot, should be preserved as long as possible, and may be amputated by processes similar to those of the fingers, either through its phalangeal joint or in the continu- ity of the phalanges. If amputated at its metatarsal joint, the two sesamoid bones on its under surface may be left attached to the flap. The amputation of the toes at their metatarso-phalan- geal joints, separately or all together, and that of the metatarsal bones through their continuity, is performed by processes so nearly similar to those for corresponding bones of the hand, that it would be useless to repeat the description here, and the little differences will be sufficiently explained by reference to Plates XLI. and XLIL, in which the operations are shown. It may be observed, however, that there is more objection to the removal of the metatarsal bones when it can possibly be avoided, as it necessarily diminishes the breadth and solidity of the support furnished by the foot. This is particularly the case in reference to the first metatarsal, the whole or a part of which should always be left whenever the nature of the disease will admit of it. If it become necessary to remove this latter bone at its metatarso-tarsal joint, the knife must be used with caution at the inner side of the base, for fear of wounding the anterior tibial artery, which dips down at this point to reach the sole of the foot. If this vessel should be wounded, it may be secured with a ligature, and usually without much difficulty. In spite of every care as observ- ed by Professor Ferguson, troublesome bleeding will sometimes occur at the deep-seated corner of the wound, which can only be arrested by a graduated compress, made by first introducing small and then larger pieces of lint, and securing the whole by compression with a bandage. There is also, as I have observed in one instance, and which has been noticed by the same writer, a tendency in the adjoining toes, from the want of support at their inner margin, to curve inwards, so as to become a source of in- convenience by pressure against the boot; to obviate this incon- venience I have been obliged to remove the second toe at its root. 1. AMPUTATIONS OF THE FOOT. AT THE METATARSO-TARSAL JOINTS. Since the time of Sharp and Hey, the partial amputations at the transverse joints of the foot have attracted considerable at- tention as a means of saving the heel and ankle, and preserving the length of the limb, without producing any deformity that would not be well hidden in a boot. But from thje imperfection ofthe processes employed, and theimperfect study of the irregular structure of the joints, considerable difficulty was encountered in the disarticulation in the few instances in which it was attempted, and the saw was usually resorted to for the detachment of the bones. To Lisfranc we are mainly indebted for an accurate description of the parts concerned, as well as for the precise details of the operation, which have removed nearly all the difficulties in the way of its performance. The growing sense of the importance of saving as much as possible of the body of the foot, has induced surgeons latterly to restrict the operation at this joint to cases in which the" posterior extremities of the metatarsal bones are diseased, justly preferring to divide the metatarsus in its continuity with the saw, when by so doing a healthy portion of it can be preserved in connection with the tarsal bones. Surgical anatomy.—The posterior extremities of the five meta- tarsal bones are articulated with the cuboid and the three cunei- form. The line of junction is transverse, but irregular and intricate, forming a curve, which terminates nearly an inch more in front on the inner than the outer side. On the external side, the com- mencement of this line is well marked by the projection at the posterior part of the metatarsal bone of the little toe, which can readily be distinguished by carrying the finger back along its outer side; immediately behind this projection is the depression, indi- cating the joint which separates the metatarsal bone from the cuboid. By abducting the foot, we may also either see or feel, according to the state of the parts, the tendon of the peroneus tertius muscle, which is inserted on the tuberosity. The internal end of the articular line is next to be ascertained. The three following indications will serve for this purpose, some one or more of which, whatever may be the state of the parts, it is always possible to apply. 1. From the middle of the tuberosity of the fifth metatarsal bone, draw a straight line directly across the back of the foot. Three-quarters of an inch in front ofthe internal end of this line, will be found the joint between the internal cuneiform bone and the metatarsal of the great toe, which forms the inner end of the articular line in question. 2. By passing the finger backwards along the internal and inferior side of the first metatarsal, wTe feel first the tuberosity at the end of this bone, then a little depression behind it, and lastly a second prominence which belongs to the cuneiform bone. The depression between these prominences marks the line of the joint. 3. By carrying the finger from behind forwards, along the in- ternal border of the foot, a projection is felt just an inch in front of the malleolus, formed by the scaphoid bone. An inch and a quarter in front of this, is the inner edge of the joint. In some rare instances, the tuberosity of the fifth metatarsal bone has been found extending further backwards, so as to be ar- ticulated with the side ofthe cuboid bone, and increase the length of the curve on the outer side of the foot. The direction of the articular surfaces is as follows: between the fifth metatarsal and the cuboid bones, the interline runs first in the direction of the inner edge of the metatarso-phalangeal joint of the great toe, then turns more inwards in a line towards 160 GENERAL OPERATIONS. the middle ofthe first metatarsal bone, and is next directed nearly transversely across the foot, to form the line of articulation of the fourth metatarsal with the cuboid; the whole of the curve thus described round the face of the cuboid, is about an inch in length, its internal end being about a third of an inch in front of its ex- ternal. The articulation of the third metacarpal with the outer cunei- form bone is about half a line more in front, and runs transversely. The end of the second metacarpal bone, which is the most intri- cately articulated, falls about the sixth of an inujfc further back, and is connected nearly transversely with the middle cuneiform. It is also articulated on the sides with the other two cuneiform bones ; the internal one projecting about a third of an inch more in front than the middle bone, so as to leave the end of the second PLATE ILL—AMPUTATIONS ON THE FOOT. Fig. 1.—Representation of the linear wound left after the oval amputation of the first and third toe at the metatarso- phalangeal joints.—The first steps of this operation are shown at fig. 2. (Fig. 2.) AMPUTATION IN THE CONTINUITY OF THE FIVE METATARSAL BONES. Having cut a dorsal and plantar flap—the latter being much the longer of the two—from the surface towards the bone, the surgeon inclines the foot, as shown in the drawing, so as to cut the interosseous muscles in the arch of the foot, which from their deep situation have not been included in the plantar flap. a. One hand of an assistant, steadying the leg. 6. The other hand of the same assistant, sustaining the foot, and at the same time securing the ends of the compress (c), with which the plantar flap is drawn back out of the way of the knife. d, e. Hands of the operator, who is about to divide the interosseous muscles with the knife. (Fig. 3.) AMPUTATION IN THE METATARSO-TARSAL ARTICULATION. (Mixedprocess of Baudens.) A dorsal and plantar flap have been formed, as described in the text. The joint between the internal cuneiform and the first metatarsal bone has been opened with the knife, upon a level with which, the four metatarsal bones of the smaller toes have been divided with the saw, so as to give a regular surface to the stump. (Figs. 4, 5.) AMPUTATION THROUGH THE METATARSO-TARSAL JOINTS. (Process of Lisfranc.) Fig. 4.— Opening of the joints on the dorsal surface.—A semilunar flap of skin has been cut on the back of the foot, and the extensor tendons divided somewhat nearer the line of the joints. The articulation ofthe cuboid with the two outer metatarsal bones (a), and that of the internal cuneiform with the first metatarsal (b). have been opened with the knife. The knife is shown as applied for the purpose of detaching the head of the second metatarsal bone from the mortise in which it is lodged. c. Hand of an assistant, sustaining the leg. d. Left hand of the surgeon, grasping the extremity of the foot with the palm under the sole. The thumb (e) and the fore finger (f) are applied upon the tuberosities of the first and fifth metatarsal bones, serving as a guide to the operator in determining the limits of the incision for the dorsal flap (g). ' h, i. Knife employed in the right hand of the surgeon, the point of which is plunged between the head of the second metacarpal bone and the internal cuneiform, in order to divide the internal interosseous ligament. At h the knife is entered at an angle of 45 degrees, till it divides the ligament and the point"is arrested against the bone. The dotted line (i) indicates the track of the handle of the knife in effecting the division of the ligaments of this joint, which is the most difficult part of the operation. Fig. 5.—Formation of the plantar flap.—The stage ofthe operation shown is that where, after having separated the articular surfaces, the surgeon insinuates the knife between the internal cuneiform and first metatarsal bones, to begin the section of the plantar flap. The shape of this flap is to be the same as that shown-at Plate XL1I. fig. 3. The surgeon, with his left hand at a, depresses the points of the toes, while he employs the knife in his right-(b). (Fig. 6.) OVAL AMPUTATION IN THE CONTINUITY OF THE FIRST METATARSAL BONE. The oval incision of the skin having been made, the bone isolated, and the soft parts drawn away from the bone by the aid of a compress, the surgeon takes the toe in his left hand (a), while he makes the section with the saw in his right (b). Plate 41 On Stone hy Pi' Uotli Philadelphia., Published by Carey & gart AMPUTATIONS. 161 metatarsal lodged in a mortise, shelving on the sides, a little more than half an inch broad at its base on the middle cuneiform, a sixth of an inch wide on its outer side, and a third of an inch at its inner. The articulation of the first metatarsal with the inter- nal cuneiform, is about a quarter of an inch in front ofthe preced- ing, and slopes in the direction of a line passing from its internal edge to the middle of the fifth metatarsal bone. All the metatarsal bones are articulated with the others upon the sides, with the exception of the first. On the plantar surface, the metatarso-tarsal joint is much more narrow than on the back, on account of the arched form of the foot, and the second cunei- form is found almost entirely concealed by the first. The ligaments which connect the bones together are found on their dorsal, plantar and lateral surfaces, and do not require to be particu- larly studied, as they are readily divided with the point of the knife by following the line of the joint. There are three interos- seous ligaments, the position of which should be well known. The internal one of these is very strong, and is called the key of the articulation. - It runs from the external face of the first and from the internal face of the second cuneiform, and is inserted upon the corresponding faces of the first and second metatarsal bones. The second or middle interosseous arises from the ex- ternal face of the second cuneiform and the internal face of the third, and is inserted upon the corresponding surfaces of the second and third metatarsal. The third or external interosseous ligament is connected in a similar manner with the adjoining faces of the external cuneiform and cuboid behind, and the third and fourth metatarsal in front. It will therefore be seen that the mor- tise at the head of the second metatarsal, which is the cause of the greatest difficulty in the operation, lodges ligaments upon its sides, and leaves room, as shown by Lisfranc, for their easy division by the introduction of the point of the knife. Anchylosis has occasionally been observed in some of the joints. If this is firm or extensive, the bones will have to be divided with the saw. If, as is more commonly the case, it is limited to the mortise, the head of the second metatarsal may be divided so as to form a straight line with the ends of the two cuneiform bones upon its sides. Process of Lisfranc. Plantar flap. (PL XLII. fig. 4, 5.) Left foot.—The patient is to be placed on his back ; and the foot, half flexed, projecting over the bed, and resting on the heel, is to be steadied by an assistant who grasps it above the malleoli. The surgeon, taking the foot in his left hand with the palm applied under the sole, and the thumb and fore finger just half an inch in front of the two extremities of the articular line, and marking out in his mind or with the handle of the scalpel the course of the articulation, makes a semicircular division ofthe integuments, with a narrow, straight knife, half an inch or more in front of the line ofthe joint, commencing and terminating at the two extremi- ties of the articular line. The skin, loosened if necessary with the knife, is now to be drawn backwards by an assistant, and the extensor tendons and the remaining soft parts divided down to the bones, as nearly as possible on a level with the joint. With- out changing the position of the left hand, the surgeon carries the point of the knife upon the external side of the joint, and cuts the dorsal ligaments, with a slight sawing motion, along the curved .line of the articulation of the last two metatarsal bones, 41 until the instrument is arrested against the outer edge of the third cuneiform bone. The point is now to be turned so as to advance a line in front, and then carried across the transverse articulation of the third metatarsal with the middle cuneiform bone. The knife is next to be shifted to the inner side of the foot, and the point alone entered as before (the blade held nearly vertical) between the adjoining surfaces ofthe first metatarsal and the inner cunei- form, separating the dorsal ligaments in the direction of the joint towards the middle of the fifth metatarsal bone, till the knife is ar- rested against the second metatarsal. The head of this latter bone> locked within the three cuneiform by strong ligaments, is next to be loosened by inclining the handle ofthe knife towards the toes, with the edge towards the ankle, so as to form an angle of 45 degrees; then pushing up the point along the inner edge of the mortise till it is checked against the middle cuneiform bone, and raising the handle vertically, the first interosseous ligament is di- vided with the edge. Now, raising the point and turning the edge ofthe knife outwards, follow the mortise round so as to divide its ligaments, depressing at the same time the anterior portion of the foot, in order to raise the bases of the metatarsal bones and make the line of the joint conspicuous. The articulations are all now opened; luxate next the whole metatarsus backwards, by shift- ing the thumb forwards upon the dorsum, pushing wdth it strongly downwards, while the fingers on the sole press upwards against the base. The remaining interosseous and plantar ligaments are then to be divided through the gaping joint with the point of the knife. By another effort, as before, complete the luxation, shave with the point of the knife a part of the under surface of the me- tatarsal bones, so as to gain room behind them to lay the blade and turn it round the tubercle of the last metatarsal bone. We then finish the operation by holding the sole ofthe foot somewhat obliquely, so as to shave the under surface ofthe metatarsal bones, (which is most concave on the inner side,) till the edge of the knife comes in contact with the sesamoid bones of the great toe. Then, turning the foot still more upon its side, cut obliquely through the skin, from the outer to the inner margin of the foot, in order to form the plantar flap, which should be convex in the middle, two inches long at the inner, and a little more than an inch at the outer edge. Right foot.—For the right foot the process is precisely the same, with the exception that we reverse the position of the thumb and finger of the left hand, and finish the division of the plantar (lap from the inner towards the outer border. If the first cuneiform bone should be found unusually prominent, or the flap prove too short to cover it completely—a circumstance against which, however, the surgeon should carefully guard—the end of the bone might be removed with the sawr. It is scarcely necessary to say that means must be taken to command the circulation during the operation, either by pressure on the anterior and posterior tibial arteries with the fingers of an assistant, or by the application of a tourniquet to the thigh. The dressing is simple. The bleeding vessels are to be tied • the flaps brought together over tbe ends ofthe bones by adhesive straps, and sustained by a roller bandage. The patient should be placed in bed with the leg half bent, and resting on its outer side, so as to facilitate the discharge of any matter that may form in the wound. 162 GENERAL OPERATIONS. Mixed process of Baudens. (PL XLII. fig. 3.)—The foot held as in the process last described, enter the point of a double-edged knife under the base of the first or last metatarsal bone, according to the foot on which we act, and glide it across to the opposite side along the plantar surface of the bones, which are to be shaved downwards to form the plantar flap. Unite then the lateral mar- gins of this wound by a semilunar incision over the back of the foot, and dissect up and revert the dorsal flap. Draw back also the plantar flap ; divide by a circular incision the remaining soft parts, including the interosseous muscles on the sole ; disarticu- late the first metacarpal bone from the internal cuneiform, and divide the four smaller ones with the saw in advance of their joints. This process is more rapid and more easy of performance than that of Lisfranc, leaves a more regular surface, and is entitled to a preference when the bases of the last four metatarsal bones are not involved in the disease which has called for the operation. AMPUTATION AT THE MIDDLE TARSAL JOINT.—AMPUTATION OP CHOPART. Surgical anatomy.—This joint is formed by the os calcis and astragalus behind, and the scaphoid and cuboid bones in front. Two distinct articulations exist—one between the calcis and cu- boid bone, and one between the astragalus and scaphoides. The general direction of the joint is transverse, but the bones are not exactly upon the same line when the foot is extended ; the calcis then projecting about a quarter of an inch in front of the astra- galus. But when the foot is flexed they are nearly on the same level. PLATE XLII.—AMPUTATIONS ON THE FOOT. (Fig. 1.) FLAP AMPUTATIONS OF THE FIVE TOES AT THE METATARSO-PHALANGEAL JOINTS. A dorsal incision, convex forwards, has been made in front of the ends of the "metatarsal bones, the skin drawn back and the extensor tendons divided over the line of the joint. The articulations have been opened and the knife is shown in the right hand (d) of the surgeon, after it has been carried through the line of the joints, and is about to finish the division ofthe plantar flap by cutting out at the plantar crease at the root of each ofthe toes. The surgeon holds the joints of the toes in his left hand (b), while an assistant (a) sustains the foot. (Fig. 2.) AMPUTATIONS OF THE TOES. (A). Oval amputation of the great toe. An oval section of the skin has been made, and the operation is shown as the knife, which has cut the ligaments and entered the joint, is about to detach the phalanx. On the same foot is shown the appearance of the stump after the removal of the third toe by a double flap. In PL XLI. fig. 1, is seen the linear wound formed by the approximation of the adjoining toes after the same operation, as well as that after oval amputation ofthe great toe. (B). Oval amputation of the metatarsal bone of the small toe at its junction with the cuboid. The anterior end of the bone is shown drawn outwards with the left hand of the surgeon, while he opens the joint with the point of the knife. (Figs. 3, 4.) AMPUTATION AT THE MIDDLE TARSAL JOINT OF THE RIGHT FOOT. (Process of Chopart, modified.) Fig. 3.—Disarticulation. The foot is shown properly sustained by the two hands of an assistant. a. A semi-elliptical incision has been made over the dorsum, the flap (e) drawn back, the tendons divided over the joints, and the ligaments cut at the free borders of the two joints. At this period of the operation, the knife (f) is shown passing under the posterior end of the scaphoid and cuboid bones to form the plantar flap. The surgeon with his left hand (b) grasps the plantar surface ofthe foot, the thumb (c) and fore finger (d) being placed on the prominences ofthe scaphoid and cuboid as a guide to the line of the double articulation. Fig. 4.—Formation of the plantar flap. g. Hands of an assistant steadying the limb. h. Left hand of the surgeon depressing the toes, and at the same time forcing up the posterior end of the fragment (on which are seen the scaphoid and cuboid bones), to give room to the knife (i) as it forms the plantar flap (I). k. Dorsal flap of integuments. On the surface of the stump are seen the articular faces of the astragalus and the apophysis of the os calcis. The anterior tibial and plantar arteries (m), which will require to be tied, are shown on the face of the wound. Ft ate 4, I'll \y,m. bi- S i u-/t,iiv.,k, Pliiladelphui, PtU>lislied by Carry &Bart P. S Duval, Ltth.Phil* AMPUTATIONS. 163 In order to find the internal end of the articulation, trace with the finger the inner border of the foot from the malleolus forwards. The first tuberosity met with, distant about three quarters of an inch from the malleolus when the foot is extended, belongs to the scaphoid bone ; and immediately behind it is the joint. Tracing in the same manner the external border of the foot, the first tuberosity encountered belongs to the calcis. In front of this is the line of the joint, about an inch and a quarter in advance of the external malleolus, and half an inch posterior to the tube- rosity of the fifth metatarsal bone. The ligaments of this middle tarsal joint are loose and easily divided, with the exception of one, that unites the calcis and the outer part of the scaphoid, and which is properly considered the key of this articulation. The direction ofthe line between the os scaphoides and the head of the astragalus, which may be made visible through the skin by strongly abducting the foot, is that of a half moon with the convexity in front. To follow this line from above downwards, so as to divide the parts next the sole, the handle of the knife must be depressed towards the toes. The joint between the calcis and cuboides forms an oblique plane directed from within outwards and slightly forwards. The foot is to be put in the same position and the circulation controlled as in the preceding amputation. Process of Chopart a little modified.—(PL XLII. figs. 3, 4.)— The surgeon places his left thumb and fore finger on the lateral projection of the scaphoid and cuboid bones, and divides, with a semicircular incision over the dorsum—convex forwards and half an inch in front ofthe joint—all the soft parts down to the bone. He thenopens the calcaneo-cuboid joint, andtheastragalo-scaphoid, by cutting their dorsal ligaments in succession. Pressing down- wards the end of the foot, he next enters the point of the knife at the outer side of the joint in order to divide the strong interosseous, or calcaneo-scaphoid ligament, which forms the key of the joint. The foot, by first drawing it forwards, is now readily luxated up- wards. The surgeon then carries the knife through the joint, shaves the tuberosities of the cuboid and scaphoid bones, and those of the first and fifth metatarsal, and cuts out—with the foot turned a little upon the edge—near the heads of the metatarsal bones, so as to form a large plantar flap. The objection to this process, which has been many times practised, is the great extent of the flap necessary to cover the large surface of bone exposed, the unavoidable narrowness of its base, and the difficulty of retaining the thick flap so well elevated as not to leave any surface over the edge of the astragalus to unite by granulation. The following processes are designed to obviate these incon- veniences to a very considerable extent, and apply to cases in which the plantar surface is so involved in the lesion, as not to allow of the formation of an extensive flap. Process of Sedillot. Oval process. (PL XLII. fig. 6.)—Begin the operation by making a transverse incision over the external semicircular edge of the tarsus—that is, from over that part of the middle tarsal joint in range with the second cuneiform bone—and then bring the knife round the lower surface of the cuboid to the apophysis, over which is reflected the tendon ofthe peroneus lon- gus muscle, dividing everything down to the bone in its course. From the upper angle of this incision, make another obliquely downwards so as to cross the middle of the first metatarsal bone ; carry the knife round this bone, and continue its course diagonally across the sole to the termination of the first incision over the cuboid, dividing in its track everything down to the bones, but with the handle inclined forwards so as to leave a beveled edge. Dissect from the bones and elevate the large internal oval flap thus marked out, loosen the integument also on the upper and outer part of the foot behind the transverse incision, so that the whole covering of the bones may be drawn backwards by an assistant as far as the middle tarsal joint, the position of which will be indicated by the projection of the head of the astragalus. The articulation is then to be opened as in the process already de- scribed, and the knife passed between the bones, so as to com- plete the separation by dividing the soft parts below, on a line with the base of the plantar flap. The separation of the plantar flap from the bones may, if the surgeon prefers, after it has been marked out with the course of the knife across the sole, be left for the last step of the operation; the knife, after it has passed through the joint, being carried downwards, so as to shave the under surface of the bones to the line of incision. The anterior tibial and plantar arteries are to be tied, and the flap applied to the ends of the bones, so as to form a linear cicatrix at the outer margin. Mixed method of Baudens.—The object of this surgeon is to pre- serve a greater length to the foot by avoiding the removal of the scaphoid, and the posterior half of the cuboid bone, in those cases in which the lesion ofthe tarsus does not extend further back than (Fig. 5.) AMPUTATION AT THE ANKLE JOINT. (Ovalprocess of Baudens.) The large oval flap of integument has been traced out and reflected upon the leg, as described in the text, and the stump is shown after the division of the malleoli and the posterior border of the tibia has been made with the saw. The posterior tibial artery is secured with a ligature. The anterior tibial is seen accompanied with its veins on the lower surface of the dorsal part of this flap. (Fig. 6.) AMPUTATION AT THE MIDDLE TARSAL JOINT OF THE LEFT FOOT. (Process of Sedillot.) The large internal oval, and the small upper and outer flap, have both been dissected loose and reverted, and the foot detached at the joint, so as to show the form of the stump and the kind of covering obtained by this process. Ligatures have been applied to the anterior tibial and plantar arteries. 164 GENERAL OPERATIONS. the cuneiform bones, and the anterior half of the cuboid. The process for the operation is very simple. A double-edged knife is to be passed across close under the bony arch of the tarsus, from the back part of the tuberosity of the fifth metatarsal bone to the posterior part ofthe internal cunei- form bone for the left foot, and in a reverse direction for the right. The knife is then to be carried down along the under surface of the metatarsal bones, so as to cut a plantar flap two inches in length. A little behind the termination of this, a transverse incision is to be made through the integuments on the back of the tarsus, and the flap dissected up and reverted as far back as the joint between the scaphoid and cuneiform bones. The surgeon now disarticu- lates the two outer metatarsal bones from the cuboid, in the man- ner described at page 161; then on the inner side of the foot opens the joint between the scaphoid and cuneiform bones, and depressing the point of the foot, completes the disarticulation by dividing the interosseous, transverse, and strong plantar ligaments, so as to remove the whole metatarsus and the three cuneiform bones. The projecting end ofthe os cuboidesis then to be sawed off on a line with the surface of the scaphoid bone. The advantage resulting from this modification of Chopart's pro- cess, consists in the preservation of the insertions of the muscles on the scaphoid and cuboid bones,—muscles which serve to keep the stump of the foot flexed and prevent the club foot deviation, too apt to result in the former process, from the unresisted action of the sural muscles. Each of these processes, it may be observed, is suited to peculiar cases of injury or disease of the foot; and has its appro- priate value. Whichever one is followed, it will be well to leave the flexor and tibialis anticus tendons, of sufficient length to enabk them to contract adhesions with the end of the stump, and coun- teract the disposition of the gastrocnemius muscles to keep the heel in a state of permanent elevation, with the cicatrized surface pre- senting toward the ground. Bandages drawn from behind the heel and over the sole to the front of the leg, will have some tendency to prevent the production of this serious deformity, which impairs to a great extent the use of the heel as a point of support. In one case of the kind that came under my notice, the pressure from walking had produced ulceration of the cicatrix, followed by ex- tensive caries of the bones, and I was compelled to resort to am- putation of the leg. If the means already noticed do not suffice to prevent this deformity, the surgeon should nOt hesitate during the cicatrization of the stump, to take off the action of the gastroc- nemius muscles by dividing the tendo-achillis, as in the opera- tion for club foot. , AMPUTATION AT THE ANKLE JOINT. Though mentioned by some of the older surgeons and advo- cated by some few of the modern, this operation is seldom prac- tised at the present day ; amputation of'the leg being in almost all cases preferred to it. Instances in which the operation at this joint will be justifiable, may, however, occur among individuals whose circumstances in life place them above tbe necessity of physical exertion, to whom the preservation of a limb without ob- vious deformity and moderately useful, would be preferable to the more serviceable artificial leg. Serious objections to this ope- ration are found in the extensive surface of the joint, and the scantiness of its covering, which together render it difficult to form a stump that will not ulcerate from the pressure to which it is necessarily exposed in walking, even with the best arranged and best padded boot. Lisfranc and Baudens, however, mention instances in which individuals who had undergone this operation were able to walk with ease ten or twelve miles a day. The process best suited to this amputation is the following, which it is said has been several times successfully performed by its author. Process of Baudens. (PL XLII. fig. 5.)—The leg is to be sustained by an assistant, and the foot allowed to hang loose. The surgeon starts an incision below but on a line with the exter- nal malleolus, and runs it first along the outer border of the foot, then across the middle ofthe dorsal surface ofthe metatarsus, (so as to be here convex in front,) and then back along the inner mar- gin of the foot, and round the heel to the point of commencement. The large oval flap of integuments thus traced out is to be rapidly dissected from the bones, and reflected circularly upon the leg. The surrounding parts are now to be cut so as to expose the cir- cumference of the joint. The anterior and posterior portions of the . capsule of the joint are next to be divided, and a rout for the saw traced with the knife across the two malleoli on the same level. The foot is then to be drawn a little downwards so as to admit the saw under the anterior edge ofthe tibia, and enable the surgeon to divide at the same time the two malleoli and the promi- nent posteriorborder of the tibia, and detach the foot. The an- terior and posterior tibial arteries are to be tied, and the sides of the flap brought together over tbe ends of the bones so as to unite by first intention. A tight fitting boot is subsequently to be worn, and the absence of the heel supplied by a piece of cork and a soft elastic pad, upon which the stump is to rest. 2. OF THE LEG. AMPUTATION IN THE CONTINUITY OF THE LEG. Surgical anatomy.—The leg is formed of two bones connected together laterally at their upper and lower extremities, but sepa- rated in the rest of their extent by an interval which gradually de- creases in breadth from above downwards. The bones are not upon the same level, the outer and smaller one—the fibula- being placed more posteriorly than the tibia. But inasmuch as the latter is much the larger of the two, the posterior surfaces of the two bones will be found nearly on the same level. Across the space between the bones is stretched the interosseous ligament, which serves both on its anterior and posterior faces for the origin of muscular fibres. The surfaces by which the bones look to each other are excavated in front and back to give space for the muscles, which, with several important vessels and nerves, are thus lodged between the bones, and can only be divided in amputation by a knife passed between and around the bones for that purpose. On its front and inner portions the tibia is merely covered with the in- teguments ; on every other point, with the exception of the lower end of the fibula, the.bones are covered with muscles. In their upper part they are most deeply covered; but as the limb tapers AM PUT. from above downwards, the tendons will be found gradually sub- stituted for the bellies of the muscles. In the calf, where the limb is thickest, the centre will be found behind the tibia, and the great or transverse diameter passing along the posterior face of the tibia goes through the centre of the fibula. In amputation of the leg for diseases of the foot or ankle, the surgeon frequently has a choice of the point at which the bones may be divided. - The general rule previously mentioned, of preserving in amputation the greatest possible length of tbe limb, is not so applicable to the leg as to either of the portions of the upper extremity. It is true, that the smaller the part lopped away, the less will be the shock upon the system ; but as ampu- tation ofthe leg, in any part ofits course, is not under favourable circumstances attended with any great danger, the question is solely to be settled in reference to the use, for the future, of an artificial limb. There can be no doubt, that if the limb be cut off high up, preserving the flexor tendons of the ham, in order that, when bent, the end of the stump shall not make a very ob- vious projection behind the thigh, so as to proclaim the deformity and expose itself to injury, a simple and cheap substitute may be fitted to the knee under the most favourable circumstances pos- sible for restoring the uses of the member in station and locomo- tion—the point of motion being, however, only at the hip joint. For these reasons the place for dividing the bone chosen by the great majority of practitioners, or the place of election, as it is called, is, for an adult, four fingers' breadth below the tuberosity of the tibia. But many individuals so circumstanced in fortune, or follow- ing such sedentary pursuits as render unnecessary a constant or prolonged use of the limb in locomotion, are willing to sacrifice in part, the stability of the apparatus, and the ease and facility with which it may be worn—preferring one, which, though less substantial, shall completely hide the deformity and restore the natural movements of the limb. To obtain this object, the motions of the knee joint must be preserved, and the'stump left of sufficient length to be enclosed in a hollow boot and serve as a lever by which this may be swung like the natural limb by the flexor and extensor muscles of the thigh, the insertions of which upon the leg'remain uninjured. The movements of the ankle joint are readily imitated by machinery, and to work well must occupy the interior of the substitute, a little space above the natu- ral position of the ankle joint. The support of the limb must be got in a great measure from tbe ischium, and not from the cicatrized surface of the stump, which would be liable to ulcerate under pressure. To leave the stump of the appropriate length for this purpose, the bones should, therefore, be sawed about the middle of the leg, at what I would propose to call the second place of election. I amputated a few years ago in this manner the leg of a Swiss gentleman, for whom an apparatus such as I have described was prepared by M. Martin, of Paris, which ena- bled him, as I have since been informed, to walk and dance with ease and facility, and without exciting in lookers-on any suspicion of the extent of his misfortune. The apparatus is necessarily expensive and beyond the reach of many; complicated, and there- fore liable to accident, rendering it convenient or necessary that a duplicate should be. kept at hand. A clumsy and ill-fitting contrivance would only serve as a constant source of vexation 42 \TIONS. 165 and pain to the patient, which is sometimes so great as to induce him to solicit a secondary amputation nearer the knee joint; and unless he can provide himself with a good apparatus of the kind, the operation at the common place of election, and the use of the usual more simple artificial leg, are decidedly to be preferred. Several ofthe older surgeons, and some of those ofthe present day, have proposed, in order to preserve the greatest possible length of the limb, to amputate about three inches above the malleoli, where the bones are smallest and least resisting, and trust to means of support somewhat analogous to those provided in cases of amputation at the ankle joint. Various processes have been employed for this purpose, of which the common cir- cular is usually considered the best—and there is no difficulty in effecting the cicatrization of the stump. But the measure has received but little favour, and is not likely to obtain much, unless it should be found possible to improve much beyond its present state the means of supplying artificial support. -In cases of injury or disease of the leg, extending so high up as to involve the first place of election, and yet allowing room for the covering ofthe stump by sawing through the spongy head of the tibia, the operation may be performed at this point, (which might be called the place of necessity,) in preference to ampu- tating at the thigh or knee joint. By this practice, which was introduced by Barron Larrey, and has been approved by most operating surgeons, a tolerably good stump will be formed. In many cases it may be necessary, from the height at which the section is necessarily made, to disarticulate the head of the fibula. In my own practice I have generally managed to divide the head of this bone and leave it in its place, for fear that its articulation might communicate with that of the knee joint,—a circumstance which is said to occur in about one case in ten, and which, if found to exist, might give rise to extensive synovial inflammation. AMPUTATION AT THE FIRST PLACE OF ELECTION. Circular method modified. (PL XLIII. fig. 1.) 1. The instruments usually required consist of the tourniquet, a straight-edged amputating knife at least seven inches long in the blade, an interosseous knife or catling, two or three scalpels, a saw, a pair of cutting pliers, forceps, tenaculum, a few threaded needles, and a three-tailed retractor. Some surgeons prefer for every step of the operation a strong double-edged knife or catling; others have the back of the amputating knife ground for a little distance from the point, so as to avoid the necessity of changing it for the small catling in dividing the parts between the bones; and if an assistant be at hand who may be relied upon to make firm and steady pressure upon the artery of the thigh*with his thumbs or fingers, the tourniquet may be dispensed with. If the latter instrument be used, it will be well, immediately before it is tightened, to elevate the limb for a few moments, in order to diminish the amount of blood accumulated in the veins, which would necessarily be wasted. 2. Position of the patient and assistants.—The patient should be placed semi-recumbent upon a bed, or a narrow table well garnished with blankets, the trunk supported with pillows, and the legs pendent over the end. An assistant draws with one OPERATIONS. 166 GENERAL ( hand the healthy leg, flexed, to one side, and rests the other upon the shoulder of the patient. Another assistant sustains the foot of the opposite side, and watches attentively the movements of the surgeon, so as neither to splinter the bones nor pinch the saw. A third assistant supports the diseased limb above the place of operation, and draws back the soft parts. A fourth manages the tourniquet, or compresses the artery with his thumb over the pubis. And a fifth should be prepared to hand the instruments in the order in which they are wanted, and receive them again as the surgeon is prepared to lay them down. 3. Position of the operator.—This is a point in regard to which there is a great diversity of opinion ;—some surgeons always placing themselves on the inner side ofthe limb, so that in divid- ing the bones the section of the fibula may be completed before that of the tibia, in order to guard the more surely against the splintering of the former. Others, believing the neat division of the soft parts a matter of greater importance, take a position always on the right side of the limb, so as to be able to grasp it with the left hand immediately above the place of operation. The latter I have found most convenient in practice, and a sur- geon familiar with the use of the saw will have no difficulty even in operating on the right leg, of dropping the hand so as to divide the fibula before finishing the section of the larger bone of the limb. For the posture of the operator, the following minute directions have been given by Lisfranc:—The right thigh flexed at a right angle with the pelvis, the leg bent upon the thigh, and the foot resting flat upon the floor;—the left thigh flexed at an obtuse angle with the pelvis, the leg at an acute angle with the thigh, the tuberosity of the ischium supported upon the heel, and the point ofthe foot upon the ground, with the legs separated in order to give greater solidity and precision to his movements. 1st step.—The surgeon having previously determined how far it is necessary to go below the intended place of section of the bones to get a sufficient covering for the stump,—which must depend in a measure on the thickness of the limb,—marks with his left thumb on the crest of the tibia the point for commencing the incision. Then carrying the amputating knife below and around the limb, he lays the edge, with the wrist bent and the hand strongly pronated, upon the internal face of the tibia, (or if it be the right leg, and he stands at the outer side, as far as pos- sible on the external face of the crest,) and pressing so as to cut through the skin and fascia, brings the knife round the leg at a steady and single swTeep, carrying the heel up to the point at which the incision was begun. As the handle of the knife is brought upwards, it shifts its position in the palm, which gradu- ally becomes more supine, and the circular incision is finished with the handle placed between the thumb and the first two fin- gers. A little practice will render this tour de maitre easy. It is not, however, absolutely indispensable that the incision should be made by a single cut, many surgeons contenting themselves with making two separate incisions from above dowmwards, which unite below. The surgeon now changes the amputating knife for a common scalpel or bistoury, dissects up rapidly the skin and superficial fascia for the space of an inch and a half from the apo- neurosis of the leg, and turns them back in the form of a sleeve with the fat outwards. 2d step.—With the amputating knife carried round the limb and held in the same manner as for the incision of the integu- ments, a circular cut is made at the base of the reflected skin so as to divide all the soft parts down to the bone. As the knife is brought under the calf, where the greatest amount of muscular structure is found, it is necessary to give it two or three sawing movements to make it penetrate to the bone, after which the cir- cular incision is to be completed. The muscles, vessels and nerves, lodged in the interosseous spaces, still remain to be cut; their division is to be accomplished by carrying the catling or the double-edged amputating knife, if such has been used, between the bones, each of which is to be circumscribed separately. The same result may be accomplished with more rapidity in the follow- ing manner. Pass the knife from above so as to divide vertically the interos- seous membrane for the extent of an inch, (which is usually ren- dered easy in the living subject by the retraction of the divided muscles,) for the purpose of facilitating the entry of the knife and the action of the retractor. Then carry the knife below the limb, pass it transversely through the anterior interosseous space, and, using it like a bow, make the cutting edges act alternately upon the tibia and fibula, so as to divide as much as possible the in- cluded parts ; then turning it round one of the bones, enter it again through the posterior interosseous space to complete the division of the remaining fibres ; and lastly, carry it over the other bone to the point at which it started. 3d step.—The middle one of the three tails of the retractor is now to be passed with the dressing forceps from below upwards through the interosseous space; the two outer tails are to be crossed, and an assistant seizing the two ends of the retractor draws the soft parts well upwards. The surgeon, grasping the retracted flesh with his left hand, applies the heel of the saw, propped against the nail of the left thumb, upon the crest of the tibia, and begins the division of the bone by drawing the saw lightly to him; when the saw has fairly cut its groove on the tibia, he pro- ceeds with a bolder stroke to complete the section, taking care to divide the fibula first. If the subject is thin, and the amputa- tion is done low on the leg, the spine of the tibia, which will be found very prominent and liable to become denuded or cause ulceration of the integument, should be removed with the saw. This may readily be done after the transverse section of the bones, by passing the saw obliquely across the spine and anterior edge of the tibia. Beclard directed the first strokes of the saw obliquely upon the crest, a little above the place of the intended section, and then withdrew the saw to begin the transverse cut below. Any spiculae or rough edges of the bone are to be removed by the cutting pliers. As the muscles on the posterior part of the leg retract more than those on the anterior, various modifications have been suggested as to the manner of dividing them. Alan- son cut them with a bevel inwards. Sir C. Bell directed the gastrocnemii to be cut obliquely from below upwards, and the others to be divided on a level with the top of this incision. B. Bell, with the object of keeping them as much as possible on the same level, and cutting the bones high, separated the fibres from round the tibia and fibula with the scalpel, so that they might be pulled up by the retractor. This last, with the direct AMPUTATIONS. 167 •circular section ofthe muscles, is the plan more usually followed. It is a modification of considerable importance, when the limb is emaciated and the bones large. Dressing.—The arteries to be tied are, 1, the anterior tibial, which will be found in front of the interosseous ligament, in close contact with its nerve, from which it is to be carefully isolated. Sometimes it is difficult to discover this vessel; the tourniquet must then be slacked after the other vessels are secured, to dis- cover its position ; 2, the posterior tibial; 3, the peroneal—both of which are found behind the interosseous ligament, and near the surfaces of the tibia and fibula; 4, the two gastrocnemial, and occasionally a fifth of considerable size, the nutritious artery of the tibia. If this last is cut in its sheath of periosteum, it must be dissected up before it can be tied ; if in its passage through the bone, the orifice must be plugged with a piece of wax. The arterial distribution will be found, however, to vary, according to the height at which the limb is amputated. If the operation be performed as high as the tuberosity,of the tibia, the popliteal, which is cut before its division, the gastrocnemial and some articular branches, are all that require the ligature. In one instance in which I operated for dry gangrene, the main trunks were found so plugged with coagula, that none but the gastrocne- mial branches required to be tied. The arterial hemorrhage having been completely arrested and the tourniquet slacked, the surface of the wound is to he well cleared of the coagulated blood, and the lips brought together with the palms of the two hands in the direction in which they will best cover the bones and supply the deficiency of the soft parts in front. Reunion obliquely from above downwards and within outwards, will be found best to subserve this purpose, as it allows the skin to fall easily onVthe anterior part of the tibia, and facilitates the discharge of pus at-fhe lower end ofthe wound —an object which will be further promoted by the introduction of a small linen compress between the edges at this point. The flaps are now to be secured with adhesive straps, and the dressing terminated as described at page 137.* Notwithstanding the general favour in which the circular method of amputating the leg as just described is held, there are some objections of moment that have been urged against it. The leg being necessarily placed in extension, the skin is drawn up towards the knee, and cut so short, that it will be found when the stump is dressed and bent at the knee, drawn more or less tightly over the spine of the tibia, so as to be exposed to ulceration. From the same position of the limb, the muscles and skin on the back part ofthe leg will be relaxed, and found divided relatively too low, so as to form after the dressing an unseemly puckering of the integument, and a useless mass of muscle, which is liable to become engorged with blood, increase the amount of suppura- tion at the back part of the wound, and prolong the process of cicatrization. In my own practice these disadvantages have been obviated by the following simple modification, which forms a part ofthe oval process of Baudens ; viz., to divide the skin obliquely, or in an oval, so as to make the first incision a full finger's breadth lower on the front than on the back part ofthe limb; dissect the integu- * The surgeon should not forget previous to the operation to have the integu- ments shaved. ments up for two inches, and divide the muscles by a circular cut; —the remainder of the process being the same precisely as that already described. Flap method. (PL XLIII. fig. 6.) This has been practised either by the single flap, after the man- ner of Lowdham or Verduin, or with two flaps, as was the custom with Vermale and Ravaton. The process by single flap is the only one now7 employed, and is received in this country, England, and Germany, with at least an equal degree of favour with the circular method. The flap may in cases of necessity, be formed chiefly from one or both of the sides of the limb; but where the surgeon has a choice, it is to be taken from the posterior portion. It may be cut from below upwards, and from the skin towards the bone, as practised by Sir C. Bell, Graefe, and Langenbeck ; or, as is now more commonly preferred, by previous transfixion, and incision from within outwards and downwards. Of the processes employed, those of Liston (which is but a modification of that of Verduin,) and .Sedillot appear entitled to the greatest favour. The former I have repeatedly had occasion to practise, and have found it to answer admirably well. The only instru- ments required in this mode of operation, will be a narrow double- edged knife seven inches long and the saw. The patient, surgeon and assistant, are to be placed in the manner described for the circular method. Process of Liston.—" An assistant supports the affected foot, another puts the integument above on the stretch, and is ready to hold back the parts during the incisions, and after they have been completed. When the right limb is the subject of operation, the point ofthe knife, having been entered on the outside, behind the fibula, is drawn upwards along the posterior border of that bone, with a gentle sawing motion, for about a couple of inches ; the direction of the incision is then changed, the knife being drawn across the fore part of the limb, in a slightly curved direction, the convexity pointing towards the foot; this incision terminates on the inner side ofthe limb, and from this point the knife is pushed behind the bones, and made to emerge near the top of the first incision ; the flap is then completed. All this is done smoothly and continuously, without once raising the knife from the limb. The interosseous, muscular, and ligamentous substances are cut; the anterior flap is drawn back, and its cellular connections slightly divided; both are held out of the way by the assistant, and the separation completed with the saw. By proceeding thus, all risk is avoided of entangling the knife with the bones, or betwixt them. In dealing with the left limb, the proceeding is very simi- lar; the internal incision is not made quite so long; but it should still be practised, for a longitudinal opening of about an inch or more in extent is more easily found in the transfixion, than the mere point at which the interior incision is commenced. In sawing the bones of the left leg, the tibia may safely be cut first, as the surgeon commands the limb during the process, and can easily obviate the risk of snapping the fibula. The awkwardness attendant upon a change of position is thus avoided. Disarticula- tion of the fibula is not advisable, owing to the connection of its head with the bursae and knee joint. It is seldom necessary to round off the spine of the tibia. " Amputation close to the joint is performed precisely in the 168 GENERAL OPERATIONS. same manner; the incisions being made so that the fibula is exposed and sawn immediately below its head, the tibia close to the tuberosity. One great advantage attending this amputation is the shortness of the stump ; the patient, resting on the knee, can cover both his wooden support and stump with his trowsers. Another immediate advantage is the facility and rapidity with which the whole proceeding can be executed. In very many cases I have managed so, as to tie one vessel only—the popliteal —and this materially shortens perhaps the most painful part of the whole process."* Process of Sedillot.—Enter the point of the knife about three- qunrters of an inch to the outer side of the crest ofthe tibia, and carry it downwards till it strikes the fibula ; slide it round the outer face of this bone, bring it out at the posterior aspect of the leg, and cut from above downwards a flap three to four inches long. This is to be immediately raised by an assistant. Detach the muscles thus put naked for half an inch above the base of the flap, from the tibia, fibula, and interosseous ligament. Unite the two angles of the incision by a circular division of the remaining parts, and dissect them up as far as the muscles have been detached. Turn back this cutaneous and fleshy mass in the form of a cuff"; cut sloping inwards, in the manner of Alanson, the muscles on the internal and posterior face ofthe leg; divide the interosseous muscles; apply the retractor, and saw the bones. After the arte- ries are tied, the flap is to be brought down over the entire surface of the tibia, and attached to the integuments of the inner side with the twisted suture. The cicatrix will occupy one-half of the circumference of the stump; viz., that Of the internal and poste- rior side. The above is the description of this operation as given by M. Bourgery, who witnessed its performance, and makes in regard to it the following observations. "We do not fear to present this process as one of the most rational that can be contrived for am- putation of the leg at the place of election: the end of the tibia is completely covered by a muscular flap, and cannot escape through the anterior angle of the wound ; the skin is not exposed to gangrene, the cicatrix is linear, and the union of the surfaces ought readily to take place. The covering of the stump presents a good cushion, if we wish to employ the artificial leg of Ver- duin;! and, in a word, this process unites all the advantages of the circular and flap methods." The oval method, with the exception of its application for the division of the integuments as the first step to the circular opera- tion, has not been to much extent employed in the amputation of the leg. .imputation at the second place of election—in the middle ofthe !'»ii — "i- at a point three inches above the malleoli, which some have chosen, may, (provided the latter should from any circumstances be deemed justifiable,) be practised by the circular and flap me- thods, according to the processes above given. But if the muscles be but little developed, or thinned considerably by emaciation, • Practical Surgery, p. 378-80. American edition, 1843. f The substitute of Verduin was intended to support the limb, by receiving the surface of the stump against a well-arranged pad, and is to a considerable extent analogous to the apparatus recommended by Professor Fergusson. The objections that may be urged against this mode of support have been stated in another place—p. 165. the paucity of materials for the flap renders the circular most eligible. AMPUTATION AT THE PLACE OF NECESSITY, OR THROUGH THE CONDYLES OF THE TIBIA. This is but seldom called for or even practicable, except in cases of traumatic injury. I have, however, witnessed its suc- cessful execution in the hands of my friends, Prof. Horner and Dr. E. Peace, of this city, and in one instance had occasion to perform it myself with a like result. The spot, however, is not favourable to the operation, in consequence of the necessity of avoiding the division of- the ligamentum patella?, the scantiness of the muscular tissue about the bone, and the large size and vascular structure of the latter, which render the cure tedious and expose the patient to the risk of phlebitis and purulent ab- sorption. It offers, nevertheless, the advantage of preserving the knee joint, and is attended by less risk than the amputation ofthe thigh or, the disarticulation of the knee. Modes of operation.—The choice of the process must be de- termined at times by the nature of the lesion. If the soft parts in front are involved, the ends of the bones must be covered by a flap taken from the posterior part of the leg. If the bones are shattered on their back portion, the saw entered near the tubero- sity of the tibia may be made to act obliquely upward and back- ward. We may divide the bone even through the insertion of the ligament ofthe patella, leaving enough remaining to preserve its attachment and protect the bursa behind it. In general, the circular method, which was the one employed by Larry, will be found the most appropriate for this operation. It is to be practised according to the usual process, with no other modifications than those rendered necessary by the peculiar structure of the parts. In dissecting the fold of skin, which is to be made as large as possible, the operator should guard against doing violence to the cellular tissue of the ham, as this part might otherwise become the seat of abscess. The section of the muscles will be found more difficult than in the ordinary amputation of the leg, in con- sequence ofthe narrowness ofthe interosseous space and the size of the tibia, which render the manoeuvre with the catling difficult. Whenever it is allowable, the head ofthe fibula should be sawed rather than disarticulated; but if it is necessary in consequence of its condition to disjoint it, the surrounding muscles must be dissected off, and the knife carried through the articulation in a curved direction from within outwards and from below up- wards. AMPUTATION AT THE KNEE JOINT. The propriety of the performance of this operation under any circumstances, is one of the controverted points of surgery. It has been alleged, that even after a cure the patient would be unable to make a point of support of the stump, by applying it upon the padded end ofthe ordinary wooden leg; but the obser- vations of Velpeau and Baudens, and my own experience in a single case, prove at least its possibility. That instances may occur affording a choice, only, between amputation at the knee joint or the thigh, in which from the exhausted state of the patient, the chance of recovery will be greater by the comparatively small division of parts at the joint, I have little reason to doubt, espe- cially when we consider the ratio of mortality which attends the amputation of the thigh. But as my own experience is exceed- ingly limited, and not more than two or three amputations at most at the knee joint have been performed in this country, I cannot do better than quote the following statements of Dr. King, and let the practitioner make his own estimate ofthe arguments. " The question of amputation at the knee joint has been long regarded by the generali y of surgeons as finally settled. Nume- rous successful cases, however, in which this operation has been resorted to of late years, either from necessity or the individual views of the surgeon, have again brought it under consideration. Some very eminent practitioners have thought that the amputation of the leg at the knee joint has been too indiscriminately proscribed, while others, going still further, blame the timidity that has pre- vented surgeons from boldly penetrating into large articulations, and assert its superiority over amputation as performed in the con- tinuity of the bones, either of the leg or thigh. The arguments against amputating in joints, especially of large size, have been laid down, and though we still adhere to our objections to these amputations, unless as exceptional proceedings, where an un- usual prospect of success, or an unusual necessity might justify us in deviating from what we deem a safer course, still we see no reason against briefly stating the arguments of those who con- sider that this operation has been too lightly condemned. " They affirm, that so long as the periosteum of a bone, or the articular cartilage covering a bone, is uninjured, no bad con- sequence can arise from exposure to the air, as these coverings afford a perfect protection against inflammation; that there is no synovial membrane spread over the cartilages; that it is almost always possible to save a sufficient quantity of the surrounding integuments to form a good and ample covering for the exposed condyles; that the wound is not so large as some imagine, the flap being formed almost exclusively of integument, which adheres most readily to the condyloid surfaces; and finally, that the dis- articulation of the leg leaves not only a good stump, but that it preserves the mobility of the head of the thigh bone in the aceta- bulum, which is lost when the amputation is performed in the continuity of the femur. When the amputation is performed at the knee joint, the individual walks with an artificial leg, as if he had a stiff knee. But when the thigh is amputated, progression is by no means so free—he walks as if the head of the thigh bone was anchylosed."* Surgical anatomy.—Notwithstanding its complex structure, the articulation of the knee presents few obstacles to the performance ofthe operation. The condyles ofthe femur and tibia are readily felt from the exterior, and indicate the position of the joint, which is found behind the patella, and four lines above the head of the fibula. Strong lateral ligaments, tendons, and aponeurotic expan- sions are found on the sides of the articulation; on its posterior surface are the ligament of Winslow, the popliteal vessels and nerves, and the heads of the popliteus and gastrocnemius mus- cles. The latter muscle is the only one fleshy at this point; it cannot, however, be made available as a covering for the stump, as it receives its supply of blood from arteries that arise below the * Cyclopedia of Surgery, art. Amputation, by T. C. King, M. D. 43 169 joint, which must necessarily be cut off by the division of the main trunk on a line with the condyles, rendered almost unavoid- able in consequence of the close contact of the popliteal artery with the posterior part of the joint. At the interior of the joint, the attachments of the crucial ligaments to the condyles, which are readily presented to the knife, are the only fibrous parts of importance to be divided. The question of removing or leaving the patella has been much debated. It is now decided, however, that it ought to be preserved, and for this purpose the incision into the front part of the joint must be made through the ligament below that bone. The three methods have been employed for this disarticulation. That of the flap was employed by Hoin so early as 1764. The circular and the oval have been but recently practised. x Flap method.—By the processes of Hoin and Blandin, the flap is formed out of the muscles and skin on the posterior part of the leg, and the joint opened by a division of all the parts from the surface of the skin below the patella to the posterior part of the condyles. Leveille, Smith, and Beclard, raised in addition a semi- circular flap of skin from the surface below the joint. Rossi formed two lateral flaps, by making first two vertical incisions— one in front and one behind the leg, uniting them by a circular incision, dissecting up the integuments, and subsequently dividing the parts on a line with the joint. Neither of these processes can be considered favourable; for such is the retraction of the skin upwards by the strong muscles, whose tendons have been cut, that a part of the articular surface is ultimately left naked. The muscular flap at the posterior part is difficult to be kept applied, and requires to be punctured largely in its middle, to allow the sero-purulent secretion from the condyles to escape. The follow- ing process will be found to give a very efficient covering for the stump, and supply a ready outlet to the matter. Process employed by the author.—In the winter of 1841 I re- moved the leg of Rachel Morris at the knee joint before the class of the Jefferson Medical CoHege at the Philadelphia Hospital. The patient was about thirty-five years of age, and had suffered for several years with necrosis of the entire shaft of the tibia. The profuseness of the purulent discharges, in conjunction with repeated attacks of diarrhoea, had so broken down her strength, that it had been difficult to prevent her sinking. As the bone was found involved up to the condyles of the tibia, and the integu- ments were impaired so high up as to render it impossible to per- form even amputation through the condyles after the manner of Larrey, there was no alternative save the removal of the limb through the thigh or at the knee joint. As the chances of recovery after amputation of the thigh, considering her exhausted state, were deemed but small, I decided to remove the limb at the knee joint, especially as the structures of this articulation were unaf- fected by disease. The operation, in which I was assisted by Drs. Mutter, Coates, and others, was done in about two minutes with the scalpel merely, according to the following process, though from the extension of the disease on the front of the leg, I was unable to cut the anterior flap of the length described as most appropriate. The cure, which was not rapid, as the cicatrization was not completed till the end of four weeks, was unattended by a single bad symptom, the patient gradually increasing in health and iTIONS. % 170 GENERAL OPERATIONS. strength from the first day of the operation. From the unavoid- able shortness of the flap covering the condyles, one of these processes became partially exposed, so as to allow me to observe the changes which the articular cartilage underwent. This struc- ture neither reddened nor became painful, so as to exhibit any coating of synovial membrane, or other appearance of organiza- tion. It became by the end of a week softened and pulpy on its free surface, in the same manner as when a recent joint is sub- jected to the macerating tub of the anatomist. The pulpy layer, which was so soft as to leave a track when rubbed with the end of a probe, was insensibly removed with the discharges ; by a continuation of the same process of softening and removal, the thin lamina of bone covering the articular face of the condyles was completely bared of the cartilage in the third week. This PLATE XLIII.—AMPUTATIONS OF THE LEG AND THIGH. (Fig. 1.) CIRCULAR AMPUTATION OF THE LEG OF THE RIGHT SIDE. incision of the skin. First place of election.) (Modified by an oval The first two steps of the operation have been accomplished—1, the oval incision (d) of the integuments, (as in the process of Sedillot; the skin has been subsequently dissected loose from the fascia and turned back;) 2, the circular section of the muscles at the base of the fold of skin, and the division of the interosseous muscles and ligament with the catling; the retractor is also shown applied. The drawing represents the period of the operation when the surgeon is about to apply the saw for dividing the bones. a. The hand of an assistant sustaining the leg at its lower end. b, c. Left hand of the surgeon grasping the upper end of the leg, so as to steady it for the saw. The hand is applied over the three-tailed retractor, with which another assistant draws up the divided soft parts; one of the tails has been passed between the bones. ■ (Figs. 2, 3, 4.) AMPUTATION AT THE KNEE JOINT. (Process of the author.) Fig. 2.—Anterior incision. The patient has been laid on the abdomen, and the leg raised so as to flex it on the thigh. A semilunar incision convex downwards has then been'made across the front half of the leg, three fingers' breadth below the tubercle of the tibia, so as to mark out an anterior flap of skin. Fig. 3.—Posterior incision. The position of the patient remaining unchanged, the leg is brought down so as to be placed in a state of extension.. The scalpel has then been entered on the back part ofthe leg, just below the popliteal fossa, so as to make a vertical incision in the middle line; from the lower end of this a semilunar incision convex down- wards, has been directed on either side to the rounded track of the first or anterior incision. Two posterior lateral flaps are thus formed, one of which is seen dissected up from the fascia of the leg, and partially reverted. Fig' 4.—This drawing represents the mode of closing the flaps over the condyles of the thigh. The three flaps are attached together at their place of junction by sutures. A small greased compress is placed between the lips of the posterior flaps on the popliteal surface of the stump, to give vent to the sero-purulent discharge which attends the softening and exfoliation of the cartilage on the face of the condyles. The rounded upper portion of the figure is the end of the femur and patella covered by the anterior flap. The stump of the patient upon which this operation was performed, still presents very much the same appearance as seen in the drawing. The whole line of the cicatrix is over the notch at the posterior surface of the condyles, behind the point of pressure upon the wooden leg, and the patella is now immovable upon the femur. (Fig-. 5.) DOUBLE FLAP AMPUTATION IN THE MIDDLE OF THE LEFT THIGH. (Process of Liston.) The circulation in the femoral artery is to be arrested by pressure by an assistant, or with the tourniquet. The soft parts have been grasped in the left hand of the surgeon, and drawn as much as possible in front of the bone, and the knife passed from the outer side—first down upon the bone; then the handle has been inclined down- wards, to allow the point to slide over the anterior surface, and again raised to let the point descend on the inner side of the bone and pierce the skin as far back as possible on the inner side to give breadth to the anterior flap. The knife has then been carried down wdth a sawing motion to form the anterior flap. In the period of the operation shown in the drawing, the flap has been raised by the hand of an assistant (a), exposing the front half of the bone (b), and the knife has been again passed across between the two angles Plate 43. On Stone by C. Kuchcl Philadelphia, Published by Carey 8f Hart. PS.VnralK-Co. Lith. Phil? AMPUTATIONS. 171 lamina first presented a dark gray aspect; some small gray conical elevations soon after made their appearance on its surface, and shortly grew into florid, healthy granulations, to which and to other granulations that sprang from the severed ends of the crucial liga- ments the cutaneous flaps were ultimately firmly united. No appearance of synovial inflammation of.the bursa above the joint was manifested during the treatment, and the patella remained movable on the upper anterior surface of the condyles. The dine of cicatrization was drawn backwards by the hamstring tendons, so as to be opposite the notch between the condyles, and the patient now preserves a useful limb, with which she moves about with great ease and facility, by applying the healthy surface of the skin covering the condyles upon a hair cushion at the top of the ordinary wooden leg. Process of the author. Three cutaneous flaps. (PL XLIII. figs. 2, 3, 4.)—The patient is to be placed upon the abdomen. The leg, flexed at a right angle with the thigh, is held by an as- sistant. The surgeon, placing the thumb and fore finger upon the condyles of the tibia at the opposite sides of the leg, makes with a common scalpel on the front of the upper part of the leg, a semi- lunar incision which extends as far as three inches below the tu- bercle of the tibia—one extremity resting on either side an inch below the joint. The flap of skin is now to be rapidly dissected towards the joint. The leg is then to be extended and made horizontal. The point of the knife is next to be entered through the skin at the middle of the back part of the leg, an inch and a half to two inches below the fossa of the popliteal space, and carried vertically downward to the extent of three inches. From the lower end of this, the knife is to be continued round on one side to strike the line of the first or anterior incision, so as to mark out a second flap, convex^downwards, and extending, a little lower than that of the one in front. The lower end of the verti- cal cut is then united by a similar convex sweep of the knife to the other margin of the front incision, so as to form a third flap. The two posterior flaps are next to be dissected from the fascia up to their base. The leg is now to be again flexed, and from the general loosening of the flaps already made, the insertion of the ligamentum patellae upon the tibia will be exposed. This is to be divided across and the joint opened upon the front and sides so as to leave the semilunar cartilage on the head of the tibia; the crucial ligaments, as they become subsequently useful as a nidus for granulations, are to be divided at their connection with the latter bone, and the posterior ligament lastly cut. The leg, which is now loose, is to be twisted on the thigh. An as- sistant grasps the popliteal artery with the thumb and finger, and the surgeon divides below at one stroke with the knife the remaining parts, consisting mainly of the .two heads of the gas- trocnemius, some of the hamstring tendons not previously cut, and the popliteal vessels and nerves. The patella is to be left in its position. The whole operation may be done with the scalpel; the femo- ral artery should be compressed with the tourniquet. Dressing.—The anterior flap is to be brought over so as to cover the condyles, and united by suture to the two lateral flaps, which will be found so considerably retracted as to fit in neatly to each other along the notch between the condyles. A few strips of adhesive plaster are to be applied, and a roller brought down from the upper part of the thigh, in order to overcome the tendency ofthe loosened muscles to retraction, and fix the patella near to the end of the bone. Circular method. Process of MM. Velpeau and Cornuau.— The leg is to be extended on the thigh, and the skin divided circularly three or four fingers' breadth below the patella, with- out interesting the muscles. It is then to be dissected loose, preserving all the adipose tissue on its under face, and drawn upwards by an assistant to the level of the joint. The ligament of the patella and the lateral ligaments are next- divided in suc- cession. The leg is now to be flexed so as to separate the osse- ous surfaces, and the semilunar cartilages detached so as to be left on the tibia. The operator then cuts the crucial ligaments, traverses the joint, and finishes the operation by dividing at a single stroke of tbe knife, the vessels, nerves and muscles of the ham, on a line with the base of the reflected skin. Oval method. Process of Baudens.—The leg is to be extended on the thigh. The surgeon starts, five inches below the patella, a semicircular incision of the integuments, which is to be carried obliquely upwards upon one of the sides of the leg, and turned round the ham one finger's breadth below the top of the tibia; the incision is then'to be brought downwards in the same manner on the other side of the leg, so as to terminate at the place of com- of the wound, but behind the bone, for the purpose of forming the posterior flap, which should be an inch longer than the anterior. (Fig. 6.) FLAP AMPUTATION OF THE LEFT LEG. Process of Liston, slightly modified by giving a greater length to the covering in front of the tibia, so as to obviate any liability to the projection of the crest of this bone during the cure. The knife has been entered on the outside of the leg, so as to make a short vertical cut on the posterior face of the fibula, and then brought round over the tibia in a semi-elliptical sweep and passed through the leg, shaving the posterior face of both bones, as seen in the drawing. The common tourniquet is applied just above the * knee, with a compress in the ham, so as to command the popliteal artery. The surgeon grasps the calf of the leg with his left hand in order to draw back the soft parts, while he employs the knife with his right to make the incisions and puncture above described, and cut out so as to form the posterior flap. In making the transfixion on the left leg, the handle of the knife should be kept more elevated than the point, to prevent the latter getting entangled between the bones. If he operate on the right leg, and stand on the outer side, the handle may be depressed a little, so that the point of the knife may shave the posterior surface of the bones. 172 GENERAL i mencement. The oval section of the skin in front is now to be dissected and turned up so as to expose the circumference of the joint. The ligaments, muscles and vessels are next to be divided by a circular incision on a level with the joint. The articulation is then to be opened, and the semilunar cartilages and crucial liga- ments detached as in the circular process. By this process, which may be rapidly executed, the surface of the condyles can be covered by a large cap of integument, which leaves the line of union behind so as to form a ready outlet for the discharges, and be posterior to the point of pressure after the cure. Relative value of these methods. As the chief accident to dread after the operation is the exposure of one or both of the condyles, the oval, which leaves the larger fold of skin in front, has some advantages over the circular method. But in most cases admitting of its employment, we might, except there be some injury or disease of the bone extending high up, advantageously substitute for it the flap operation of Liston for the leg, sawing through the tubercle of the tibia. The operation by three flaps, such as has been de- scribed on the preceding page, will, I believe, be found to form a still neater and better fitting covering to tbe uneven surface ofthe bone than the oval, and is moreover applicable to cases where the disease of the integuments of the leg has extended so near to the joint as to prevent the employment of the latter. Dressing.—The popliteal is the only large artery to be tied. The gastrocnemial and some small branches from the articular arteries, will also require the ligature. The parts are to be brought together with adhesive straps, so as to leave the cicatrix as much as possible behind and between the condyles, and a roller brought from above downwards on the thigh, in order to overcome the tendency of the muscles to retract. In case the covering should be found insufficient for the end of the bone, the condyles might, I believe, be amputated with great propriety, thus reducing the operation to that of the ordinary amputation of the thigh, but preserving nearly the whole length and the action of most of the muscles of the limb. 3. OF THE THIGH. AMPUTATION IN THE CONTINUITY OF THE THIGH. Surgical anatomy.—The structure of the thigh is in many respects analogous to that of the arm. It consists of a single bone, surrounded on all sides by a mass of muscles, which are more or less capable of shortening themselves after division in amputation, according to the degree in which they are connected with the shaft of the bone. On the inner and posterior surface, the bulk of muscles will, however, be found the greatest. There are three classes of muscles: those which connect the limb with the trunk—those that stretch loosely along it, connected below only with the bones of the leg, and above with those of the pelvis —and those which, having their origin from the pelvis, cover and are connected only with the surface ofthe thigh bone. They are all, however, for practical purposes, arranged into two groups—a superficial and a deep-seated.—The superficial are those which have little connection with the femur, and are stretched mainly between ERATIONS. the pelvis and the leg. In consequence of this and of their greater length, they will retract more after amputation than the deep- seated, which are connectedwith the bone; the extent of the retraction will also be the greater the longer the muscles are left, or the nearer the operation is done to the knee joint. In the cir- cular amputation, if all the muscles were divided on a circular line, this inequality in the degree of retraction of the two sets would render the bone prominent, producing the painful and annoying result of a conical stump. This difficulty is obviated by the following plan: viz., to cut first, by a circular sweep, all the layers of the superficial group, and divide the deep-seated by a second incision at a point a little higher than that to which the former have retracted, sawing the bone at a little distance still fur- ther up. If the first incision should be carried down to the bone, w-e insure more completely the division of the outer set, and the disadvantage of making a second cut ofthe deep-seated is of but little moment compared to the general result. In the flap operation the same arrangement of parts must be held in view, and the flaps cut of a length apparently unneces- sarily great, in order to admit of the subsequent shortening from muscular contraction. At the end of the cure the cicatrix is near- ly always carried inwards and backwards, and the bone pressed towards the upper surface. This may be remedied by dividing the muscles lowest on the posterior and inner face of the limb; especially the semitendinosus and semimembranosus, as these are found susceptible ofthe greatest degree of shortening. The skin is loosely united to the fascia of the thigh, everywhere, except at the popliteal region. It is sometimes in obese individuals doubled with so thick a layer of adipose tissue, that the surgeon in turning the fold of skin in the circular operation will find the cure of the wound facilitated by leaving a portion of the fat adherent to the deep fascia. The extent of the fold of skin required for the cir- cular process must be calculated according to the diameter of the limb, without reference to the shortening of the muscles, for the base of the fold will be found to ascend nearly in proportion to the retraction of the latter. In general, it should be about equal to its distance from the bone, whether we operate at the upper or lower part of the leg;—at the upper in consequence of the thickness of the muscles, and at the lower on account of their retraction. There is no place of election, admitted by common consent, for amputation ofthe thigh. The general rule is to preserve as much of the limb as possible, and the danger to life is certainly propor- tioned to the height at which the operation is performed. Mr. Liston has, however, recommended that the division of the bone, for the greater convenience of fitting the stump to the artificial leg, should not be made below the middle ofthe thigh. Circular method.—The patient should be placed nearly horizon- tally upon the table, with the pelvis resting over its edge, and the same instrumental and other preparations made as in amputation of the leg. In order to diminish the degree of the subsequent shortening of the muscles, the leg may be slightly bent on the thigh, and the latter on the pelvis. The position of the surgeon will be found most convenient on the right side of the limb, so that he may grasp it with the left hand above the place of operation. The skin and muscles are to be well drawn upward by an assist- ant, who at the same time renders the limb steady. The surgeon AMPUTATIONS. 173 carries the amputating knife below and around the limb, and divides the integument down to the fascia, with one circular sweep of the knife, as in the amputation of the leg. The skin and adipose tissue are to be still further retracted by the assistant, and such bands divided as oppose their ascent; or, what is still better, dissected up for the space of two or three inches and turned back in the form of a cuff. For though the ample provision of skin can in no manner prevent the tendency to the formation of the conical stump—that depending on the division ofthe muscles —it is well understood that there ought to be enough to freely cover the wround, in order 'that cicatrization may go on rapidly. The muscles are next to be divided circularly at the base of the elevated skin down to the bone, or the cut must "at least extend down to the deep-seated group. The superficial muscles are now to be retracted upwards ; this is to be done with the fingers of the assistant, especially if the tourniquet has been applied, which by pressure interferes with their tendency to spontaneous contraction. By a third circular sweep of the knife, the deep-seated muscles are then to be divided on a level with the retracted end of the first set. A two-tailed linen retractor is next to be applied, and the tails crossed on the cut surface above the bone. The assistant, laying hold ofthe ends, draws the divided mass strongly upwards. The surgeon divides with a circular turn of the knife any .fibres yet remaining attached to the bone, and saws the latter four inches above the point, at which the first incision was made in the skin. If there be any fear that the deep-seated muscles are not cut suffi- ciently high, we may run a scalpel round the bone, in the manner of B. Bell, so that they may be drawn an inch still further upwards with the retractor before the saw is applied; or we may follow the advice of Sir C. Bell-—raise the limb to the vertical position, which exposes a greater portion of the bone, and apply the saw horizontally. Some little care is to be observed in dividing the bone, in order to prevent the splintering of the little crest found on its back part. If any prominent spiculae are left, they are to be removed with the cutting pliers. If the great sciatic nerve is left unduly prominent, so as to involve the risk of its being com- pressed against the end of the bone, it must be retrenched by a second incision. Dressing.—The arteries to be tied will vary in number accord- ing to the height at which the operation is performed. After these are secured, the soft parts are to be brought down with the palms of the hands, and if the operation has been well done, the end of the bone, as observed by Sir C. Bell, will be hidden by the cen- tral mass of the muscles. The sides and lips of the wound are then brought together, so as to form a transverse line ; or, which" I think still better, in a direction obliquely from above downwards, and secured in the usual manner with adhesive straps and a roller bandage. Flap method.—When the tissues on one side of the limb have been destroyed by injury or disease, the thigh may be successfully amputated by a single flap taken from the anterior surface,—which is to be preferred, as it allows the flap to fall by its own weight upon the face of the wound,—or if need be either from the pos- terior or lateral. Under other circumstances the double flap ope- ration will be found the more appropriate. The double flap method will be found to present more advan- tages for amputation in the upper part of the thigh than the 44 circular, in consequence of the greater facility with which the flaps may.be kept approximated, as the shortness of the stump renders the dressing more difficult after the circular operation. By two lateral flaps.—These may be made by transfixion from the anterior to the posterior part, and cutting out to the surface, as practised by the French surgeons; or they may be raised by incisions in the opposite direction, cutting from the skin towards the bone, after the manner of Langenbeck. Whichever plan is pursued, the operation is done so nearly like the processes already described for the arm and leg, that it is not necessary to repeat the description. The only important modification is that of inclining the knife so as to cut the flaps larger on the posterior part of the limb than the anterior, in order to allow for the greater shortening of the muscles in the posterior region. The surgeon may form first, either tbe inner or outer flap, as is most convenient to him, provided the circulation is well commanded with a tourniquet at the upper part of the thigh, or by pressure on the artery over the pubis. In the operation by two lateral flaps there is a strong tendency (which by great care in the dressing may partially be obviated), in the end of the bone to approach too nearly the anterior angle of the wound, partly from its rising upwards under the action of the muscles inserted on the trochanter minor, and partly from the retraction of the posterior margins ofthe flaps towards the hip. For these reasons preference is commonly given, in this country and in Great Britain, to the formation of flaps in the opposite direction, by a lateral or oblique transfixion of the thigh, leaving the posterior flap considerably longer than the anterior, in order to compensate for the greater tendency to contraction in the posterior —the operator standing on the outer side of the limb. Anterior and posterior flaps.—Process of Liston. (PL XLIII. fig. 5.)—"The surgeon places himself on the tibial side of the right limb, on the fibular side of the left; and everything being ready, he lays hold of the soft parts on the anterior aspect of the bone, lifts them from it, enters the point of his knife behind the vena saphena, in operating on the right side, passes it horizontally through .to the bone, carries it closely over the fore part, and brings out the point on the outward side ofthe limb, as low as possible: then by a gentle and quick motion of the blade, a round anterior flap is completed. The instrument is again entered on the inner side, a little below the top of the first incision, passed behind the bone, brought out at the wound on the outside, and directed so as to make a posterior flap a very little longer than the former. The anterior flap is merely lifted up after it is formed ; but now that both have been made, they are drawn well and forcibly back, whilst the surgeon sweeps the knife round the bone, so as to divide smoothly the muscles by which it is immediately invested. The bone, grasped by the left hand, is sawn close to the soft parts, the saw being directed perpendicularly. The femoral artery will be found on the posterior flap, is tied along with the other vessels, and the stump is treated as recommended after the other amputa- tions. Great care must be taken, during the securing of the ves- sels, and in steadying the bone for that purpose, not to injure the medullary web ; to this cause may often be attributed inflammation and consequent necrosis. The proceeding is, in all respects, the same on the left limb, only the incisions are commenced from the outer side. After the lapse of six or eight days, or sometimes OPERATIONS. 174 GENERAL < earlier, a roller should be applied and made to embrace the wdiole face of the stump, in order to cause reduction of any cedematous swelling that may remain, and bring the parts into a good form. This is the only interference with the part after the first dressing, and is unattended with pain."* The mixed method and the oval method have both likewise been employed in the amputation of the thigh—but not as yet to a sufficient extent to prove that they possess any peculiar advan- tages over those already described, which have been sanctioned by general experience. The process for employing the mixed method, as given by Baudens and Sedillot, is as follows. Cut by transfixion two small lateral flaps, which shall involve only the superficial layer of muscles ; draw them upwards and divide cir- cularly at their base and at the same time sloping upwards the deep-seated muscles down to the bone, so as to leave a conical hollow, at the upper part of which the bone is to be cut. The oval process, as described by Malgaigne, consists in making an oval or rather elliptical incision of the skin—one extremity of which oval rests on the anterior and outer portion of the thigh, and the other at the posterior and inner part, an inch and a quarter lower down than the former. The skin is to be dissected up, and the surgeon proceeds precisely as in the common circular amputation, with the exception that both layers of muscles are to be divided in the same manner as the skin—obliquely from above downwards. The sole object of this method is to divide the muscles on the back part of the limb lower than those in front, so that after their retraction the stump may be left square and even. The principle involved in this method seems well founded in the anatomical structure of this limb, and I have applied it in one instance myself with a most happy result upon the.living subject. AMPUTATION AT THE HIP JOINT. Amputation at the hip joint, though by no means very difficult, is undoubtedly to be classed among the most severe and dangerous surgical operations. The idea of attempting this fearful mutila- tion originated with Morand in the early part of the eighteenth century. Since that time fifty-four cases in all have been re- corded of the operation, of which nineteen only have been claimed as successful. Though it may be difficult to collect the true sta- tistics in regard to this amputation, the danger attending it may be wTell understood when we consider the extent of the wound necessarily inflicted; the huge mass of divided muscles; the dif- ficulty of effecting union by first intention at the part; and the shock to the nervous system—which has in some cases been almost immediately fatal—arising from the loss of a limb which represents nearly a fourth part of the whole structure of the body. It may be important, however, to observe, that nearly all the successful cases have been those in which the operation was practised for traumatic injuries, and almost immediately after their infliction; w'hile the greater number of fatal results were con- sequent to the operation on subjects previously exhausted to more or less extent by disease. Still the surgeon may in some cases be justified in performing it as a last resort, under circum- stances analogous to the following, which have been laid down by Barbet in a prize memoir as the indications for the operation; • Liston's Prac. Surg., Am. ed., p. 383-4. viz.: where from sudden violence, as by gunshot wounds, or crushing from machinery, a comminuted fracture is produced of a healthy bone at its head, neck, or upper part; where the limb is carried away or extensively injured by a cannon shot near the trunk; or where gangrene has so far extended, or threatens to extend its ravages, as to render it impossible to obtain a sufficient covering of the stump by other means. And to these, as the principal cases in which the operation is likely to be attended with a favourable result, have been added those for which exci- sion is recommended in other joints—caries, necrosis, osteo-sarco- ma, spina ventosa, or other incurable affections beyond the chance of relief by amputation in the continuity of the thigh. But in re- gard to this latter class it is almost indispensably necessary, in order to render the operation justifiable, that the diseased action should be limited to the head ofthe femur, and not have invaded the structure of the pelvic bones. But the extreme difficulty of determining this point beforehand, and the rareness in fact of such limitation in caries—r-the more common disease ofthe part— must restrict its performance in the hands of careful surgeons to very narrow grounds. If, however, after the operation has been undertaken, the surgeon should find the margins of the cotyloid cavity carious or necrosed, he would be justified in removing them, as in resection, with the cutting forceps, gouge, or chisel, before closing the wound. The operation has, nevertheless, been recommended for caries of the head of the bone following coxal- gia. In a case said to be of this description, its removal was successfully effected by Dr. J. W. Duffee, of this city. But the observations of Mr. Pott, who witnessed a like operation by Mr. H. Thompson, the first that was ever performed, are in the main so just in reference to the practice, that they can scarcely fail to meet the sanction of every practitioner familiar with surgical pa- thology. He observes, " that the parallel which is drawn between this operation and that in the shoulder will not hold. In the latter it sometimes happens that the caries is confined to the head of the os humeri, and that the scapula is perfectly sound and un- affected. In the case of a carious hip joint this is never the fact; the acetabulum and the parts about are always more or less in the same state, or at least in a distempered one, and so indeed are most frequently the parts within the pelvis."* Surgical anatomy ofthe joint.—The hip joint, which is every- where surrounded by muscles, can only be felt in the anterior region of the thigh, where the head of the femur, covered by the tendon of the psoas and iliacus internus muscles, forms a globular prominence under Poupart's ligament. On its outer side lies the rectus muscle, which crosses the neck of the bone, and behind and within lies the great muscular mass of the limb. The crural artery crosses the joint on a line with the junction of the internal with the middle third of the head of the femur, but only becomes parallel with the bone at a distance of three or four inches below, leaving between it and the greater part of the neck the space of at least an inch. The profunda descends in nearly the same an- teroposterior line. Space is thus left for the safe passage of the knife in some of the processes for amputation, as well as for the seizure of the trunk of the vessels in the internal flap. The po- sition ofthe joint may be determined with considerable precision by the following rules. * Pott's Surgery, vol. III. p. 374. AMPUTATIONS. 175 1. If we draw an imaginary line between the anterior superior spine of the ilium and the tuberosity of the ischium, it will cut the cotyloid cavity a little behind its middle. 2. If we drop a vertical line an inch and a quarter long from the anterior superior spinous process of the ilium, the external and upper portion of the joint will be found half an inch to the inner side of the termination of the line. 3. If we draw in like manner a line half an inch long from the anterior inferior spinous process, its extremity will rest on the superior part of the joint. 4. The great trochanter is superficial and easily felt: it takes a direction upwards and inwards, and is then turned a little back- wards. It forms a prominence about half an inch or a little more above the neck of the femur, and a line drawn horizontally from its top crosses fife upper third of the joint. 5. The trochanter minor projects nearly half an inch from the inner side ofthe bone, so as to form wdth its upper surface nearly a right angle with the axis of the shaft. Its under surface is about an inch long, and is continued obliquely into the shaft, with which it forms an angle of about 50 degrees, opening upward. 6. When the patient is lying on his back, the tuberosity of the ischium will be found to project an inch and a quarter in advance of the margin of the acetabulum, a fact of much importance to remember, especially in the transfixion for the purpose of forming flaps. The acetabulum or cotyloid cavity is about two inches in di- ameter, and is inclined obliquely downward, inward and forward. The spherical head of the thigh bone is of equal size ; a large part, especially ofits posterior portion, is received into the acetabulum —but it is not entirely sunk in the socket. The capsular liga- ment, which is very thick and strong, springing above from the margin of the acetabulum, covers the remainder ofthe head, and shrinks closely round it to embrace the narrow neck upon which it is inserted. If, in the disarticulation, the ligament is divided round the neck, the head still remains fast closed within its cavi- ty ; and hence the rule always to divide it over the circumference of the head of the bone. The interarticular or round ligament, which connects the top of the head to the corresponding portion of the cavity, is put on the stretch when the thigh is abducted, and presents itself to the knife over the inner edge of the socket. Hence, the most favourable point for opening the capsule to effect luxation ofthe head, is on its inner and lower portion. The sur- gical neck of the bone is about an inch and a half long, and oc- cupies the space between the trochanter and the head ; it is direct- ed downward and outward, and affords room on its sides for the passage of the knife in amputation. At its base, the knife becomes arrested against the trochanter of either side, around which it must be made to turn, except the subject be under twelve or fifteen years of age, when these processes are found so cartilaginous as to be readily divided. From the position which, as has been shown, the muscles occupy about the limb, it would be impossible to split them into two equal flaps, unless we could pass the knife from the anterior spine ofthe ilium to the tuberosity of the ischi- um. As this cannot be done, the internal flap must be made much the larger of the two; and it is well to remember, that the muscles are cut short and will not therefore diminish much in length. The operation is performed by the different methods—flap, circular and oval. Some fifteen different processes have been devised for this disarticulation; but it will only be necessary to detail those which are most esteemed, Flap method. This method is the most ancient, and has in consequence been practised the greatest number of times. It may be done with the single or double flap. The patient is to be placed either on the back or the opposite hip, according to the process employed, resting upon a stout narrow table, which should be covered with a couple of pillows and a folded blanket. The pelvis must be advanced so as to extend a little over the edge. Several assistants will be required in order to steady the patient and assist in the operation. One secures the pelvis and keep the trunk from slipping down- wards and forwards; one sustains the shoulders so as to prevent the patient's rising; another holds the diseased limb, (that of the opposite side being secured to the leg of the table, or held by the assistant who secures the pelvis,) and a fourth controls the circulation by pressure on the artery above the groin, and holds himself in readiness to raise the first flap. In the earlier accounts of the operation, it was recommended as a proper precaution against hemorrhage, to make a previous ligature of the femoral artery, close to Poupart's ligament and above the origin of the circumflex and profunda. This method of proceeding is deemed by many unnecessary and superfluous, as the circulation may effectually be controlled by pressure over the pubis, or in the thickness of the flap ; but it was strenuously inculcated by Lar- rey, and is still advocated by Blandin and others. It does not, however, in any way compromise the chance of cure; and as it effectually guards against hemorrhage from this large trunk, it is a step which I believe should always be taken when an assistant is not at hand on whom implicit reliance can be placed, or when the patient is already weakened so as to render it important to prevent as far as possible all effusion of blood—leaving, as it does, another hand of the assistant free to close the mouths ofthe larger arteries (which come from the back of the pelvis), on the surfaces of the flaps, until they can be secured with ligatures. From the anato- mical arrangement of the parts, it is difficult to apply any form of tourniquet that shall securely compress the vessel without pre- senting too much embarrassment in the way of the operator. Double flap, formed from the outer and inner sides of the limb. Process of Lisfranc modified. (PL LXIV. fig. 3.)—The suro-eon stands on the outer face of the thigh, or by the side of the trunk, according as he is to operate on the left or right limb. The as- sistant holding the limb, flexes it slightly on the pelvis. 1. Formation of the outer flap.—The surgeon then, having all his assistants placed, and fixing in his mind the relation of the dif- ferent parts, enters perpendicularly the point of a stout but narrow double-edged knife, ten inches long in the blade, on the outer side of the neck of the femur, with the lower edge looking to- wards the summit of the trochanter major. The point of the knife should graze the neck of the bone, or rather the top of the trochanter; and as it advances towards the inferior surface of the limb, the handle must be inclined upwards and outwards, so as to form behind with the axis of the trunk (which is supposed to be 176 GENERAL OPERATIONS. horizontal) an angle of 50 degrees, in order to bring out the point half an inch below the tuberosity of the ischium—the surgeon with his other hand, or an assistant, drawing outwards at the same time the mass of flesh on the posterior part, so as to allow the knife to penetrate more within and give greater dimensions to this outer flap. The surgeon, still holding the flesh outward, keeps the knife in the same state of inclination, and by a sawing motion, brings it down over the outer face of the great trochanter, and raising the handle, shaves the thigh bone for two inches, and cuts directly outwards so as to complete the external flap. The flap is to be raised by the assistant, and the divided gluteal and ischiatic arteries either immediately tied or secured temporarily by pressure with the fingers, or compressed after the manner of Baudens, with a couple of pair of artery forceps, \vhich are left pendent. 2. Formation of the inner flap.—The surgeon inclines the soft parts inwards with the left hand, enters the point of the knife at the top of the first incision, and carries it on the internal side of the neck of the bone, with the handle inclined as before towards the abdomen of the patient, so as to bring the point out at the posterior angle of the wound without touching the bones of (he pelvis. The knife is now raised perpendicularly to the horizon, by bringing the heel downwards so as to shave the neck of the bone—but without carrying backwards the point; it is then made to cut directly towards the surface of the trochanter minor, and shaving the internal side of the bone is brought out so as to finish the internal flap at the same height as the outer, leaving a V shaped portion of skin remaining on the front of the femur. As soon as the structures during this incision are sufficiently loos- ened from the neck of the bone, the surgeon is to pause for a PLATE XLIV.—AMPUTATION AT THE HIP JOINT. (Fig. 1.) PROCESS OF BARON LARREY. (A mixed process between the oval and circular, shown upon the light leg, with a previous incision to secure the femoral artery.) A longitudinal incision (a), commencing just below Poupart's ligament, is made over the track of the femoral vessels, which are to be tied temporarily over a strip of linen, cut below the knot, and reversed as seen at b; the ligature by which they are drawn up being secured to the surface by a strap of adhesive plaster, and the fingers of an assistant (c), to keep it out of the Way of the knife. "The surgeon then takes his position on the inner side of the limb, and divides the integuments with an oval sweep of the knife round the limb, leaving them the longest on the posterior face ofthe limb, as described in the text, and showed by the outline (e, g). The oval section commences on the outer side (d), at the lower end ofthe longitudinal cut (a), and the knife, in the right hand of the surgeon (f), is brought round posteriorly and up again in front to the place of beginning, as shown in the drawing. The genital organs are to be drawn by a compress towards the opposite groin, so as to be out of the way of the knife. The subsequent steps of the operation are described in the text. (Fig. 2.) PROCESS OF M. CORNUAU. (Ovalprocess.) A vertical incision has been first made from over the joint down to the trochanter. This incision is then branched below like the letter ji inverted, according to the modification of M. Malgaigne, the course of the anterior branch being from a to b, the posterior from a to c. Through the lips of this double incision the surgeon proceeds to open the joint and disarticulate the head ofthe femur. Then gliding the knife under and to the inner side of the head of the bone, he brings it down to the extremities of the j^ incision made in the skin. An assistant, as soon as sufficient space is obtained, grasps the femoral vessels in the thickness at the inner lip of the wound. The surgeon now continues the course of the knife, (as seen in the drawing, where it has already cut a great part of the large internal oval flap,) holding the handle in a direction inwards and downwards, so as to cut out on the posterior part of the leg, and give the greatest length to the inner part of the covering for the stump. d. Hand of an assistant, compressing the femoral vessels. e. Left hand of the surgeon, controlling the movements of the limb. f Knife, employed in his right hand. g. Acetabulum, from which the head of the femur (h) is detached. i. Branches of the first j^ incision continued down through the soft parts, on either side of the trochanter major, to reach the capsule of the joint. k. Section of the mass of abductor muscles. (Fig. 3.) PROCESS OF LISFRANC. (Doubleflaps.) The process of Lisfranc is shown somewhat modified, for the purpose of obviating the difficulty which attends the turning of the knife round the trochanters, leaving on the external and anterior part of the limb a V shaped flap, with the base towards the knee. The stage of the operation shown, is the disarticulation of the femur. Plate 44. Fit, / Pn Stane hv■ 4 .4'en'safit CitAii/eipluu , Pu.OLulLe.ot by Curry .£ Hurt PS On rut. Li/ti J-'hiP AMPUTATIONS. 177 moment (provided the artery has not been previously tied) in order to allow the assistant to introduce his thumb or fingers for the pur- pose of compressing the vessels at the base of the flap. This flap, as soon as completed, is also to be raised. 3. Disarticulation.—The surgeon grasps the thigh with the left hand, and presents the edge of the catling or a stout scalpel vertically at the inner side of the head, which he circumscribes as far as possible, dividing the capsular ligament without attempt- ing to penetrate into the joint, as if about to cut the head of the bone in two, and leave one-half in the cavity of the acetabulum. The limb is now held in a state of abduction, and the point of the knife carried into the open joint to divide the round ligament. The knife is next placed vertically on the inner side of the joint, and the remaining portion of the capsule, and the few muscular fibres left uncut, are to be divided from within outwards and downwards. The process as described differs a little from that of Lisfranc, inasmuch as it leaves a A shaped piece of skin in front—the con- sequence of carrying the knife directly from the neck of the bone to the top of the two trochanters ; the directions of Lisfranc being to carry the knife along the fossa so as to turn round the tip of the trochanters, which can scarcely be done especially for the outer flap, without haggling the skin both at the top and bottom of the incision. By the processes described above, the operation is perfectly easy, and the removal of the A shaped piece is found rather a benefit than disadvantage in the subsequent approximation of the flaps. If the artery be thoroughly compressed or previously tied, the operation may be done by forming the internal flap first, disarticu- lating the bone and then carrying the knife through the joint in order to cut a second flap on the outer side. Flaps formed from the anterior and posterior parts of the thigh- Process of Beclard as modified by Liston and Fergusson.—This is in general to be preferred to the operation by lateral flaps, as it is quite as readily performed, and from the fact of its splitting the muscular mass of the thigh in its narrowest diameter, does not leave so deep and extensive a wound, and furnishes flaps which are more readily kept in juxtaposition by the dressing. The femoral artery will, however, be divided in the first step of the operation. " The surgeon, standing on the outside of the limb, should insert the point of a long catling about midway between the an- terior superior spinous process of the ilium and trochanter major, keeping it rather nearer the former than the latter; he should then run it across the fore part of the neck of the bone, and push it through the skin on the opposite side, about two or three inches from the anus; next, he should carry it downwards and forwards, so as to cut a flap from the anterior aspect of the thigh, about four inches in length. When the blade is entered, the limb should be held up, and even slightly bent at the joint; the instrument will then pass along more readily than if all the textures were thrown on the stretch, and moreover, there is greater certainty of passing it behind the main vessels, and even dividing some of the fibres, if not the whole, of the iliacus internus and psoas mus- cles. As the knife is carried downwards, the assistant, who stands behind the operator, should slip his fingers into the wound and carry them sufficiently far across to enable him to grasp the femoral artery between them and the thumb : this he may do from the inside or outside at will, and with the right or left hand as may be most convenient, the same grasp enabling him to raise the flap as soon as it is completed. * * * * The flap being raised, the point of the knife should then be struck against the head of the bone, so as to divide the anterior part of the capsular ligament and any textures in this situation which may not have been included in the flap. To facilitate this part ofthe operation, the knee should be forcibly depressed by the assistant who holds it; the head of the bone will thus be caused to start from its socket, and if the round ligament is not ruptured by the force, a slight touch with the edge of the knife will cause it to give way. At this period, depression being no longer required, the assistant should bring the head of the femur a little forwards, to allow the knife to be slipped over it. * * * The knife should then be carried downwards and backwards in the course of the line, so as to form a flap somewhat longer than in front, the .last cut completing the separation of the limb. " By means of the fingers of assistants (and here one or two more than those referred to may be of service), and the applica- tion of sponges, the bleeding may in some degree be restrained until ligatures are applied. If the vessels seem large on the pos- terior flap, it will be best to secure them first, and then the femo- ral and such other branches as may require ligature in the front flap should be attended to. If, however, there is any fear of the main vessel eluding the grasp ofthe assistant, there will be greater safety in tying it first. If, in making the anterior flap, the knife The surgeon has first transfixed the limb on tbe outer side ofthe joint with a long catling, as described in the text, formed the external flap (a), and tied the ischiatic and gluteal arteries on its bleeding surface. Secondly, he has passed the knife on the inner side of the head of the femur, and formed the large internal flap (d), an assistant gliding his hand into the track of the knife, so as to compress the femoral artery before it is divided in the completion of the flap. The bleeding vessels on the surface of this flap are then likewise to be tied. In the last step of the operation the flaps are raised by an assistant, the surgeon opens the capsule with the point of the knife, abducts the limb, as shown in the drawing, so as to divide the round ligament, and finally carries the knife round the head of the bone to detach the limb by cutting the remaining part of the capsule. b. Small triangular or V shaped flap, left between the two incisions. c, e. Ischiatic and femoral arteries, tied. f g. Hand of an assistant, sustaining the internal flap while the surgeon disarticulates the bone. A. Left hand ofthe surgeon, grasping the thigh so as to make the proper changes of position to favour the action of the knife (i). 45 OPERATIONS. 17S GENERAL I is kept close to the femur for some way down, the superficial femoral will not be divided until the incision is nearly completed, and this branch with those of the profunda may all be sufficiently compressed whilst the hand is used in the manner above de- scribed."* Mr. Guthrie directs the anterior and posterior flaps to be formed in a somewhat different manner. He divides at first the integu- ments only—on the inside and then on the outside of the limb— from a point in front of the spinous process of the pubis, to another point near the tuberosity of the ischium, where the incisions are a^ain to meet. The skin is raised and reflected on each side, and the muscles cut at the base ofthe fold from the surface to the centre obliquely upwards towards the articulation. An obvious advantage obtained by this process of Mr. Guthrie, is that of leav- ing more integument and less muscle in the wound, disposing the parts better for reunion, which, in an operation of such magnitude as this, is a consideration of greater importance than the facility of its performance. Single flap.—The operation with a single flap is the only one that can be performed in certain cases, when the soft parts have been impaired on one of the surfaces of the limb. The flap may be taken from the anterior and internal, or internal and posterior parts of the limb, but the anterior and internal is to be preferred when admissible, as the flap will then fall by its own weight upon the surface of the stump, afford a ready outlet below for the pus, and leaves a chance of cure as good at least as that by any other process. The flap must be cut at least eight inches in length, and rounded at its extremity, to suit the form of the limb. If taken from the posterior part of the limb, in order to keep it well applied upon the surface ofthe stump, a matter of considerable difficulty, it should be secured wnth the twisted suture to the integument of the opposite side, as well as supported with the ordinary dressings. The flap may be first formed by transfixion and cutting outwards, then opening the joint and carrying the knife around the bone so as to divide transversely or with such obliquity as the state ofthe parts will allow, the tissues on the opposite surface of the limb. Or an incision may at once be made on the outer side of the thigh, so as to expose the joint, and terminate near the tuberosity of the ischium ; the joint opened from the outer side, and the flap cut last upon the anterior and inner face of the limb. Dr. Wra. Ashmead, of this city, prefers to cut the anterior and internal flap first, by an incision from the surface towards the joint, and has suggested the important modification of first dis- secting up the skin so as to tie the artery before proceeding to the section of the muscles. Circular Method. The circular method, as well as the plan of arresting the cir- culation by pressure over the pubis, was first proposed by Aber- nethy for amputation at this joint. It has subsequently received the sanction of many eminent surgeons, and every one who has amputated the thigh so high as to divide the bone through the trochanters, must be made aware of the possibility with which by this method the soft parts might be separated from the neck, and the head itself detached from the joint. The process is so nearly similar to that for circular amputation • Fergusson's Practical Surgery, Am. ed., p. 391-393. in the continuity of the bone, described at page 172, that it will not be necessary to give it in detail. The parts divided will not, however, be precisely the same, and it will be necessary to con- trol the circulation by pressure on the femoral artery above the pubis. The retraction of the muscles is also less in this region, and it is therefore usual to divide them with a single cut down to the bone. Graefe preferred to hollow them out in the form of a cone, with a concave knife, broad toward the point. The lips of the wound are to be closed in a line from above downwards with adhesive straps. Mixed method. Process of Larrey. (PL XLIV. fig. 1.)—This process, wdiich has been received with considerable favour, cannot properly be classed under either of the three more common me- thods. It consists of an ovoidal section of the s/cin, with a division of the muscles into two lateral flaps. The surgeon, standing at the inner side of the thigh, begins with a vertical incision over the course of the vessels, in order to make a previous temporary ligature of the artery and vein over a strip of linen or some similar material; he then divides the vessels, and has them drawm upwards as shown in the plate. The skin of the thigh is next to be divided nearly circularly on a line with the lower end of the incision, dissected from the fascia and turned upwards. The long catling is now to be entered on the internal side ofthe neck ofthe bone, half an inch below the pubis, and carried through in the usual manner, so as to cut the internal flap first. This is to be raised up, the capsular and round ligaments divided, and the knife carried round the joint and brought down on the outer side so as to com- plete the second flap. Oval method. This is but of recent invention, and has in consequence been only a few times applied upon the living subject. It is of easy execution, and leaves a linear wound well disposed for union. Process of Cornuau as modified by Malgaigne. (PL XLIV. fig. 2.)—The patient rests upon the hip of the other side, the pelvis is brought to the edge of the table, the artery compressed above the pubis by one assistant, and the limb—extended and slightly abducted—supported by another. The surgeon, standing behind the patient, rests three fingers of the left hand on the top of the trochanter major, makes a first incision from a point three-quarters of an inch above the trochanter directly downwards for three and a half inches below this projec- tion, cutting to the bone. From the lower end or the middle of this incision, according to the size ofthe limb, a second incision is carried obliquely in front, to a point at which a vertical line brought down from the anterior superior spine of the ilium, would form a right angle with a line drawn horizontally from the tuberosity of the ischium,—cutting in like manner down to the bone,—and leaving the great vessels to the inner side of the end of the inci- sion. A third incision down to the bone is started from the same point as the second, and carried obliquely downward and back- wards to the inferior border of the gluteus maximus muscle. By raising a little the upper flaps, the articulation will be exposed on its anterior, external and outer surface ; divide then circularly the capsule over this space, luxate the head of the femur, cut the round ligament, and carry the knife round the head so as to divide the inner portion of the capsule and descend upon the neck. An AMPUTATIONS. 179 assistant is next to pass the thumb or fingers above the knife so as to compress the femoral artery between the surface of the wound and the skin;, and the surgeon, grasping the thigh with the left hand, carries the knife down the inner face of the bone to the lower angles of the two oblique incisions, and finishes by cutting squarely at a single sweep, the remaining soft parts. Dressing.—By whatever process the operation is done, the assistants should compress as much as possible the bleeding ori- fices of the large vessels, until there is time to secure them with the ligature. On the inner side of the limb will be found the femoral artery, the profunda commonly, and the branches of the obturator and circumflex. On the outer arid back part of it are the ischiatic, and the branches of the gluteal and internal pudic. The lips of the wound are to be brought together (to form, if the process will allow it, a line, oblique from above downwards and from without inwards), and secured with adhesive straps and a few points ofthe interrupted or twisted suture. The ends ofthe liga- tures are to be brought out at the lower angle, in which should also be lodged a greased linen compress, to maintain a free outlet for the discharges. A roller bandage may be applied round the pelvis, and a few turns brought over so as to support the divided soft parts. PART THIRD. SPECIAL OPERATIONS: OR THOSE WHICH ARE PRACTISED UPON COMPLEX ORGANS IN PARTICULAR REGIONS OF THE BODY. UNDER THIS GENERAL HEAD ARE CONSIDERED: OPERATIONS-1. UPON THE EYE; 2. THE EAR; 3. THE NOSE; 4. THE MOUTH AND ITS ACCESSORY ORGANS; 5. THE NECK; 6. THE THORAX; 7. THE ABDOMEN; 8. THE RECTUM AND ANUS; AND,9.^HE GENITO-URINARY ORGANS. I. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. These operations may be arranged into four groups, ac- cording TO THE PARTS UPON WHICH THEY ARE PERFORMED I 1. THOSE FOR AFFECTIONS OF THE LACHRYMAL APPARATUS ; 2. THOSE FOR THE PROTECTING ORGANS OF THE EYE ; 3. THOSE FOR THE BALL OF THE EYE ; AND, 4. THOSE INVOLVING THE ORBIT, AND THE PARTS CONTAINED WITHIN IT NOT SPECIFIED ABOVE.--THESE GROUPS WILL BE TAKEN UP IN SUCCESSION. It may be well to observe, that in general the operations upon the left eye are directed to be performed with the right hand, and those upon the organ of the opposite side, with the left—the sur- geon standing, in both cases, in front of the patient. But to ren- der the surgeon capable of using the left hand with sufficient pre- cision and adroitness in operations delicate and important as these, it is necessary that he should have practised them very many times, with all their evolutions, upon the dead body. To obviate the inconveniences arising from this want of ambi-dextrousness, surgeons have invented elbowed instruments, so as to allow them to act over the'bridge ofthe nose, and admit ofthe employ- ment of the right hand in all cases. But such instruments have an awkward appearance at best; and it is much better for the operator, when he has not a perfect mastery over the instruments with his left hand, to place himself either behind or at the side of the patient, who may, if it is found more convenient, be laid horizontal. In this way the right hand may at need be em- ployed in all cases in which he is directed in the processes for the operations to employ the left. OPERATIONS PRACTISED ON THE ACCESSORY ORGANS OF THE EYE. Lachrymal apparatus. Surgical anatomy.—This apparatus is composed of two distinct portions—the orbital and nasal. 1. The orbital portion.—The lachrymal gland, which is placed between the conjunctiva and bone, at the outer and upper portion ofthe orbit, throws its fluid by seven or eight minute ducts upon the free surface of the corresponding portion of the conjunctiva. With this lachrymal secretion is mixed the fluid coming from the meibomian glands, the caruncula lachrymalis, and the free surface of the conjunctiva, to form the proper lubricating liquid between the lid and the ball, which, when it flows over the cheek, receives the name of tears. 2. The nasal portion.—This is composed of parts for the purpose of carrying off the fluid, and preventing in the ordinary state of the functions any of it escaping between the lids, viz., the lachrymal puncta and canals, and the lachrymal sac and nasal duct. The puncta are orifices with elastic rims, by which the two canals open on the free surfaces of each lid, near the inner can- thus. From these capillary points, the canals run at first for a line, obliquely upwards or dowrnwards, according to the lid in which they are placed, and then turn at a right angle and run for a quarter of an inch—embracing the caruncula between them —to open close together through the internal wall of the lachry- mal sac, so as to throw into this cavity the fluids which they carry. In all their track, these canals are covered by the orbicu- laris muscle and the skin, and lined within by a reflection of the conjunctiva, which is thrown, near the angle described, into a OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 181 valvular fold that sometimes presents an obstacle to the passing of instruments into the sac. The lachrymal sac is of an oval or oblong shape, with its long diameter directed downwards and a little inwards and backwards. It is lodged in the groove formed by the os unguis and the nasal process of the upper maxillary bone. The root of this nasal process, which extends outwards to form the inner part of the lower brim of the orbit, has upon it a projection called the lachrymal tubercle, (readily felt when the integuments are not too much thickened,) which is exactly opposite the junction ofthe inferior with the middle third of the lachrymal sac, and serves as an index to guide the course of the knife in the puncture of the sac. Besides its internal mucous lining, which is continuous with that ofthe puncta, the sac has an external fibrous tunic, thick and resisting, and closely united to the neighbouring bones. Across and in front of the sac passes the round tendon ofthe orbicularis palpebrarum muscle, which feels like a grain of rice below its mucous covering, and divides the sac into unequal parts. The superior portion is lodged behind the caruncula, and is covered by a firm expansion of the orbicular tendon. The inferior, which is the larger, is found between them and the lachrymal tubercle; is covered only by a few fleshy fibres and the skin, and yields readily to distension from accumulation ofthe fluid within. Oc- casionally, however, we find the whole sac distended, and then the pressure ofthe round tendon near its middle gives it a bilobu- lar shape. Where it meets the floor of the orbit, the lachrymal sac terminates in the nasal duct, by which in a healthy state ofthe parts it throws its fluid into the nose. The nasal duct is formed of two membranes like the sac, and is lodged in a delicate and fragile bony canal formed by the inner wall of the maxillary sinus, and a portion of the os unguis and inferior turbinated bone. The canal is directed with a double inclination from above downwards; 1st, bending from the perpen- dicular outwards, so that a probe introduced through it from above crosses at its upper end the middle line of the forehead about an inch above the nasal bone, so as to form with that line an angle often or twelve degrees; 2d, the inclination which is back- wards causes the probe to form in that direction with the forehead an angle of twenty to twenty-five degrees. The canal is of equal length with the sac, each being about five lines long, and opens below under the inferior turbinated bone in the lower meatus of the nose. Its inferior orifice, which is beveled at the expense of its inner wall, and looks a little backwards, terminates about half an inch above the floor of the nostril. The whole space from the floor of the nostril to the top of the sac varies from an inch to an inch and a quarter, and the nasal duct occupies about the middle third of this space. The calibre of the duct is smallest in its middle part, where it is cir- cular, and has a diameter of little more than a line ; at its upper and lower termination, it is larger by half a line, and somewhat oval, so that in shape it resembles two small cones joined at their summits. The diameter ofthe healthy lachrymal sac is about the sixth of an inch. Lachrymal tumour and lachrymal fistula. These two affections, which are often treated of as separate 46 morbid conditions, are in fact but different stages of the same, and in many cases have for their origin a chronic affection of the mucous membrane of the eye or nose, which has spread by con- tinuous sympathy along the adjoining passages for the tears, so as to involve the lining membrane of the lachrymal sac. Caries ofthe os unguis, exostosis ofthe bony passage for the nasal duct, pressure from pol)pous tumours, and analogous affections, fre- quently occasion it; and it sometimes seems to arise from primi- tive inflammation of the sac from the common causes which affect the other mucous membranes. In some few instances, of which one has come under my notice in the case of a young architect of this city, it has been owing to a congenital deficiency of the nasal duct. A lachrymal tumour is a collection of fluid within the cavity of the lachrymal sac, forming a rounded elevation ofthe integument at the internal canthus of the eye. This is at first a mere passive swelling, without redness or pain, and maybe emptied by pressure with the finger upon it, the contained fluid escaping upwards by the lachrymal puncta, as is most common, or downwards by the nasal duct. In this state the tumour will often remain for months or even years, giving rise to but little inconvenience except that occurring from the necessity of occasional pressure on the sac in order to empty it of its contents, and a flow of tears (epiphora) over the face, when the eye is exposed to causes a little more than usually excitative of the secretion, as exposure to bright light, or going from a warm room into the open air when the latter is cold and sharp. Under such circumstances the distending liquid may consist merely of the lachrymal fluid mixed with mucus, or with a puriform secretion from the surface of the sac. Sooner or later, however, this catarrhal state of the parts, if not relieved by ap- propriate treatment, is followed by acute phlegmonous inflamma- tion. The tumour enlarges more, becomes highly painful and red; can be no longer entirely emptied by compression, and the fibrous or outer membrane of the sac and the integument covering it, if not opened with the knife, ulcerate so as to give exit to the fluid within, which will then be found purulent. A complete lachrymal fistula is now formed. In some cases an internal fis- tula is developed ; the os unguis becomes softened and ulcerates, and allows the fluid to escape into the nasal cavity. This result sometimes follows as a secondary effect after the external opening has been formed through the skin ; and if the external orifice should then close up by cicatrization, a cure may be produced by the efforts of nature alone. The occasional occurrence of a cure in this way has led to the institution of processes, in order to effect artificial relief in a manner somewhat analogous. The cause of obstruction will commonly be found in the nasal duct, and, though this may occasionally be of a physical nature, it is important to remember that in a vast majority of cases it is simply owing to an inflammatory swelling or thickening of the lining membrane, and amenable to the common methods of treat- ment for strictures ofthe other narrow mucous canals ; viz., such general remedies as are used in local inflammations—topical bleed- ing, purgation, and diseutient applications,—and those that are used locally—injection, catheterism, compression, to which some have added cauterization. Ofthe latter class of remedies only, as coming within the scope of this wrork, we shall proceed to treat. 182 SPECIAL OPERATIONS. TREATMENT OF LACHRYMAL TUMOUR AND LACHRYMAL FISTULA. It has already been observed, that the inflammatory thickening of the lining membrane of the lachrymal passages, is in it's first s'age the cause of the watery eye and the discharge of tears over the cheek; in its second, ofthe formation of a tumour in addition, in consequence of the distention of the lachrymal sac; and that in the third stage of the disease, the tumour is opened by ulcera- tion so as to form a lachrymal fistula. The mode of treatment of the first and second stages will be very nearly the same, and may be divided into the medical and surgical. When the medical treatment—which consists of the application of mildly stimulating ointments and collyria to the conjunctival membrane for the purpose of altering the character of its secretion, the use of local bleeding, (and of venesection, if there be any arterial excitement,) the application of emollient poultices, and the administration of alteratives and cathartics— have been fairly tried without effecting a cure, we proceed to the employment of surgical measures. These consist of injection, catheterism, and compression. Injections through the puncta. Process of Anel. (PL XLV. fig. 3.)—The instrument required is a small syringe attached by its beak to a capillary tube. The patient is to be seated in front of a good light, and the surgeon holds the syringe in his right hand so as to be able to force down the piston with the thumb or fore finger, the other hand being left at liberty to act upon the lids. In case the puncta should not be found patulous, a common toilet pin, with the point a little blunted, may be used to dilate the orifice. 1. Injection by the lower punctum.—With the fore finger of the Jeft hand, depress the lower lid opposite the punctum, so as to reverse it and expose the orifice. Taking the syringe in the other hand, and resting the two smaller fingers below the superciliary arch, insinuate the end of the capillary tube through the orifice ofthe punctum obliquely from above downwards and backwards, so as to bury it to the extent of a line. It has now arrived at the turn of the lachrymal canal, and the instrument is to be inclined downwards in order to efface the curvature, and make the point of the tube take the ascending direction of the canal. The tube is now to be passed on half a line farther, and the piston pushed gently down with the thumb or finger, to throw the fluid forwards. Some surgeons direct the capillary tube to be buried for a quarter of an inch, so that it may enter the sac ; but this does not increase the facility of injection, and exposes the lining membrane of the sac to irritation from the point. When assured by the flow of the fluid from the upper punctum that the superior canal is free, pressure may be made upon its orifice by an assistant, or with the fore finger of the other hand of the operator, so as to cause the fluid to accumulate in the sac, and find its way by the nasal duct into the nostril. Its entry into the latter cavity will be made known by the trickling of the fluid forwards upon the lip, or by its passing backwards into the pharynx, so as to produce an effort to swallow; the one or the other result following according to the degree of inclination which is given by the position of the head to the floor of the nostril. 2. Injection by the upper punctum.—The upper lid is to be ele- vated with the thumb of the left hand ; the fingers resting upon the forehead. The mode of introduction ofthe tube in this rase, is in all respects similar to the process just described, except that the two last fingers of the right hand are to rest on the cheek bone, and that the instrument is to be raised in order to pass the point of the tube beyond the angle, as the course of the canal on the inner side of this curvature is from above downwards. Remarks.—The injection by the lower punctum is almost the only process employed—the injection through the upper, being chiefly resorted to only in cases where some obstruction is met with in the passage ofthe lower lid, or there is fear of irritating it by too frequent repetition of the process. It is directed by many surgeons to hold the syringe in the right hand for the eye of the right side, and in the left hand for the other. But the operator will find it perfectly easy, by placing himself either in front or behind the patient, to employ the same hand for the eye of either side. The fluids for injection may be simply aqueous or mucilaginous, if wre wish merely to wash out the irritating contents of the sac and soothe the lining membrane of the passages; or they may be medicated by the addition of a few drops of the wine of opium ; or with the sulphate of zinc, in the proportion of a grain or more to the ounce, or of corrosive sublimate, or lunar caustic in that of a half to one and a half grains to the same quantity of the fluid. It is by its tendency to remove inflammation rather than by the force of distention, that we may hope by this means to restore the free passage of the tears into the nose. But from the rude manner in which it is too commonly practised, it is not perhaps too much to say, that this process of Anel, which by proper management and repeated at intervals of not less than one or two days, may be occasionally rendered useful, has on the whole been productive of more injury than good. Many practitioners have in consequence abandoned its use altogether, and rely for the intro- duction of fluids into the sac upon the natural process of absorption through the puncta, first pressing upon the sac so as to evacuate its contents, and then introducing an astringent solution between the lids. In many cases the fluid will not find its way into the nose until the injection has been frequently practised, and in some others, before it can be effected at all, it will be necessary to resort to one of the following operations in order to remove the obstruction in the nasal duct. Catheterism, or the introduction of a solid sound or hollow catheter through the lachrymal passages. 1. From above downwards by the upper lachrymal punctum. Process of Anel.—The patient is to be seated, with his head inclined backwards and rested against the chest of the surgeon, who stands behind him. The operator then raises the upper lid with the end of the fore finger, and inserts into the punctum the rounded head of the delicate probe of Anel, in the same manner as directed for the tube in the process for injection. Having passed it beyond the curvature, he lessens the traction with the fore finger upon the lid, and carries the probe downwards into the sac, following the direction of the canal, and rendering in conse- quence the skin tense toward the root ofthe nose. On its arrival at the sac, a result which will be known by the extent of the probe OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 183 hidden, and the freedom with which its end moves, the instrument is to be raised vertically and the head passed on along the internal side of the sac, inclined outward as much as possible so as to follow the tract of the nasal canal and glide gently through into the cavity of the nose. The manipulation must be delicately done. The probe is apt to get arrested in a follicle, or in a fold of the mucous membrane which it raises before it. It must then be with- drawn a little, and again passed forward with its direction somewhat altered. If after some trials we do not succeed in getting it clear of the obstruction, it is better to withdraw it, and repeat the attempt at a subsequent period, rather than run the risk of lacerating the lining membrane, which is usually found somewhat softened and thickened in these cases by the previous disease. This method was devised exclusively by Anel for the purpose of freeing a passage for the injection downwards into the nose. It has also been employed for two other objects. First, as a preparatory step to the process of Mejean shortly to be noticed. Secondly, for the purpose of dilating the strictured portion of the nasal duct, on the same principles that bougies are employed in the urethra. For this purpose the practice is warmly recom- mended by Mr. Travers, and Dr. Hays,* of this city. In my hands, it has seldom proved useful, and it is evident that the small size of the punctum must prevent the introduction of a probe of sufficient diameter to render the treatment efficacious. It has not, moreover, received the sanction of either Dr. Mac- kenzie or Mr. Lawrence. 2. Catheterism of the nasal duct through the nostril. This is called the method of Laforest, from the surgeon who first put it into practice. It is applicable to various diseases of the nasal duct and lachrymal sac, and allows of the introduction of sounds and catheters of considerable size, without any previous opening made with the knife. It has latterly been much employed, especially by the French surgeons. The operation is one, however, which requires accurate knowledge of the structure of the parts, and considerable practice on the dead body. Remarks.—The instrument employed first enters by the lower meatus of the nose, and penetrates from below upwards through the interior or nasal orifice of the nasal duct, and follows the course ofthe latter up to the lachrymal sac, so as to be felt at the internal canthus of the eye. In the adult the lower orifice ofthe nasal duct, which is under the inferior turbinated bone, will be found on the average at a point about two-thirds of an inch in a vertical line above the floor of the nostril, and about three-quar- ters behind the lower and lateral border ofthe anterior opening of the nose. The length of the nasal duct itself, which is rather less than half an inch, and the direction in which it runs, have been before described. Evjery instrument passed by this method from below upwards into the lachrymal sac, should penetrate through the anterior nares to the extent of nearly an inch and three-quarters, and have such a curvature as is calculated to turn the angle that the axis of the canal forms with the inferior meatus of the nose, which angle opens forwards, and is found to measure about 28 degrees. • Vide Lawrence on the Eye, with additions, etc., by Dr. Hays. Lea & Blanchard. 1843. Process of Laforest. (PL XLV. fig. ls)—^The instrument em- ployed is a small silver tube or catheter, of which the exact size and shape are shown at figs. 1 and 6. A wooden handle intro- duced into the tube serves to direct it with more precision. The same hand may be used to introduce it on either side, but in gene- ral it will be found more convenient to employ the right hand for the left duct, and the left for the right,—a little practice rendering the manipulation with either hand perfectly easy. The patient is to be placed in a sitting posture, with his head thrown back and sustained by an assistant. 1. The surgeon then, seated in front, holding the instrument between the thumb and fore finger, rests the middle finger on the cheek bone, presents horizontally the point to the opening ofthe nostril, with the convex portion ofthe curve turned towards the septum, upon which he glides it back until the whole curved portion is entered; this curved portion should be exactly of the same length as the distance of the duct from tbe orifice, which, as has been observed, is about three- quarters of an inch. 2. He then turns gently upwards the handle of the instrument, describing an arc of about 40 degrees, passes it a little forward upon the pulp of the middle finger, so that it is placed exactly in a line between the eye of the operator and the middle of the superciliary ridge. By this movement the beak of the instrument is made to ascend from the floor of the meatus, under the turbinated bone, so as to present to the lower orifice of the duct—the convex portion resting by its middle on the maxiL lary border of the meatus. 3. If the point has entered the ductj which may be readily ascertained by attempting to slide it slightly backwards and forwards, the handle is to be gently lowered by rocking it over the thumb in the direction of a plane extended between the caruncula lachrymalis and the external margin ofthe first incisor tooth of the opposite side. If the point has fairly entered the duct, and this passage is free, it will have traversed its whole length, so as to be felt with the finger, and make the skin tense over the lachrymal sac at the lower and inner side of the caruncle, by the time the handle has been brought in front of the incisor tooth of the opposite side. The catheter having been thus introduced, Laforest injected fluids through it, securing it in its position by a thread passed through the ring at its free extremity; afterwards he substituted for it a flexible sound or catheter, which was passed through its cavity and left in the canal. Process of Gensoul.—The instrument (PL XLV. fig. 6, b, c), employed by this surgeon is more easy of introduction than that of Laforest, and is the one which the author has found most con- venient and useful. It is modeled on the form of the passage, and curved at an angle of about 100 degrees, so as to facilitate its introduction. Special instruments are required for each nostril; each set con- sists of a curved sound for the opening ofthe passage, (PL XLV. fig. 6, b,) and a flexible catheter, (fig. 6, c,) through which passes a stilet, supporting a little porte-caustique at the end. The sound is graduated in order to show the depth to which it penetrates. This apparatus, devised for the purpose of applying caustic to the duct, answers equally well for injection and dilatation. The instrument is to be held as a writing pen, and presented at first a little obliquely, with the beak of the horizontal portion supported upon the septum. By a quarter rotation ofthe handle, the extremity glides from behind forward over the septum and 184 SPECIAL OPERATIONS. the floor of the inferior meatus. By this movement the handle is placed nearly vertically downwards, but inclined a little so as to be in front of the inferior canine tooth of the same side, while the point is brought at the outer side of the meatus exactly under the orifice of the duct. Carrying the handle then in a direction upwards and outwards, so as to describe 80 degrees of the arc of a circle, the point, which has glided during this movement from below upwards on the external wall of the meatus, will be found at the orifice of the nasal duct. Then by a rocking or balancing movement, which shall be at the same time from above down- wards, from without inwards, and from before backwards, the handle is brought to a horizontal position, and in the direction of a plane extended between the caruncula lachrymalis of the same, and the first incisor tooth of the opposite side; and the point, which has moved in an inverse direction, will, if the duct be free, have entered the lachrymal sac. This process is very rapidly executed, and may be rendered very easy by a little practice. Other instruments have been employed for the cathe- PLATE XLY—OPERATIONS UPON THE EYE, LACHRYMAL PASSAGES. Fig. 1.— The usual position of the head in operations upon the eyes and through the vasal fossa is here shown. The patient is seated, with his head slightly inclined upwards and backwards, and secured by the hands (a, b) of an assistant standing behind him. The head of the patient should also be a little inclined to the side opposite to that on which the operation is to be performed. The instruments shown refer to the three principal operations performed on the ball of the eye and the lachrymal passages. c. The cataract knife held ready to begin the puncture of the cornea in the operation for extracting the cataract. d. Bistoury of Petit, applied in the direction proper for the puncture of the lachrymal sac and nasal duct in fistula lachrymalis. e. The sound of Laforest introduced into the nasal duct through the nostril. (Fig. 2.) PERFORATION OF THE INTEGUMENTS OVER THE LACHRYMAL SAC FROM WITHIN OUTWARDS, WITH THE TROCAR OF MANEC. The canula in which the trocar is concealed has been introduced from the nasal fossa after the manner of Laforest. (A, B). Introduction of the tube or canula after the manner of Dupuytren. The bistoury has entered through the sac as shown in fig. 1, and is represented here as partly withdrawn and at the same time inclined forward and outward so as to widen the orifice and facilitate the introduction of the tube, wdiich is seen descending into the passage on the mandrin or stilet as the knife is being withdrawn. (Fig. 3.) INJECTION THROUGH THE INFERIOR LACHRYMAL PUNCTUM, WITH THE SYRINGE OF ANEL. The surgeon depresses the lower lid with the fore finger of one hand, so as to render the punctum prominent while he insinuates the point of the syringe into its orifice, and makes the injection with the other. (Fig. 4.) PERFORATION OF THE WALL OF THE ANTRUM MAXILLARE, WITH THE TROCAR OF M. LAUGIER. This operation is intended to make a new route for the tears, and can only be proper in cases of closure of the nasal duct by exostosis. (Fig. 5.) INTRODUCTION OF THE NAIL-HEADED STILET. The puncture of the sac has been made as shown in figs. 1 and 2, and the stilet has been partially introduced as the bistoury was withdrawn. (Fig. 6.) INSTRUMENTS EMPLOYED IN THE TREATMENT OF OBSTRUCTIONS OF THE NASAL DUCT. a. Silver catheter of M. Serres d'Uzes, with the proper curvatures for its introduction into the nasal duct from the left side of the nostril. It is introduced in nearly the same manner as that of Gensoul. A separate instrument is required for the two sides. b. Sound of Gensoul—on account of its double curvature an instrument will be required for either side. Plate ^ IhiladrLplna . Published h, Cnrey .i Ha rt P.V //.,,;,. I..II,.Ph.I OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 185 terism of this duct, by the process of Laforest, but they are mere- ly modifications of the two already described. That of Serres d'Uses, a good instrument, more curved than that of Gensoul, is shown at PL XLV. fig. 6, a. To an instrument curved like that of Gensoul, Manec has added a little dart (PL XLV. fig. 2, B), for the purpose of penetrating the sac from within outwards, and to allow ofthe introduction of a mesh, with the object in view of effecting a gradual dilatation of the passage. The repetition of the use of the sound of Gensoul or Laforest, for the purpose either of dilatation, employing injection, or the cautious application of lunar caustic, should be made at intervals of not less than three or four days, for fear of exciting too much irritation in the lining membrane of the nose and duct. If none of the measures above alluded to succeed in removing the obstruction to the course of the tears, the inflammation of the lachrymal tumour may sooner or later be expected to terminate in ulceration and form proper fistula lachrymalis. When the opening of the tumour has taken place spontaneously, I have on several occasions, in subjects who were young and otherwise healthy, known the engorgement of the sac relieved by the sup- puratory discharge, and the ulcer subsequently to cicatrize and leave the passages perfectly free without the aid of instrumental treatment. But so happy a termination is not commonly to be expected, and it is better, as a general rule, when the opening appears unavoidable, to discharge the pus by puncture with the knife, lest it should burrow and excite ulceration of the skin at a point not opposite to that of the sac, or involve the delicate bones in the vicinity. If the case has been of long standing, and there are great thickening and induration of the lining membrane of the duct, the restoration of the passage for the tears is not likely to be effected except by instrumental measures. These consist of compression, dilatation, cauterization, and the formation of an artificial canal. Compression.—This is suited only to the lighter cases of disease, and when the inflammation has been so far reduced that pressure may be borne without pain. It is employed both for lachrymal tumour and lachrymal fistula. It may be made temporarily with the finger, for the purpose of evacuating the contents of the sac, or permanently with a little pad or graduated compress, secured by a bandage, or one of the instruments newly devised for compress- ing the arteries of the face. In itself compression is little to be relied on, as it acts only upon the lachrymal sac, but I have found it occasionally useful in conjunction with the employment of antiphlogistics and the injection of astringent fluids through the puncta or nasal duct. Dilatation.—The object of this process is, by the introduction of some foreign body, to effect a permanent compression of the thickened lining membrane of the nasal duct from within outwards, so as to remove its tumidity, and limit and restore the duct to its usual patulous condition. Concurrently with this measure, antiphlo- gistic remedies and different topical applications are to be employed in order to facilitate the cure. The various modes in which dila- tation is employed, may be thus classed :—1. The introduction of some foreign body by the natural orifices—the puncta or the nasal duct,—a method which has also been occasionally employed for the cure of lachrymal tumour. 2. The introduction of some for- eign body through an orifice in the anterior wall of the sac, which orifice is either kept open round the instrument, and the latter allowed to project above the skin; or the instrument is so pressed in that its upper extremity is lodged in the cavity of the sac, and the wound by which it was introduced closed above it. 1. Dilatation by the natural orifices. By the upper lachrymal punctum. Method of Mejean.—This has been employed only in cases of lachrymal tumour, where, though there has been no fistulous opening of the sac, it was thought desirable to try permanent compression from within out- wards,—as a sort of appendix to the treatment with the instru- ment of Anel. The delicate probe of Anel, (with an eye near the end armed with a silk thread,) is to be carried by the process for catheterism, described at page 182, from the punctum into the nose. The thread thus carried into the meatus, is to be seized and brought out through the anterior nares and tied to a small seton. The probe is then to be retracted, drawing out with it again through the punctum the thread, which now pulls after it the seton so as to lodge the latter in the nasal duct. To the lower end of the seton a thread is to be left attached, so that the surgeon may withdraw it at will, for the purpose of renewal or of augmenting its size. The thread of the upper end of the seton, which traverses the punctum, is secured upon the forehead with a piece of adhesive plaster, and left of sufficient length to admit of being drawn down for the purpose of renewing the seton from time to time. This process is difficult of performance, and a variety of means have in former times been suggested to render it more easy. But it is scarcely necessary to enumerate them, as the permanent pre- sence of the thread is found to excite so much irritation and ulcer- ation of the punctum, that the process has been almost wholly laid aside. Dilatation by the lower orifice of the nasal duct, called the process of Laforest.—This surgeon insinuated a solid sound, as far as the obstruction would permit, by the process already described, c. Graduated flexible sound or catheter of Gensoul, enclosing a stilet which has a porte-caustique at the end for the cauterization of the passage, from below upward. Both these instruments have a double curve as showrn by the shading. d. Sound of Laforest—the external orifice closed by the handle. e. Tube or canula of Dupuytren. f. Tube or canula of M. Malgaigne. g. Canula of Gerdy. The last two instruments are devised as substitutes for the tube of Dupuytren, and from the irregularity of their surfaces, are less liable to become displaced, h. Nail-headed leaden style of Scarpa. 47 DERATIONS. 186 SPECIAL C at page 1 S3. This he allowed to remain till it became movable by the retreat of the walls of the duct, resulting from the secretion excited by the presence of the sound. A hollow sound or cathe- ter was then substituted for the former, introduced with a movable handle, and secured with a thread as before mentioned. Through this he also practised injections, upon the efficacy of which he mainly relied for the cure. Vesigne followed the same method, gradually augmenting the size of the instrument up to that of the natural dimensions of the passage. He employed a gum-elastic catheter, which was introduced on a curved stilet. Some diffi- culty will, however, be experienced frequently in the substitution of the larger instrument for the smaller, which Malgaigne has pro- posed to obviate by introducing a curved stilet into the one to be removed while yet in place, withdrawing the latter over it, and making it serve as a means of conducting the new one into the passage. The sound and catheter of Gensoul answer for this purpose better than the instrument of Laforest. But by this pro- cess, and all the various modifications of it which have been de- vised, the cure is slow, the necessary manipulation disagreeable to the patient, and relief by no means so certain as by the methods about to be described. Dilatation through an orifice in the sac. (PL XLV. figs. 2 and 5.)—Introduction of a foreign body from above downwards.—If the sac has ulcerated spontaneously so as to leave a free route to the nasal duct, the dilating instrument may be passed at once from above downwards. But if the ulcerated opening of the skin does not correspond with that of the sac, or it is thought judicious to resort to this method of cure before the ulceration has taken place, the sac is to be opened by puncture in the following manner, which is but an improved modification ofthe plan of Petit. The patient is to be seated in front of a good light, with his head supported against the chest of an assistant, who with one hand sustains his forehead, and with the other draws upon the external border of the orbit, so as to stretch the lids and render the round tendon of the orbicularis muscle prominent in front of the sac. The operator, seated in front of the patient, feels with the pulp of the index finger of one hand, below the obvious promi- nence of the orbicular tendon, for the ridge of the nasal process of the maxillary bone, which confronts the lachrymal sac. Resting his nail upon this, a small rhomboidal space will be observed between the nail and the tendon, and between the rising swell of the lower lid and the bone. If the parts be much swollen or painful, it may not be possible to feel the ridge of the nasal pro- cess, but it is not difficult to ascertain the position of the sac, which it must be recollected is to be opened below the orbicular tendon, and seemingly the nearer to the nose the less sloping are the bony sides of the upper part of the nostril. The want of knowdedge of this apparent change of position of the sac, dependent upon the varying shapes of the nose, I have known the cause of con- siderable embarrassment in this simple operation. Through the centre of this rhomboidal space, guided by the nail of the finger resting on the ridge of the bone, the surgeon lowers the point of a bistoury (PI. XLV. figs. 1, 2), held as a writing pen, with the back to the nose and the edge directed outwards and slightly downwards, so as to divide the space in the direction of its dia- gonal. The point is first to be passed from without inwards and from before backwards, as if we were about to strike the os un- guis behind the sac. When it has pierced the wall in front and fairly entered the sac, the handle is to be raised, describing an arc of a circle from below upwards and from without inwards, till it comes in front of the internal end of the eyebrow, and in the direction of a line drawn from this point to the outer side of the ala of the nose. It now corresponds with the long axis of the sac and nasal duct, and is to be passed, lightly held, down- wards without changing the double oblique direction of the blade and handle. The bistoury enters the orifice of the duct and is arrested by the edge and back coming in contact with its bony margin. It is not usually deemed necessary to enter it for more than half an inch, though the author prefers in all cases a knife narrower than the one represented in the plate, in order that it may pass freely into the duct, and divide any stricture that may exist within it. The common straight sharp-pointed bistoury of the pocket case, I find answers perfectly well for making the puncture. By following the process above described, the surgeon will freely open the sac, and avoid the chance of a result which I believe occasionally happens, viz., of the knife passing down on the anterior surface of the sac—the cavity of which is often considerably diminished by thickening of the lining membrane— thus rendering the introduction ofthe dilating body almost useless, as it would under such circumstances in all probability follow the knife and merely separate the membranous wall of the duct from the bone. After the incision of the sac, the mode of proceeding is varied by different surgeons. Petit tilted the bistoury so as to make the wound gape; and, as he withdrew it, directed down along the channel near its back a grooved sound, which he passed through the duct into the nose to open the way, and finally substituted for it a small conical wax bougie, which was allowed to remain, and secured against sliding into the nostril by a thread fastened to its upper free extremity, attached upon the face by a strip of adhesive plaster. The bougie was renewed from time to time, and gradually increased in size, and when the duct had Become restored to its natural diameter, removed altogether and the ex- ternal wound allowed to close. This may still be considered an excellent method of treatment, and is advocated by some judi- cious practitioners of the present day.* Some surgeons, after the artificial opening ofthe sac, have pre- ferred the practice of Mejean, of introducing the dilating body, consisting of a seton or a piece of catgut, from below upwards through the nostril, with the exception that they first passed their conducting instruments, of which various kinds were contrived, from above downwards through the orifice in the sac. This method, though advocated by Desault and Boyer, is now, however, almost entirely abandoned, since it ill accomplishes the effects desired, and the manipulation through the nostril proves both tedious and painful. Beer introduced catgut from above downwards, beginning with the size of the smaller strings of the violin, and ending, as the passage became more open, with the largest. The lower end was passed completely into the nose, and a few hours after, when it had become softened, it was blown or hooked out from the nostril and secured upon the cheek. * Vide an article on the cure of fistula lachrymalis, by Dr. Parrish: Philad. Med. Examiner for July, 1843. OPERATIONS PRACTISED UPON THE 1 The introduction of a nail-headed style, (PL XLV. fig. 5,) after the manner of Scarpa and Ware, is the means employed most commonly by practitioners for effecting dilatation after the opening of the sac. The former surgeon employed a lead, the latter a silver style, about an inch and a quarter long and the twentieth of an inch in diameter. The style is to be introduced much in the same manner as the bougie of Petit, care being taken to push it at first from before backwards—especially if the common probe of the pocket case, which answers very well, has been used to clear the duct—so as to get the point well within the sac before the style is raised in the proper direction, to be carried down into the nose. In pressing down the probe to clear the way for the style, no force should be used, for fear of lacerating the os unguis or breaking into the antrum. If a probe of small size will not pass through, it should be entered as far as it will readily go under gentle pressure, and secured in its position by a strip of plaster to the forehead. In a day or two the opening may be thus enlarged by frequent trials till the probe or style will pass. The following judicious directions are given by-Mr. Mackenzie for the management of the style, which is nearly after the manner of Ware. " It is an instrument which generally may be worn for an un- limited time, not only without annoyance to the patient, but with a great degree of comfort. The probe being withdrawn, and a little tepid water injected, the style, previously passed through a bit of court plaster, is introduced from the sac into the duct, and pushed down so that the bit of plaster comes into contact with the integuments. The plaster serves to bring the edges of the incision as much together as the presence of the style will permit, and prevents the style from sinking into the wound. The wound closes gradually round the style, which is not to be entirely taken out for the first four or five days, but merely raised a little daily, so as to allow the parts to be cleaned. After the wound has healed so much that the opening closely embraces the style, this is to be taken out every morning, the nasal duct injected with tepid water, or some weak astringent solution, and then replaced. The aperture through the integuments into the sac soon becomes fistulous, having no disposition to close. "During the time that the style is worn, the previous symp- toms disappear almost completely. The style dilates the duct in the same way as a bougie dilates the urethra. The tears and mucus, absorbed by the lachrymal canals, appear to be attracted between the surface of the style and the lining membrane of the nasal duct, and thus the function of the parts being restored, the inflammation, watery eye, and the blennorrhceal discharge quickly subside. " It frequently happens that a patient, after wearing a style for three or four months, has it removed, thinking the disease per- fectly cured. After a time, however, the blennorrhcea returns, the style is re-introduced, and the symptoms again subside. After three or four months more, it again becomes a question whether the style should be removed. The patient often objects to its removal. He knows the inconvenience of the disease, and the little trouble of the remedy, and prefers continuing the use of the style, rather than run the risk of the blennorrhcea returning. I have known even ladies object to giving up the style, having once experienced a relapse from its removal. 187 "The style should be gold or silver gilt, to prevent it from becoming oxydized, and should have its head japanned of a skin colour, so that it may scarcely be observed, or blackened with sealing wax, so as to look like a little patch. The edges of its head should be rounded off, lest by pressure it cut the skin. It must on no account be left without regular removal and replace- ment. A patient in the lower ranks of life called upon me, with a silver style, which had been introduced by the late Dn Mon- teath, and which had not been taken out for more than six months. It was all but corroded through, about a quarter of an inch below the head. " In one instance, I witnessed profuse bleeding from the nos- tril during the day and night after pushing down a style. A short one had been worn, but not reaching the nostril, a longer one was introduced, and was followed by this effect. "It is important to remark, that the style itself is occasionally a cause of irritation. It often is so, for some days after it is first introduced. We are obliged to apply an emollient poultice over the sac, or even to withdraw the style. Months after it has been introduced, and proved highly serviceable, we sometimes find that the patient complains of matter being still discharged by the side of the style. In such cases we should consider how far the style itself is a cause of this discharge ; and if the Meibomian follicles, conjunctiva, and lachrymal passages, appear in every other respect sound, except only in the puro-mucous discharge by the side of the style, let it be gradually shortened, and at length removed, and a trial made wdiether everything will not, now that the passage is patent, go on as it ought to do. " By shortening the style bit by bit, we try the state of the lower portion of the duct. If matters go on well with a short style, we may conclude that the passage is healthy, and think of removing it entirely; but if the disease returns under the use of the short style, we must re-introduce one of the original length. When we withdraw the style, with the intention of no longer replacing it, the edge of the opening through the integuments must be made raw; for if this is not done, it is apt to contract to an almost capillary fistula, very difficult to close. Sometimes, indeed, this minute callous opening may, in itself, furnish a pal- liative cure for chronic dacryocystitis. A lady consulted me, who had long been under the care of Dr. Monteath, for blennorrhoea and relaxation of the sac. She had worn a style for a length of time, but without a cure being effected. Dr. Monteath proposed laying open the sac and stuffing it, as is recommended in certain cases by Scarpa, but the patient declined this. The style was removed, the opening did not close, but continued patent for years; mucus continued to collect in the sac, and kept it greatly dilated; the eye was strong, and the patient thought nothing of the inconvenience of being obliged several times a day to press out the mucus through the callous orifice."* Mr. Liston, after the tube is worn for a short period, directs the style to be taken away entirely, the passage being kept clear by the occasional introduction of a probe or sound from the side of the nostril; or causes the patient to wear for some time, during the night, a very small style, which there will seldom be any * A Practical Treatise on the Diseases of the Eye, by Wm. Mackenzie, M. D. London, 1840, p. 256-8. FEBALL AND ITS ACCESSORY ORGANS. 1SS SPECIAL OPERATIONS. difficulty of inserting through the minute and almost imperceptible fistulous aperture that remains in the front part of the sac. Permanent dilatation with a tube, the wound cicatrized above it. This is an old practice which was revived by Dupuytren, and has since been extensively employed. It consists in the intro- duction of a small gold or silver gilt tube into the canal through a puncture of the sac, which is allowed immediately to heal, as in the case of the wound after venesection. The tears find their way at once by the cavity of the tube, and the epiphora ceases. In the lapse of time—weeks, months, or even years, as it may be —the tube gets loose in the duct, which has become enlarged in consequence of its presence, and falls finally into the nasal fossa, from whence it is readily expelled. This may be the result in fortunate cases, but it by no means invariably follows. The tube may fall prematurely, and before the dilatation has been protracted for a sufficient length of time to remove the stricture of the duct, thus rendering it necessary to repeat the operation. Occasionally it has been found so loose as to rise up when the nose was blown, and become by its pressure against the top of the sac, a source of so much irritation, as to require to be cut down upon and removed. To obviate these inconveniences various modifications have been given to its form, rendering it more bulbous and irregular on its surface, so as to prevent its too easily sliding in either direction. Occasionally it happens that the very presence of the tube in an inflamed cavity like that of the sac under circumstances requiring the operation, has been a cause of so much irritation as to require its speedy removal. To obviate this necessity J. Cloquet and Malgaigne, after the puncture of the sac, dilate the passage for a few days with a mesh or sound, before the tube is introduced. The tube has been known many times to descend, so as to press by its lower end and excite ulceration through the palatine arch. It has in a few instances given rise to such inflammation as to pro- duce a carious condition of the delicate bones about it. The tube itself is exceedingly liable to be choked up with mucus from the side of the sac, by calcareous concretions within its cavity, or by snuff on the side of the nostril, when the tears must find their way by its side, as in the case of the style; the good which it then effects accruing only from the dilatation, as in the case of the latter instrument. The comparative merits of the two instruments have not yet perhaps been fully decided. With the tube the operation is rapid, but little painful, and at once finished. There is no deformity left, and though there is some risk of the contrary, it may be fol- lowed with no further trouble or inconvenience. The tube is not, however, suited to cases where there is much thickening or ulceration of the sac, as the parts will not, under these circum- stances, close above it. With the style there is a mark for obser- vation left upon the cheek, the cure may be less complete or followed even with a fistulous ulcer of the sac, but the operation is unattended with risk, and the instrument is always under the control of the surgeon—a circumstance which weighs strongly in its favour with the profession. Mr. Travers, who asserts that he has introduced the tube fifty times with excellent success, without having been required to remove it in more than two instances, nevertheless, for reasons analogous to the above, gives preference to the mode of cure by the style. The process of Dupuytren for introducing the tube is as fol- lows :—The instruments required are, 1. A tube (PL XLV. fig. 6, e), three quarters of an inch to an inch long, slightly curved, and tapering gently to its lower extremity, which should be beveled on the side corresponding with the concavity of the curve. At the top it should be furnished with a rim to lodge against the surface of the os unguis, a sixth of an inch in diame- ter, and diminish to about half the same dimensions at its lower end. 2. A mandrin or steel stilet for introducing it (fig. 2), with a handle joining it at an angle of 125 degrees ; and 3. A narrow- bladed bistoury (fig. 2). The tube should in addition have a groove sunk along the inner side of the head for the purpose of affording a hold to a small hook or a bifurcated spring stilet, with a catch at each extremity, for the purpose of withdrawing it if such a measure should become necessary. The sac having been punctured, as described at page 186, the tube, carried on the mandrin, is glided along the groove on the back of the bistoury into the upper orifice ofthe nasal duct. The bistoury is then gradually withdrawn, and the tube finally carried through the sac completely into the duct, upon the orifice of which the rim is to, rest. Pressure is then to be made with the finger nail upon the lower part of the sac, so as to allow the mandrin to be withdrawn without raising the tube. If, on causing the patient now to blow through the nose, a few drops of blood appear in the nostril, or some blood mixed with air escapes from the wound, the operation has succeeded. If these signs do not appear, the instrument has made a false passage, or it is sunk too deep, or the curve does not hold the proper direction of the duct. In the first case the tube must be withdrawn and introduced anew. In the latter it will only require to be raised a little in the sac, and turned to its proper position. The operation being done, the wound is to be accurately closed with a piece of court plaster; the patient may resume his usual occupations, the course of the tears is re-established, and in a few hours all sensation of uneasiness at the angle usually subsides. It may be mentioned here that Pouteau has proposed to open the lachrymal sac by an incision different from that of Petit, though the suggestion has not to any extent been carried into practice. His object was the avoidance of a scar upon the face, but the plan proposed incurs the risk of a still greater deformity in the internal canthus. He directs the internal canthus to be drawn inwards, and the lower lid depressed. The bistoury is then to be passed in between the caruncula lachrymalis and the border of the lid. By the plan of Petit no very obvious mark of deformity follows—unless the operator should be so ignorant or heedless as to divide with the bistoury the round tendon of the orbicularis muscle. This result has occurred in one instance within my knowledge, and was attended with singular deformity. The internal canthus being loosened in a great measure from its attachments, it was started a little outwards by the orbicular muscle, towards the middle of the orbit. By cauterization. This is a practice of ancient date, which has been latterly revived, in consequence of the advantages alleged to attend the treatment of strictures of the urethra by the same means. But the analogy between the cases of obstructions of the two organs OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 189 is only approximative, and the use of caustic for the cure of fistula lachrymalis has proved more often injurious than beneficial. Cauterization has been employed from above downwards, after puncture of the sac—and from below upwards through the lower orifice of the nasal duct. 1. Cauterization after puncture. Process of Harneng.—A small conducting tube is introduced into the nasal duct. Through this is passed down a heated stilet, or an instrument with a vertical groove, charged with argentum nitratum. The inflammatory symptoms which follow are to be treated as under ordinary circumstances ; the process has com- monly to be several times repeated. Caustic potash has in a similar manner been introduced, and very serious consequences have followed the rashness of the practice. 2. Cauterization from below upwards. It has been done by M. Bermond, by attaching the thread of Mejean (see page 185) to a seton covered with a caustic paste. The only method of cauterization entitled to any credit as a means of cure, is the following, and by which it has been said considerable success has been obtained. Process of Gensoul.—The instruments employed are those already described under the head of catheterism of the nasal duct (page 183). A porte-caustique, charged with the nitrate of silver, which is securely lodged in the little cup by being por- phyrized over the flame of a candle, is introduced through the curved tube which has been previously passed into the duct, and applied to the seat of stricture. The operation requires to be frequently repeated, and may be aided by the occasional use of the sound as a dilating body, and by injections thrown up through the tube. FORMATION OF AN ARTIFICIAL CANAL. This was a method in common use with Celsus and the Ara- bian surgeons before the structure of the lachrymal passages was well understood. It is now employed only as a dernier resort in cases of absence of the nasal duct, or when it has been oblite- rated by a diseased condition of the bone, or by the effusion of lymph between the opposite surfaces of the duct. A new canal has in some instances been spontaneously esta- blished by the ulceration of the os unguis, through which the lachrymal secretion passed readily into the nose. Three methods have been devised for the formation of the new passage. 1. By perforation of the os unguis. 2. By the maxillary sinus. 3. By the old route of the duct or,at least in its direction. 1. Through the os unguis.—This is the process of the older surgeons, who made the opening through the bone with a heated iron, a trocar, or the end of a quill. The sac should be freely iaid open in- the ordinary meatier, '^d to render the operation at all likely to succeed, it will be necessary, in order to prevent the subsequent closure of the new opening which is likely to happen, to remove a portion of this delicate bone, and introduce a gold tube, bulbous at its two extremities, which is to remain permanently, and over which the wound is to be immediately closed as in the process of Dupuytren. To remove the piece of 18 bone, Jno. Hunter recommended the use of a punch with a plate of horn or wood passed up through the nostril to serve as a point of resistance. But this method may be considered imprac- ticable in consequence of the shape of the nasal fossa. The removal will be much better accomplished, and without fracture, by the ingenious instrument of M. Fabrizi, of Modena, for the perforation of the membrane of the tympanum. 2. Through the maxillary bone. Process of Pecot and Laugier. (PL XLV. fig. 4.)—The mandrin of Dupuytren, (fig. 2,) or a small trocar, similarly bent at an angle, is to be passed down upon the groove of the bistoury after the puncture of the sac. When the point has entered as far as it will into the duct, break through into the antrum by carrying the handle of the instrument upwards in the direction of the middle of the frontal suture, and enlarge the opening by movement with the point before its with- drawal. A tube is subsequently to be introduced. This operation has not, however, been employed intentionally on the living sub- ject, and it is not known how the presence of the tears would be borne on the lining membrane ofthe maxillary sinus, or how great would be the risk of inflammation and caries. In the direction of the natural duct. Process of Wathen.— An opening is to be made as much as possible in the direction of the duct, with a small drill, which is to be introduced through a puncture previously made in the sac. The gold tube of Dupuy- tren is then to be introduced and firmly fixed through the new made passage, and the wound immediately closed above it. This method, it is said, has. been employed in one instance, with entire success by Dupuytren. In a case somewhat similar, M. Mal- gaigne succeeded in making a perforation in the direction of the natural passage by forcing down the steel mandrin of Dupuytren, for the introduction of the tube. The gold tube of Pellier, with an enlargement at each end, was inserted as usual to keep the passage open. From the little resistance encountered in making the new passage, it is very probable that in this case of Mal- gaigne, the occlusion of the duct was owing merely to the in- flammatory adhesion of the inner surfaces of its lining membrane. OBLITERATION OF THE LACHRYMAL PUNCTA AND CANALS. This obliteration may be either congenital, or which is much more frequently the case, the result of long-continued inflamma- tion of the margins of the lids. It is an affection exceedingly difficult to remove, and for which no method of treatment yet devised has given very satisfactory results. 1. The imperforation or atresia of the puncta, is usually con- genital. A thin pellicle is found closing the orifices, the position of which is marked by a slight depression, the construction ofthe canals below usually being perfect. It suffices in these cases to pierce the pellicle with a needle after the manner of Hiester, and keep the orifice open for some time with a fine metallic thread, or slender piece of catgut. If any little fungous growths arise about the orifice, they are to be repressed by the application of astring- ent washes, or by being lightly touched with lunar caustic. When the obliteration is the result of chronic inflammation, or is occasioned by ulceration from the injudicious use of the instru- ments of Anel and Mejean, the same method is to be pursued, but the cure will be more uncertain. 190 SPECIAL OPERATIONS. 2. Obliteration of the lachrymal canals.—This may likewise be either congenital or acquired. That which is acquired as a con- sequence of disease, occurs usually only in the passage of the lower lid. In a case of double obliteration, J. L. Petit is said to have completely restored the canal ofthe lower lid, that had been closed only at a few points, by the introduction of a fine gold thread, which was allowed to remain until it moved freely in the passage. Where no remains of the canal can be discovered, it has been proposed to form a new passage from the border of the lid to the lachrymal sac. Pellier made the perforation from without inwards, and relied upon the use of simple injections to keep it open. Monro pro- posed to open the sac and make the perforation from within out- wards, a measure certainly not likely to be followed by much benefit. Malgaigne advises the use of the elastic dart stilet of Manec, (PL XLV. fig. 2, A,) which should be introduced through the catheter of Gensoul, into the cavity of the sac, and then passed forward so as to penetrate as nearly as possible in the natural direc- tion of the canal, from the sac towards the free edge of the lid. The process of Pellier is perhaps of all the most rational. But none of these measures have been successful in my hands except where the obliteration has been slight. Besides the difficulty attending the first formation of the canal, it is scarcely probable that it would ever become endowed with the active absorbing function of the natural passage. Operations to effect the obliteration of the puncta and sac.—In some obstinate cases of fistula lachrymalis, incurable by the ordi- nary means of treatment, it has been observed that the epiphora gradually ceased after a destructive inflammation of the sac, puncta and canals. This led the two Nanoni, father and son, to open the sac with the knife and obliterate its cavity. The one effected the obliteration with the actual cautery, the other with a mixture of alum and precipitate. This is a measure, however, which the surgeon should not lightly undertake, so great is the uncertainty of its being followed by atrophy of the gland. Bosche recommends under such circumstances, the obliteration ofthe puncta by exciting ulceration at these orifices with a pointed stick of lunar caustic, a process which seems entitled to a prefer- ence over that above described. For if the sac remained of its full size, and should afterwards fill up with its secretions so as to form a mucocele, it might be laid open and dressed with stimulating substances like an ordinary cyst. I had, two years since, under my care a young gentleman, in whom there was a congenital deficiency of the lower part of the sac and its nasal duct, whilst the puncta and lachrymal canals were perfect, and communicated together at the internal canthus ofthe eye. In this case, a style was, with some difficulty, inserted in the usual manner. It was worn during nine months, being frequently withdrawn, for the purpose of having the probe of Anel and injections passed in through the puncta, so as to keep open their communication with the new made route to the nose. By these means all the inconvenience arising from the epiphora, which had been troublesome from childhood, has been removed, except at times when the eye becomes suddenly exposed to he influence of a cold wind or is otherwise unduly excited. In some instances, after the treatment of fistula lachrymalis with the nail-headed style of Ware, considerable difficulty is encoun- tered in effecting the closure of the fistulous orifice through the skin. If the use of caustic to the edges, compression and tbe application of a heated needle, should fail in eff'ecing the cicatri- zation, it may be closed by excising its edges with the point of a small bistoury, and engrafting upon it after the manner of Dieffen- bach, a piece of skin raised from the adjoining surface ofthe nose, but left attached at one point so as to keep up its supply of blood. The flap should be fastened with a few stitches, and cold applica- tions kept assiduously applied for the first few days. The wound on the side ofthe nose should be allowed to close by granulation. JEgylops or anchylops.—This is an abscess at the internal angle of the eye, immediately in front of the lachrymal sac, but without involving the apparatus for the transmission of tears. The ulcer which it occasions in its second stage, gives to the eye some- what the appearance of that of the goat, from whence the disease has received its name. In its first stage it may readily be mistaken for lachrymal tumour; it requires, however, a very different mode of treatment. If the nature of the disease be not recognized, it may, in the end, not only excite ulceration of the skin, but also open backwards into the lachrymal sac so as to establish a fistula of that organ. In its early state, the asgylops may be readily distinguished ; the seat of the disease is superficial, and accom- panying it there are redness of the skin and congestion of the subcutaneous cellular tissue, whilst the flow of tears continues uninterruptedly along their proper channels. In this first stage, recourse must be had to local depletion by leeches, the use of emollients, and the employment of the antiphlogistic regimen. As soon as matter forms, it is to be evacuated; and if the prac- titioner be not called to the case till it has advanced to suppuration, the diagnosis will be rendered obscure in consequence ofthe col- lection of pus pressing upon the sac so as to prevent the passage of injections, or the introduction ofthe probe of Anel through its cavity. The character of the pus discharged by puncture will assist to disclose its seat—for if it does not come from the sac, it will be unmixed with mucus ; and in general, it will be found that the sac, as soon as relieved from the compression, will admit the passage of the injected fluid from the puncta to the nostril. After the pus of the segylops is discharged, the abscess is to be dressed with dry lint, touched, if its edges become fungated, from time to time with caustic, and the thin edges of the ulcer subjected to gentle but steady pressure, by the aid of a small graduated linen compress and a monoculus bandage. The administration of tonics will also in general be required. OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. These consist of Ectropion, Entropion, Trichiasis, Distichiasis, Blepharoptosis, Adhesion ofthe Lids, Tumours ofthe Lids, Colo- boma Palpebrse, and Epicanthis. ECTROPION. In this affection the lid is drawn away from the eyeball, its lining membrane more or less everted, and the ciliary margin Ptnfv fh. PhilOeU&ijihia.. Pu.diisht.at by Carey <£■ Hart rs uum; Lith r*.i/" OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 191 displaced upwards or downwards according as the seat of the deformity is in the upper or lower eyelid. In a great majority of cases it is, however, confined to the lower. When it involves the upper lid so as to keep the eye permanently open, it consti- tutes the disease which has been called lagophthalmia or oculus leporinus. There are three principal varieties of ectropion. 1. One, and the only variety which may.be considered acute, depends upon an inflammatory swelling of the conjunctival membrane which presses upon the lid so as to cause its eversion. 2. One, which depends upon the morbid contraction either of. the lid itself or the surrounding integuments. This occurs frequently after burns or ulcers, the eversion then being produced either by the short- ening of the skin or by a loss of its substance. 3. One, which depends upon caries or tumour of the margin of the orbit, by which the lid is pressed off from the eyeball and everted. 1. Of ectropion caused by tumefaction of the conjunctiva.—In its recent state this affection may usually be cured without any form of cutting operation, by resorting to the usual modes of treatment for conjunctival inflammation, conjoined, when the case proves more obstinate, \vith the use of lunar caustic or the mineral acids, so as to whiten for the moment the surface of the conjunctiva, and dispose it to contraction. But when the disease does not yield readily to these means, or the tumour is very considerable, or of long standing, one of the following operations is to be em- ployed. The method of operation is varied according as the seat of the alteration is confined to the conjunctiva—or when there is, in addition to this, as often occurs in the progress of the disease, a preternatural lateral elongation ofthe skin ofthe lid and the tarsal cartilage, so that if the lid were restored to its proper position it would not adjust itself accurately over the ball. For the first, a PLATE XLVL—OPERATION FOR ECTROPION AND BLEPHAROPTOSIS, ECTROPION. Fig. 1.—Excision of the middle portion of the tarsal cartilage for the cure of ectropion of the lower lid. (Method of Welter.) Figs. 2, 3.—Excision of a triangular or V shaped piece of the lower lid for the cure of the same affection. (Process of Dorsey and Sir W. Adams.) In fig .2 is represented the mode of removing the piece. A first incision has been made on the side next the outer canthus, and the forceps and scissors are seen applied for the purpose of making the second cut. In fig. 3, the triangular wound left has been closed with the twisted suture, so as to turn the shortened lid inwards in its proper relation with the ball. (Figs. 4, 5.) CURE OF DOUBLE ECTROPION. (Process of Dieffenbach.) In fig. 4, an incision slightly curved has been made through the integuments of the upper lid down to the conjunctiva. The conjunctiva is shown drawn out through the wound for the purpose of having a portion of it removed with the scissors. In fig. 5, a similar operation is represented as having been performed on the lower lid. The cut margins ofthe conjunctiva are to be attached to the lips of the cutaneous wound with harelip sutures. The lower lid is seen raised to its natural position by the shortening of its conjunctival lining. BLEPHAROPTOSIS. Figs. 6, 7.—Removal of an elliptical portion of skin from over the superciliary ridge and the upper part of the eyelid. (Process of Hunt, of Manchester.) In fig. 6, the portion of integument is represented as removed with the knife, exposing the fatty layers below, and some of the muscular fibres over the superciliary ridge. In bad cases of blepharoptosis, I have found it necessary to remove a larger portion of the integument of the lid than is here shown in order to render the operation completely successful. In fig. 7, the lips of the wound are seen united by three harelip sutures, which raise the upper lid and open the eye. The lower segment of skin gets an attachment after the cure to the muscular fibres over the orbit, so that the lid can subsequently be raised at will by the action of the occipito-frontalis muscle. The use ofthe common interrupted suture has appeared to me to be attended in these cases with less irritation than that of the harelip pins. Figs. 8, 9.—Excision of an elliptical portion of skin from the middle of the outer surface of the lid. (Ordinary process, suited to less extreme cases of blepharoptosis or palsy of the levator muscle of the lid.) In fig. 8, a longitudinal fold of skin is seen raised with a pair of forceps, so that it may be removed at one cut with the scissors. In fig. 9, is represented the closure of the wound after the removal of the skin. OPERATIONS, 192 SPECIAL 0 simple excision of a part of the thickened and sarcomatous con- junctival membrane will suffice—but in the case of the latter com- plication, it will often be necessary to excise also a portion of the substance ofthe lid, including the tarsal cartilage. Excision of the conjunctiva.—This is, though an ancient, a simple process. The patient is to be seated with the head inclined back- wards. The lid is to be depressed or elevated according as it is the lower or upper upon which we act. Then with a pair of good flat forceps, raise upon the middle of the conjunctival tumour a portion of it just sufficiently large to bring the cilia to their proper direction, and excise it by an elliptical cut with a pair of scissors curved on the flat, or a small scalpel, the sides of the ellipsis being left parallel with the free border ofthe lid, and the incision made from the external towards the inner canthus. The piece re- moved should be nearer the ball than the free edge of the lid. The subsequent treatment is to be the same as in ordinary acute oph- thalmia—except that the bleeding from the wound will obviate the immediate necessity of local depletion. Benefit will often be derived after the bleeding has ceased by bringing the cilia towards the ball by a strip of adhesive plaster, and supporting the parts with a compress and monoculus bandage. Excision of a wedge-shaped piece of the lower lid. (Process of Dorsey and Adams. PL XLVL figs. 2, 3.)—This is usually em- ployed in addition to the excision of the conjunctiva; but in cases where the deformity arises merely from the lateral elongation of the lid, the operation in question alone is needed. This con- sists in the removal of a wedge-shaped piece comprising the whole thickness of the lid ; the base of the piece corresponding to the free margin, and the apex descending a little below the inferior border of the tarsal cartilage. The breadth of the piece should be such as will reduce the margin of the lid to the proper length, and cause it when the wound is closed to rise up to its natural posi- tion. The excision should be made rather towards the external canthus than in the middle ofthe lid, in order to render the mark of the cicatrix less apparent, and interfere less with the movement of the organ. Having determined on the size ofthe piece to be removed, the surgeon lays hold of the lid with a pair of forceps, and draws it out from the ball. With a pair of strong straight scissors he cuts out the piece completely at twTo strokes—one on either side of the scissors—the two meeting below at an acute angle; or if he prefers, he-may, in making the second cut, take a new hold of the lid, and apply the scissors on the outer side of the forceps. The lid is then to be restored to its proper position, and the edges of the wound united with two twisted or interrupt- ed sutures. The first suture should be passed close to the ciliary margin, at the distance of about the tenth of an inch from the cut surface, in order to render the edge of the lid even. The other is to be introduced lower, and the lid supported with strips of adhesive plaster and a compress and bandage. The pins should be removed on the second day, lest they should cut out and pro- duce lateral cicatrices. Excision of the conjunctiva through the slcin. (Method of Dief- fenbach. PL XLVL figs. 4, 5.)—This maybe applied upon either lid. The object ofthe process is to remove a portion ofthe con- junctiva, and attach the cut edges to the skin by a common cicatrix, so as to prevent its subsequent morbid elongation. It is done as follows:—The inverted lid being placed as much as pos- sible in its natural position, the operator makes with a short straight bistoury, about a quarter of an inch from the ciliary margin, a semilunar incision of the skin, parallel with the edge of the lid, and occupying the middle two-thirds ofits length. He next dis- sects the skin down a little towards the free edge of the lid, and divides the orbicularis muscle and the adjoining conjunctiva parallel with the orbital edge of the tarsal cartilage, to the same extent with the previous wound. Through this opening he seizes with a pair of forceps the cut edges of the palpebral conjunctiva and the tarsal cartilage which is adherent to it, and draws the conjunctiva out through the wound. The redundant portion of the mucous membrane is then excised above the level of the skin. The margin of the lid is at the same time turned in by the trac- tion on the membrane, so as t0:.have its proper relation with the ball. The wound is now to be closed with the twisted suture, the pins fastening together the two lips of the cutaneous incision and the included portion of conjunctiva, which is rendered raw by the previous incision. The pins are to be twisted outwards at their extremities, and cut off near the threads. They are to be removed between the third and sixth days, according to the judgment of the surgeon. After the cure a linear cicatrix only is left. This is an ingenious operation. It may, however, be observed that it is not in any way better calculated to remove the deformity than the simpler method above described. Partial excision of the tarsal cartilage. (Process of Weller. PL XLVL fig. 1.)—It has been observed that in old cases of ec- tropion, the tarsal cartilage is elongated with the other consti- tuents of the lid. This surgeon, in order to bring it to its proper dimensions, after the excision of the hypertrophied conjunctiva, removed with the bistoury or scissors about a third of an inch of the middle part of the cartilage, so managing, however, as to leave at this point the palpebral margin of the tarsus entire, by splitting the cartilage near the edge. This operation resembles that known under the name of the process of Antylus. It leaves no cicatrix upon the surface of the lid, but is not on the whole deserving of so much reliance as the process of Dorsey and Adams already described. We meet frequently with cases of excoriation and shrinking of the skin of the lid, accompanying and aiding in the first form of ectropion, which is kept up by the irritating secretion from the diseased membrane.. This complication requires the same treat- ment as mentioned on the last page, with the addition of the ap- plication of the oxide of zinc ointment to protect the excoriated .surface, and restore it to a more healthy condition. Cases of partial eversion are also occasionally met with in old subjects, the con- sequence either of palsy of the ciliaris muscle, or a relaxation of the palpebral ligaments that attach the tarsal cartilages to the two canthi, for which little can be done except by medical treat- ment. 2. Ectropion from shortening of the skin, the consequence of bad cicatrices. This may effect, 1st, either lid singly according to the site ofthe cicatrix; or, 2d, it may effect both—especially if the injury be upon the temple near to or involving the outer canttms. In the variety of ectropion now under consideration, the eversion is generally very complete : sometimes when a single lid is affected, the ciliary OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 193 margin is found drawn downwards so as to be lost in the cheek, or upwards so as to occupy the position of the eyebrow. Ectro- pion of the upper lid, as will be obvious, leaves the eyeball more exposed than ectropion of the lower. If it be caused by a cicatrix on the side of the temple, the canthi maybe drawn outwards, and one or both ofthe lids at the same time more or less everted. Of the eversion of the free margin of the lids. Method of Chelius. A modification of the old operation of Celsus.—An incision is to be made through the skin along the whole breadth of the eyelid, and as near its tarsal edge as possible. The edges of the wound are to be dissected from the subjacent cellular tissue, so that all tension of the skin may be removed, and the eyelid brought into its natural position. The fibres of the orbicularis are then to be divided by several vertical incisions, and if the tumefaction ofthe conjunctiva be so great as to interfere with the replacement ofthe lid, a portion of it is to be snipped away with the scissors, and the external commissure of the eyelids slit up to the extent of some lines in a horizontal direction. Two loops of thread are then to be drawn through the skin near to the tarsal edge of the lid, and the ends secured with sticking plaster to the cheek or forehead according to the lid affected. By these means the eyelid will be kept in its proper relation with the ball. The wound of the eyelid and that of the canthus are to be covered with charpie, which is to be sustained in its position with strips of adhesive plaster. No other dressing is to be applied. This process is said by Professor Chelius, even in cases of very consi- derable shortening of the skin of the lid, to have been successful beyond expectation. If there is accompanying the deformity a considerable transverse elongation of the tarsus, the removal of a wedge-shaped portion in addition, after the plan of Dorsey, might be practised with advantage. Process of T. Wharton Jones.—The peculiarity of this plan, according to its author, consists in the following particulars. " The eyelid is to be set free by incisions in such a way, that when brought back into its natural position the gap which is left may be closed by bringing its edges together by suture, and thus ob- taining immediate union. The flap of skin embraced by the in- cisions is not separated from the subjacent bone ; but advantage being taken of the looseness of the cellular tissue between the skin and the bone, the flap is pressed downwards, and thus the eyelid is set free. The success of the operation depends very much on the looseness of the cellular tissue. For some days before the operation, therefore, the skin should be moved up and down over the frontal bone, to render the tissue more yielding." The operation was done as follows (on the upper eyelid). " Two converging incisions were made through the skin, from over the angles of the eye upwards to a point where they met, somewhat more than an inch from the adherent ciliary margin of the eyelid. By pressing down the triangular flap thus made, and cutting down all opposing bridles of cellular tissue, but without separating the flap from the subjacent parts, the eyelid was brought down nearly into its natural situation, by the mere stretching of the subjacent cellular tissue."* A piece of the everted conjunctiva is also to be snipped off, and in some instances it will be necessary to take away a piece of the tarsal cartilage, in order to bring the free edge of the lid in its proper relation with the ball. The edges of the * Cyclopedia of Practical Surgery, art. Ectropium. London, 1841. 49 gap left by the drawing down of the flap are to be closed by su- ture, and the eyelid retained in its place by adhesive strips, com- press, and bandage. This operation has been several time j repeat- ed, but with very variable results, Sanson modified it by dissecting the long V shaped flap complete- ly up to near its base. He then drew the lid at once to its pro* per position, united the two edges of the open fissure by suture, and left the flap loose, with the intention of removing at a later period all the redundant portion. Method of Dieffenbach. Employed in eversion of the lower lid. —He includes the cicatrix in an incision of a triangular shape, and dissects it away—the base of the triangle being towards the ciliary margin ofthe lid, and concentric with it; the apex directed downwards. He then extends the line of incision which forms the base of the triangle, by another short incision at each end in the form of a crescent, and directed slightly dowmwards. Two lateral portions are thus marked out on the sides of the triangle, which are to be loosened a little by dissection, brought over to- wards each other, and secured together in the middle line by four or five small twisted sutures. As they come together they press up the remains ofthe lid, to the divided skin of which they are to be attached by their upper surfaces, thus being made to supply with new skin the place ofthe old cicatrix. This method by itself has not in my hands proved satisfactory. But in some bad cases of ectropion, I have found it highly useful conjoined with the excision of the wedge-shaped piece after the manner of Dorsey.* Process of Horner.f—Professor Horner has succeeded in re- lieving a case of ectropion of the lower lid by the following operation:—the whole tarsus was permanently everted, the con- junctiva of the lid exposed nearly half an inch in breadth, and inflamed, ulcerated, and thickened. " An incision, two inches in length and down to the bone was made parallel with and at the inferior margin of the orbicularis muscle. The whole thickness of the eyelid was then dissected up from the adjoining bones. From about the middle of that incision started another, of an inch in length, downwards towards the angle of the jaw. From the termination of the latter another incision of the same length was directed towards the root of the nose. The last two incisions consequently defined an angle of integuments, which, being dis- sected up as far as its base, was then turned into the beginning of the first incision. "An almost immediate correction of the deformity ensued. Common dressings were put on, and at the end of two weeks the cure was accomplished, with the exception that the margin ofthe lid was rather loose, but still leaving the prospect of that being corrected by a natural process of shortening in due time. The patient, in fact, was so far well, that he was discharged from the wards a week or two afterwards." One or other of the above processes will answer in the major part ofthe cases of ectropion which occur from shortening ofthe in- tegument; but if there be any feature in the deformity different from the usual cases of ectropion it must be met by some exercise of ingenuity on the part of the surgeon. A fewT months since I had the son of a gentleman from Wood- * Vide Amer. Journ. of Med. Sciences for 1842. f Vide ditto, Nov., 1837, for a communication by W. E. Horner, M. D. 194 SPECIAL OPERATIONS. burv under my care, in whom an extensive burn on the outer side ofthe cheek and temple had produced not only a bad case of ec- tropion of the lower lid, but had formed in addition two promi- nent, vertical, subcutaneous bands, tightly adherent to the skin, and riding over the external canthus. After taking out a large V shaped piece at the outer border of the everted lid, I passed a blunt pointed tenotome between the skin and the bridles, so as to divide the latter completely at two different points down to the bone. This allowed the skin to lay flat on the temple, and on the closure of the V shaped wound with pins, nearly every trace of the deformity was removed. The cure effected was permanent. But in the more extensive cases of deformity, where the lid has been in a great measure destroyed, or it has been requisite to re- move it on account of lupus or cancer, if is necessary to re-construct the lid by one of the plastic processes detailed in Part Fourth of this work. It may be well to observe, that whenever we can at the same time preserve the ciliary margin of the lid and lift it up to its place so as to form with it one line for the attachment of the flap, the result of the plastic operation will be rendered much more satisfac- tory. On the lower lid, the deformity will be found more readily removed than on the upper. For in regard to the upper, though the substituted lid may serve to cover and protect the ball, it cannot ordinarily be made to play upwards and downwards, as it will want the muscular structure necessary to the execution of these movements. Eversion of the external commissure and the outer part of the lids, the consequence of a cicatrix in the region of the temple.— A different method of operation is required in this species of ectropiura. Tarsoraphy. Process of Walther.—This surgeon excised the tarsal edges of both eyelids including the commissure and a part of the neighbouring integument, in the form of a V shaped flap, the base of which was towards the eye and the apex to- ward the ear. The piece was about three-eighths of an inch broad at its base. The wound was closed with two harelip sutures. In a case of extreme deformity of this kind, I practised with entire success the following modification of this process, suggest- ed by Dieffenbach. After the removal of a large wedge-shaped piece, two semilunar incisions were carried from the cut edges of the lids—one upwards and inwards—and one downwards and inwards. The two crescentic flaps thus marked out were then raised, and after the closure of the wound in the temple, adapted as new lids to the remaining conjunctiva. 3. Ectropion from caries ofthe orbit and from tumours. In eversion occasioned by carious ulceration of the margin of . the orbit, no attempt is to be made to relieve the deformity by operation, until the cure of the bony structure has been effected. It will usually then be found necessary, in consequence of the destruction of the lid, to resort to one of the plastic processes for relief. Dr. Amnion has observed that considerable deformity is sometimes produced when but a small part of the skin is tucked in and rendered adherent to the bone. In such cases, without removing the little cicatrix, he circumscribes it by an elliptical wound and detaches the neighbouring integuments by dissection from the lines of incision so as to set the lid free, and allow it to take its proper shape. The wound is then closed over the old cicatrix. When ectropium depends upon the presence of a tumour within or below the lid, the removal of the tumour by extirpation or otherwise, is the obvious means of cure. ENTROPION, OR INVERSION OF THE EYELID. This affection involves most frequently the upper lid, is exactly the reverse of the one described under the name of ectropion, causes greater suffering than the latter, and is much more apt to be attended with an impairment of vision. The free margin of the lid is turned with its cilise inwards upon the eyeball, and from the friction the cilise exert upon it, keep it in a continual state of irri- tation. In trichiasis, the eyelashes alone are inverted upon the lid, without any morbid change of the tarsal cartilage ; but in entro- pion, the cartilage is rolled inwards to a greater or less extent in the same direction with the hairs. There are two principal forms of entropion—one depending upon a great relaxation of the skin ofthe eyelid, so that the skin, no longer reacting with the conjunctiva to hold the lid in its proper state of equilibrium, allows it to roll inwards when the mucous membrane suffers from chronic disease;—the second, upon a con- tracted and deformed state of the tarsal cartilage, the consequence more usually of ophthalmia tarsi or of protracted scrofulous or catarrhal conjunctivitis, without any preternatural laxity of the skin ofthe lid. In some cases the cartilage will be found rolled inwards at its free surface, almost into the form of a scroll. Hence, there are two principal indications for operation,—to restore the margin ofthe lid to its proper direction,—or when this cannot be accomplished, which is but very rarely the case, to destroy the bulbs from which the eyelashes—the cause of irritation —grow. 1. Entropion from relaxation of the integument. In the lighter and more recent forms of this affection, we may sometimes succeed in restoring the lid to its right direction by the use of strips of adhesive plaster, conjoined with the employ- ment of such other local remedies as the state of the lids may indicate. Use of adhesive straps.—The eyebrow having been shaved, three narrow strips of adhesive plaster are to be attached to the back of the upper lid near its tarsal margin. The lid is now to be raised and the other ends of the strips stuck upon the forehead in a divergent direction to maintain it in that position. Another strip of plaster, laid crosswise, secures the upper extremities of the three which raise the lid. The eye should be thus maintained artificially opened for the space of fifteen or twenty days, in order to give time for the establishment of a proper equilibrium between the skin and mucous membrane. The plasters will require to be reapplied every two or three days. Excision of a portion ofthe integuments ofthe lid. (PL XLIX. fig- 1.)—This is a process very commonly practised and suited to the great majority of cases. The portion removed should be of an elliptical shape, and of such a breadth, that when the edges ofthe gap are brought together, the tarsus will assume its proper direction. The breadth of the piece necessary to be removed, OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 195 depends upon the state of the parts. In some instances, it is required to be an inch in breadth ; but if a portion unnecessarily broad be taken away, ectropion might follow. Seize between the thumb and middle finger ofthe left hand, or with a pair of proper ectropion forceps, a fold of skin parallel with the margin of the lid, sufficiently large when thus grasped to bring the lid to its natural position. Having carefully ascer- tained that the fold is of proper dimensions, the operator snips it away with a pair of strong scissors. One line of the incision should come close to the palpebral border, leaving, however, a strip for the passage of sutures. The edges of the wound are to be drawn together by two or three stitches. Langenbeck removes the sutures at the end of twelve hours; Weller, after eighteen hours. Much beyond this latter period, they should never be left, as they would then have a tendency to excite a phleg- monous oedema of the lids, which might lead to ulceration. For fear of such a result, Scarpa pursued the opposite extreme, and allowed the wound to close by granulation without suture. If the latter course were to be- pursued, which the author wrould not however advise, the orbicular muscle should be kept depressed by the aid of a compress and bandage as directed by Malgaigne. Dzondi has occasionally, found it advantageous to add to this transverse excision, another made in a vertical direction. Jan- son, of Lyons, trusts to the excision of a vertical fold of skin alone, the broadest part of which should be near the palpebral margin. By cauterization. Process of Quadri.—This is particularly applicable to slight and rather recent cases, where the skin is not very redundant. The object is to effect a contraction, or at most a slight ulceration of the surface of the skin. The escharotic most frequently employed is the concentrated sulphuric acid. But either of the mineral acids, or one of the solid forms of caustic, may be made to answer. The lid is to be carefully cleansed. The eye is then to be closed. It has been advised to hold the lids closed by a narrow strip of adhesive plaster laid over their fissure, in order to prevent the introduction of any portion ofthe caustic between them. But with care on the part of the operator I have not found it necessary to use the strips. By means of a pencil of wood, a drop of the acid is to be rubbed over an oval portion of the integument, for an extent proportioned to the degree of inversion, and about a quarter of an inch in breadth at its middle. Care must be observed to keep the acid at the distance of at least the tenth of an inch from the edge of the lid. After a few seconds the eyelid is to be dried with a piece of lint, and the application of the acid repeated again and again, until a sufficient contraction of the skin is produced to restore the eyelid to its proper direction. The lid is then to be washed and dried, and the plaster removed. It may be neces- sary after a time to repeat the application of the acid. It has also been directed that the straightened cilia should be collected into little bundles, around which fine silk ligatures should be passed, and the ends fastened down upon the cheek, in order to retain the edge ofthe lid in its proper position. But this is a step not likely to be attended with much advantage. 2. Inversion from a contracted and deformed stale of the cartilage. In this variety of entropion, the tarsal cartilage is indurated and shortened as well as turned inwards, and cannot by any degree of traction be brought back to its natural position. The margin of the lid is also in common thickened and uneven, and the cilia, which are few and dwarfish, are turned inwards directly on the ball, adding to the entropion that form of disease called trichiasis. Simple section of the tarsal cartilage and lid. Process of Ware and Tyrrel.—As the transverse shortening of the tarsus is the principal cause of this deformity, Mr. Ware recommended the following operation for its relief, which Mr. Tyrrel states he has performed in many cases, including those of both lids, and in every instance with perfect success. The lid is to be drawn out from the ball and divided perpendicularly through its whole substance, either at its middle or at its temporal extremity; the middle, except in cases of partial entropion of the outer portion, being preferred. The section is immediately followed by a separation ofthe edges of the wound, forming a gap, shaped like the letter V. If the lid becomes immediately straight, nothing further is required, the wound is allowed to heal gradually by granulation, and very little deformity will result. If it should not become straight at the time, or should show subsequently a tendency to turn in, an oval portion of the integument may be removed in addition from the back ofthe lid, in the manner described above. Double vertical section of the lid. (Process of Crampton modi- fied by Guthrie. PL XLIX. fig. 3.)—One vertical incision is to be made with the bistoury or blunt-pointed scissors, through the whole substance ofthe lid, just at the outer side of the lachrymal punctum ; and the other at about the same distance from the ex- ternal canthus, in order—as regards the upper lid—to avoid the lachrymal gland. The incisions need not extend higher into the lid than necessary to divide the tarsal cartilage ; the object Of the operation being in a part to remove this from under the influence ofthe orbicular muscle. The loosened middle portion of the lid is now to be raised up; if it does not immediately become straight, it is to be nicked by a transverse incision on the side. A trans- verse fold of integument is then to be removed from the back of the piece, according to the usual process, and the edges of the incision drawn together by three silk ligatures. These are to be left long, and are drawn up—raising with them the middle loos- ened portion—and fastened to the forehead by two strips of adhe- sive plaster. To prevent union by first intention in the lines of incision, the piece is kept inverted by means of the threads for eight or ten days or until they cut out. The incisions are then allowed to heal slowly by granulation. During the time the lid is maintained in its elevated position, the ball must be protected with a fold of linen spread with cerate. This operation is a serious one, from the apparent havoc which it makes with the lid. It has, however, been praised by Mr. Guthrie as successful. Excision of the tarsal cartilage. (Process of Saunders. PL XLIX. fig. 1.)—Introduce between the lid and the ball a thin plate of horn or silver. Over this the lid is to be held tense with a pair of forceps. Divide then the integument and the orbicular muscle, just above the roots of the eyelashes, parallel with the margin of the lid, and down to the tarsal cartilage. Dissect up, so as to lay bare the orbital edge of the cartilage ; detach it from the tendon of the levator palpebral and the conjunctiva, and excise with the bistoury or scissors the part exposed, leaving only the 196 SPECIAL OPERATIONS. portion next to the palpebral margin, in which are lodged the bulbs of the cilia. The object of this operation is to diminish the vertical diameter ofthe lid, by taking from it part of the structure which serves to keep it extended ; the author of it believing that the levator would still continue its action, from its connection with the other membranes of the lid. The process, however, has usually fol- lowed by deformity, and it is now with great propriety laid aside. The amputation of the edge of the lid, and the operations for the removal or destruction of the bulbs, belong properly to the subject of trichiasis, which so frequently complicates entropion ; under that head they will be considered. TRICHIASIS AND DISTICHIASIS. Trichiasis has already been described as a vicious direction of the eyelashes inwards upon the ball of the eye, which may or may not be accompanied by an introversion of the free edge of the tarsal cartilage. It is an affection apparently of minor con- sequence ; but is in reality exceedingly painful, troublesome, and persistent, and may even lead to loss of vision, by causing struc- tural disease of the cornea. Distichiasis is often congenital, and consists in the multiplica- tion of the rows of cilia, which assume a vicious inclination on the ball. The accidental development of hair (pseudo-cilia) from some part of the raucous surface of the lids, may be considered as closely allied to the same affection. Whatever is the cause of the vicious direction of the hairs, and whether or not there is introversion of the border ofthe lid, the indication for removing them and preventing their reproduction is the same. Extraction and cauterization.—Tear out the deviated cilia one by one by a steady pull with a pair of forceps square at the point, roughly ground or grooved on their adjoining surfaces, but with- out teeth. To find the smaller hairs, which are often colourless, a leris will be required. By a repetition of this measure from time to time, the bulbs may become at length atrophied, so as to cease to develop the hair. In general, however, it will be found more certain and satisfactory to proceed at once to cauterization after the extraction ofthe deformed cilise. For this purpose, the edge of the lid is to be everted, and a small plate of horn or metal introduced between it and the ball. Some apply at once the fine point of a stick of lunar caustic, or the end of a heated needle, to the orifices left by the extracted hairs. Neither can, however, be made to act upon the bulb, which is seated at a little distance from the orifice. It is better, therefore, to open the bulb at once with the point of a lancet or iris knife, and apply the caustic to its interior, so as to destroy the secreting surface. Dr. James Hunter has recommended the introduction of powdered tartarized anti- mony, which is to be collected on the moistened end of a darning needle and carried into the sac. Extraction after incision. The lid having been raised on a thin plate as above mentioned, the operator makes two vertical inci- sions through the skin merely, a sixth of an inch in length, imme- diately above the free edge of the lid, so as to include between them the bulbs ofthe deformed cilia. The vertical cuts are to be united by a transverse incision near the edge of the lid, and the little rectangular flap dissected and turned up, so as to expose the bulbs, which are to be torn away one by one with the forceps or excised with the scissors. In case of doubt as to their complete extirpation, the seat of the bulb may in addition be touched wi:h caustic. Amputation or excision of the tarsal margin. Process of Schre- ger.—Seize and reverse with the forceps the edge of the lid, and remove a semi-elliptical portion of the edge, so as to include the diseased parts, with a pair of curved scissors or a bistoury. The loss of substance should extend only to the cutaneous border, and not involve the cartilage. M. Gerdy,* in bad cases of trichiasis with inversion of the lid, not remediable by the common treatment for entropion, has effected a complete cure in several instances by excising the whole margin of the lid affected. The excision is to be carried beyond the bulbs of the eyelashes; this will require the removal of a strip from the edge ofthe upper lid, about two lines in width, and one of about a line and a half from the lower. In cases of distichiasis, the extraction merely ofthe pseudo-cilia will usually suffice, as there is less likelihood of their being repro- duced. BLEPHAROPTOSIS. Ptosis, or falling of the eyelid. This affection consists of the fall of the upper lid in front of the eye, as in a person asleep, without the ability of the patient to raise it. The loss of power may be congenital, owing to a defect in the structure ofthe levator muscle, or in the distribution of its nerve. It may be the consequence of palsy, forming the part of a more extended paralytic affection, or depend solely upon a considerable elongation of the skin of the lid, with a weakened power of contraction in the levator muscle. In the slighter cases, where it is dependent on chronic disease of the lid, we may suc- ceed in removing it by the use of astringents, and such other topical applications as the case seems to indicate. If upon a relaxation of the integuments, the process of Quadri, or the exci- sion of an elliptical piece of skin, as directed in page 195, may be resorted to. But if the ptosis be a congenital defect, or the consequence of palsy, the process of Hunt, of Manchester, is the only one that offers much chance of relief, and which has in my own practice proved highly satisfactory.! Process of Hunt. (PL XLVL figs. 6, 7.)—This process is in- genious. Its object is to attach the superciliary border of the occipito-frontalis muscle to the skin of the lid, so as to make it perform the office of the impaired levator. The eyebrow is to be shaved, and immediately below its site a curvilinear incision made, corresponding with the direction of the orbit, and of a length equal to that of the fissure between the lids. From the ends of this another incision is to be made, convex in the oppo- site direction—towards the'free edge of the lid. The dimension of the piece of skin thus included must depend upon its state of relaxation, and will sometimes require to be more than an inch in breadth. The circumscribed integument must then be extirpated with the knife. I have occasionally removed it at a single cut * Journal de Chirurgie Pratique, Oct. 1844. f Vide Phil. Med. Examiner for 1844. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 197 with the forceps and scissors, as in the common process for entro- pion. The edges of the divided skin are next to be drawn together with three twisted or interrupted sutures. The eye will be opened by this forced elevation ofthe lid ; and after cicatriza- tion, the edge of the occipito-frontalis muscle will be found to have contracted an indirect adhesion to the lid, so as to endow the patient with a voluntary power of raising it, while the orbi- cularis oculi retains its orifice of lowering it as under ordinary circumstances. ADHESION OF THE LIDS. ANKYLOBLEPHARON. SYNBLEPHARON. The adhesion of the lids together at the palpebral fissure con* stitutes the deformity known under the name of ankyloblepharon. Synblepharon consists in the adhesion of the lids to that surface of the ball which is usually free. Either of these may be con- genital, the result of some excoriating disease, or ofthe ulceration following variola or burns. Both affections occasionally exist together. In ankyloblepharon, the union may be either direct or by the interposition of a thin membrane. It may be partial or complete. If the union is only partial, a small director may be passed beneath, and the adhesion divided with the knife or scis- sors. If complete, raise the eyelids so as to remove them from the ball, and make a puncture at the external commissure to allow the grooved director to pass, which should be bent to the form of the ball; on the director, the preternatural connection is to be divided with the knife. The lids should then be kept separate till the divided edges cicatrize, by raising the upper one with strips of adhesive plaster as described at page 194. In synblepharon, the union between the palpebral and ocular surfaces of the conjunctiva must be separated by dissection with the knife. A renewal of the adhesion is to be prevented as far as possible, by the introduction of unguents, frequent motion of the lids, and the occasional use ofthe blunt end of a probe. The acute sensibility ofthe parts forbids the permanent interposition of any foreign body. TUMOURS OF THE LIDS. There are three descriptions of tumours commonly found in the lids, requiring operation. The encysted, (by far the most common,) the cellular and the cancerous. The first twro are seated in the skin and" subjacent cellular tissue. Occasionally, however, they are observed on the surface next the conjunctiva. The other most commonly affects the whole thickness of the lid inclusive of the conjunctiva. Encysted tumours.—These are the natural follicles of the part, the cavity of which has been enlarged by disease, and distended by the accumulation of their secretions. The size to which they may attain varies from that of a large shot up to a hazel-nut. They are to be removed according to the side on which they are most prominent, either through the skin or conjunctiva. 1. Excision by the slcin.—Make a transverse incision concen- tric with the wrinkles of the lid over the tumour, extending a little beyond it on either side, but without cutting into its cavity. Separate the circumference of the tumour with the point of the knife, raise it with the forceps or hook, and detach it from its 50 inner connections. The wound is to be united by first intention. I seldom fail in effectually obliterating these sacs when small without excision, by merely pushing the point of a small bistoury through their centre, and cutting afterwards from within outward so as to make a small opening in the skin; through this the con- tents of the sac are to be pressed out and the point of a caustic pencil or the end of a probe dipped in nitric acid, introduced to destroy the secreting surface. When they are large, howrever, it is best to extirpate them. I recently removed one of the largest size from a patient of Pro- fessor Meigs, which had developed itself in the lower lid and sent up two processes, in the furca of which was lodged the tarsal cartilage; the processes were prominent on both surfaces of the lid, and rose considerably above its margin. The conjunctiva on its inner face, presented a suspicious fungus-like aspect. An attempt to dissect it out might have involved the integrity of the tarsus and a portion of the conjunctiva. I therefore split it with the bistoury on its cutaneous surface, and detached the irregular- shaped sac from its bed with a couple of pair of forceps, and a few touches with the point of the knife. The cure took place with a cicatrix so small as to be scarcely obvious. Excision by the conjunctiva.—Take hold ofthe ciliae, and evert the lid over the finger, or the side of a large probe, in which position it is to be held by an assistant. Open the conjunctiva by a transverse incision, and proceed in other respects to dissect and remove the tumour as in the process above described. Tu- mours of a similar description, and requiring excision through the skin, are frequently found, especially in children, on the temple near the outer canthus of the eye. Little tumours of a like character are occasionally developed on the tarsal cartilage, the result of disease of the Meibomian glands, forming small external swellings, often reddish coloured, on the lids. By everting the lid, the cartilage below will be found thinned and yellower than natural at the point opposite the tu- mour. It will suffice for the cure to make a puncture through the thinned cartilage into the interior ofthe sac, and irritate its cavity with the probe. Cellular tumours.— Chalasion.— Grando.—Under this name are comprised little indurated masses seated near the edge ofthe lid, the result it is said of a hordeolum or stye, which has become hardened without running into free suppuration. They produce chronic irritation ofthe lids, and often form a small abscess which opens by a fistulous orifice through the conjunctiva, at one of the borders of the tarsal cartilage. They are very analogous to the class of tumours last described, and may be cured by a similar treatment. The plan of Carron du Villards is to dilate the fistu- lous orifice with the point of a knife, and carry on a small grooved director a little lunar caustic into the interior, so as to excite sup- puration. Cancerous tumours.—These if large will require the complete excision ofthe lid, and the immediate formation of a new one by a plastic process. Cancroid tubercles of limited dimensions occa- sionally form on the lid, and admit of extirpation without destruc- tion ofthe organ. I have frequently succeeded in removing them by the application of caustics, and especially by the use of the two manageable forms known under the names of the arsenious, and the Vienna paste. In general, however, the acute sensibility 198 SPECIAL OPERATIONS. of the lid, and the risk of irritating the conjunctiva, render ex- tirpation preferable. If the tumour involve only the skin and _ subcutaneous cellular tissue, it may be removed by a simple elliptical incision, cauterizing, in addition, if it be deemed neces- sary, the bleeding surface of tbe wound. If the tumour occupy the whole thickness of the lid wdthout having much breadth, it can sometimes be completely removed by the excision of a V shaped piece of the lid, the base of which shall be towards the palpebral fissure; the divided parts of the lid being subsequently united by the twisted suture, as in the ordinary hare-lip operation. COLOBOMA PALPEBR^E. This term, though usually limited to the fissure of the iris, has been applied to a gaping cleft through one of the lids, the result of an accident by which the lid has been divided through and the edges allowed to cicatrize separately, or consisting, as has in some few cases been observed, of a congenital defect. The operation required will be precisely the same as in hare-lip—the excision of the edges, and closure by the twisted suture. EPICANTHIS. This name has been given by Von Ammon to a congenital peculiarity, which consists in the extension of a crescentic fold of skin from the side of the nose over the internal canthus of the eye, existing when met with, commonly on both sides, and giving to the countenance somewhat of the expression belonging to the Calmuck. The operation performed by Dr. Ammon for the re- moval of these folds, consists in the excision of an elliptical piece of skin over the root of the nose, and bringing the edges of the wound together by suture. The folds, however, usually disap- pear as the child's nose increases in prominence. I have observed an analogous deformity accidentally produced, as a consequence of the loss of the nasal bone by syphilis and ozcena, and have succeeded in relieving it by a similar operation. OPERATIONS PRACTISED THROUGH THE CONJUNC- TIVA. The diseases of this membrane, of which we shall treat, consist of different Fungous Excrescences, Pinguecula, Encanthis, Pannus, and Pterygium. EXCRESCENCES.—ENCANTHIS.—PINGUECULA. The excrescences of various kinds which form on the free sur- faces of the. ocular or palpebral conjunctiva, are to be laid hold of with the forceps and removed with the bistoury or scissors. As they have a strong tendency to re-development, the surface from which they are removed should be at once touched with blue stone or lunar caustic. Encanthis is the name given to a tumour formed in the mu- cous and glandular structure of the caruncula lachrymalis. It may consist merely of a simple hypertrophy of the part, or it may be a cyst, or a cancerous growth. The proper mode of treating it is by excision, and this should be practised, if possible, without doing injury to the lachrymal passages. The pinguecula is a little yellowish tumour developed over the sclerotic coat. Its nature is not well known. It seems from its colour to indicate the presence of fat, though it contains none. It is not subject to degeneration like the affections just mentioned ; but if it becomes inconvenient or unsightly from its bulk, it may be removed by excision. PTERYGIUM. Pterygium consists in the development of a vascular and mem- branous growth in the subconjunctival mucous tissue. It is tri- angular in its shape, with its apex presenting towards the cornea, over which it has a tendency to grow7, covering usually the in- sertion of one of the rectimuscles. In a hundred out of a hundred and five cases it was found by Riberi* occupying the internal can- thus. Its pathological structure is not thoroughly understood. It comes on insensibly and grows very slowly, existing sometimes for years without making any apparent advance—and seems con- fined to the middle and latter periods of life. It is connected loosely with the ball, but inseparably with the conjunctiva. It first ap- pears under the guise of a few varicose vessels in the sclerotic con- junctiva, which it slightly elevates—the vessels being directed parallel with each other towards the centre of the cornea. Pterygium has been usually described as consisting of three varieties, viz: 1. Pterygium tenue, which is thin, semi-transpa- rent, and striated with blood-vessels. 2. Pterygium crassum, which from its redness, opacity, and consistence, presents the appearance of a thin muscle. 3. Pterygium pingue, which con- sists of the little masses apparently fatty, described above under the name of pinguecula; as this does not become red, and has no tendency to spread over the cornea and interfere with vision, it cannot properly be considered as belonging to the disease under consideration. The first and second varieties are evidently mere stages of the same affection, and require no specific difference of treatment. As the pterygium, when its point reaches the cornea, becomes stationary, or advances so slow that its progress is almost imper- ceptible during a course of years, it does not require operation, except for the purpose of getting rid of the unsightliness which its presence produces. But when it threatens to advance rapidly over the cornea, or has already covered this structure so as to impair vision, its removal is more imperative. To effect this when it has resisted the use of the nitrate of silver, the wine of opium, and such other remedies as have been recommended, three processes have been employed—excision, incision and the liga- ture—the last two of which have now, however, gone out of use. Excision. (PL XLIX. fig. 4.)—Place the patient as in the operation for cataract, and lay hold of the pterygium with a good pair of rat-'.oothed strabismus forceps, at the distance of a line or two from its corneal extremity. Raise it until the little cellular bands which attach it to the cornea are felt to give wyay, when it is to be excised from its point towards its base with the bistoury or scissors. However long the pterygium may be, the excision should not extend so far back as the point of reflection of the conjunctiva from the ball to the lid, lest adhesion should follow, so as to obstruct the movements of the eyeball. The base of the * Blepharophthalmo-terapia Operativa, p. 110. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 199 pterygium may be left under such circumstances, and will disap- pear under the suppuration which follows from the wound. Scarpa's practice was indeed in all cases, to excise merely in the manner above described, the triangular point which covered the cornea, a little beyond the periphery of the latter, with the expectation that the remainder would shrink and disappear. [Deraours, after raising the pterygium, separated it from the sclerotica by passing in the lancet flatwise, detaching it first from over the cornea, and then dividing it across near its base. Riberi pinches up the pterygium, divides it across near its base with the scissors, and then dissects it in the direction of the cornea with a fine scalpel. If the portion ofthe pterygium covering the cornea be thin and transparent, it has been found sufficient to excise it up to the margin of the cornea; not detaching it above this latter structure for fear of weakening it so as to give rise to staphyloma, or pro- ducing interstitial inflammation; trusting after the extirpation of the base to the action of the absorbents for the removal of the adventitious layer left upon the cornea. PANNUS.—VARICOSE CONDITION OF THE CONJUNCTIVA.—VAS. CULAR CORNEA OF THE ENGLISH SURGEONS. Pannus consists in a state of general varicose dilatation of the vessels of the conjunctiva, with thickening of its tissue, and is the consequence of chronic inflammation of this membrane. It usually covers the whole anterior portion of the ball of the eye, including the cornea. It is found at various degrees of develop- ment, either as a thin vascular veil over the cornea, or a thick red layer obstructing vision. The vascular cornea of the English surgeons is nearly allied to the same disease, but differs from it in its primitive seat. It begins as an inflammation of the sub- stance of the cornea in which the vessels become large and vari- cose, and subsequently spreads to the conjunctiva. The treatment to be relied on in these affections at their early and middle stages is chiefly medical, in which may be included the free use of lunar caustic to the membrane, and various stimu- lating ointments. Excision.—When a fasciculus of vessels is observed feeding the pannus with blood, advantage will occasionally be derived by removing with the forceps and scissors the middle portion of its tract. It has also been advised, when the cornea is thickly covered, to extirpate a circular fold round its base. But even after this operation, the central layer will be nourished from the vessels of the cornea. For this reason, Rognetta has advised the excision ofthe pannus from over the surface of this mem- brane, as well as over about a line of the corneal margin of the sclerotic coat. But even after the performance of such operations, it is the medical treatment which is mainly to be relied on for effecting a cure. OPERATIONS ON THE BALL OF THE EYE. These consist of operations for Cataract,' Artificial Pupil, Sta- phyloma, and Strabismus. CATARACT. The term cataract is used to designate that state of the eyeball in which an opaque body, situated between the iris and the vitre- ous humour, interrupts the entrance of light so as to impair or completely obstruct vision. This constitutes true cataract. The seat of the alteration is found either in the lens alone, forming lenticu- lar cataract—in the capsule alone, forming capsular cataract; or involving at the same time both lens and capsule, constituting the capsulo-lenticular cataract.* These form the three generic divisions of this affection. An effusion of opaque lymph in front of and in contact with the capsule, which has become organized like an ordinary false mem- brane without diseasing permanently the tissue upon which it is seated, is denominated adventitious or spurious cataract—a term which it is useful to retain, as a specific operation may sometimes be successfully practised for the removal of this adventitious body. The term of false or spurious cataract has, however, by many writers been very loosely and improperly applied to any acci- dental collection of pus, or blood, or lymph, within the anterior chamber. Under the term of congenital cataract is included that form of true cataract which makes its appearance at birth or a few months after—a term of which it is also important to preserve the use, as the existence of the affection at this early period influences con- siderably the general principles of treatment. Another division useful to retain in practice is that of secondary cataract, which consists in the opacity of some portion of the cap- sule developed subsequently to an operation on the lens. 1. Lenticular caturacts. These constitute the most common form of the disease, and as they vary greatly in their degree of consistence, have been divid- ed into the hard, the soft, the mixed, and the fluid. The hard cataract is met with in common only in advanced life—the lens is diminished in size, flat on its anterior surface, and convex behind. It is usually of a steel-gray colour, and has sometimes been observed of a yellowish-brown or black. The opacity begins in the centre, is slow, even years in attaining such a size as to destroy vision. There is a faint amber-coloured appearance of the lens common to old persons that interferes little or not at all with vision, which has been most unfortunately often mistaken for cataract, especially when it has been attended by an impaired state of vision from other causes. The hard cataract appears as if it had shrunk away from the iris, the margin of which, when the pupil is dilated, throws a shade upon it. The soft or caseous cataract is large, and frequently comes in contact with the iris so as to bulge forwards its pupillary margin, and interfere with its play. There is then no shade thrown by the iris on the lens, but on the contrary the edge of the iris is a little everted so as to show in the form of a ring the black border of its pupillary orifice. These cataracts are usually of a milky, a light or a bluish-gray colour, often streaked or cloudy, and are found chiefly in early and middle life. When the cataract is swollen much above its natural size, it often gaps open in front, * Many writers admit the liquor Morgagni as another seat of cataract, which they suppose to become opaque. But I believe there is no such fluid in the healthy state between the lens and its capsule. 200 SPECIAL OPERATIONS. forming three fissures, which pass from its central point to the circumference like rays. This variety is distinguished as the dehiscent or gaping cataract. .Mixed lenticular cataract.—This is denominated the demi-hard, or demi-soft, by Sichel, according to the degree of its consistence. The central nucleus is found round and hard, while the outer por- tion of the lens is of a tenacious, jelly-like consistence. The colour of this variety corresponds with the soft—its size is intermediate between the hard and the soft. It is difficult in many cases to distinguish this variety satisfactorily before the needle.is brought in contact with the lens. In my own practice, I have several times observed the dehiscence to accompany this form of cataract. Fluid cataract.—This is rarely if ever a primitive form of the disease, and appears to be the result of a loss of consistence in the structure of the soft cataract. Its colour is grayish, whitish, or yellowish, and the lens looks like a sac filled with thick gruel, cream or pus. The capsule will often be found bagged out a little at its lower border, and on shaking the head, little opaque par- ticles may occasionally be seen floating through the fluid. Though the soft and liquid cataract is usually confined to persons below the middle period of life, including infants, and constituting the congenital form of the disease, it is nevertheless occasionally met with in advanced age. 2. Of capsular or membranous cataract. This is found in individuals of all ages, and forms rapidly when the consequence of wound or inflammation. It is usually seated on the anterior half of the capsule which invests the lens. Here it is easily recognized, whether it involves, as is common, a part merely, or the whole face of the capsule. When partial only, it will form a whitish disk, if at the margin; a pearly spot, if in the centre; if it spread more generally over the lens, brilliant white striae, which appear under various forms, and have given it differ- ent appellations, as arborescent, marbled, etc. When it covers the whole surface, it has a glistening grayish aspect, and is usu- ally marked with stria?; if not distinguished by these marks, it is in general difficult to discriminate between it and the hard steel- coloured lenticular cataract. The opaque surface will, however, always be found more in contact with the iris than in cases of hard cataract. Opacity of the posterior half of the capsule is rarely met with as a separate affection. When the fluid lenticular cata- ract has been removed spontaneously by absorption, as is some- times though rarely observed in childhood, or in consequence of an operation upon it in its soft or fluid state in which the capsule has been but imperfectly divided, the anterior and posterior por- tions of the capsule are liable to become opaque, thickened, shriv- eled, and adherent together, so as to constitute the secondary cataract, which will be found tough and parchment-like when touched with the instrument. 3. Capsulo-lenticular cataract. Whenever the whole anterior surface of the capsule has become opaque, the lens behind it, according to the observations of Weller, will be found more or less in the same condition. In very many cases, the lens will also be found opaque when the capsule is but partially affected. This form of cataract is very common to all ages of life, and especially when the affection has been developed as a consequence of inflammation ofthe membrane ofthe aqueous humour, or of disease of the iris. The texture of the lens may be found in any of the various conditions above described. Remarks. 1. Age of the patient.—The operation for the removal of cata- ract may be performed successfully at any age ; but as a general rule the restoration of vision will be found the more perfect the younger the subject. It has been proved by dissection that the place ofthe lens will be partially supplied by a central prominence of the vitreous humour, the amount of this fluid being after the destruction ofthe lens increased in bulk—a change which may be expected to take place more readily in young than old subjects. The operation has, however, many times been successful at the age of eighty—one instance of which has occurred in my own practice. In congenital cataract it is of the utmost importance that the operation should be done early, and at least within the second year. According to Middlemore, it should be practised between the sixth and eighth months; and Mr. Lawrence has operated so early as between the first and second. Tbe principal reasons which render an early operation proper, are, the tendency of the capsule to become tough and flexible, either with or without absorption of the lens, so as to be not easily cut up; and that of the irregular action of the muscles to bring on a state of oscillation of the ball, which is not afterwards easily corrected, even when, by the destruction of the cataract, the entrance of light gives a fixed point for the direction ofthe eye. Saunders found the ope- ration in cases of congenital cataract, at the age of fifteen, only partially successful. 2. Season of the year.—It was formerly the practice among surgeons to defer operations for cataract to the temperate periods of the year.—spring and autumn. Any portion ofthe year, how- ever, when the weather is fine, except at periods of extreme heat, is found equally to answer. 3. Maturation of the cataract.—The older surgeons dwelt much on the necessity of waiting for what is called the ripening or maturation of the cataract before proceeding to operate. By this they meant till it should become sufficiently hard to suffer couching or extraction without breaking up. But if we modify the meaning so as to understand a postponement till all inflam- matory symptoms have subsided, when such have been the cause of the affection, or have been accidentally developed during its course, the injunction is still one of the. highest moment. Every cataract, when it interrupts all useful vision, is in truth to be considered ripe and fitted for operation, unless there exists some specific counter-indication. 4. As one or both eyes are affected.—It has long been a rule among ophthalmologists, not to operate for cataract of one eye while vision remained perfect in the other, lest the latter should sympathetically suffer, so as to have its powers impaired ; believing even if the operation should be most successful on the affected organ, that the two eyes would be left with unequal powers of refraction. This maxim is still to be considered the only proper general rule of conduct. But it must be recollected that it had its birth at a time when couching and extraction were the only methods of operation known—the safer and less perturbating manipulation with the needle for the cure by absorption, being of OPERATIONS ON THE later invention. We frequently meet with cases of single cataract in young persons of both sexes, in whom the removal of so conspi- cuous a deformity is strenuously desired, and where the operation is perfectly justifiable. In my own practice I prefer in such cases to operate early—as soon indeed as the cataract obstructs the sight and becomes a visible defect, as it will then in general be found less tough and resisting than at a later period, limiting myself to the method by absorption, the operation for which, in the hands of any one familiar with the structure, and skilled in the treatment ofthe diseases of the eye, should not be attended with suffering or danger. The inconvenience arising from the difference of refracting power is of but little moment, the best eye being the one that will be employed in vision, as in the cases in which this difference naturally exists ;—or, if necessary, glasses of a suitable description could be worn, tbe use of which would even be pre- ferred to the retention of the defect arising from the cataract. When, after complete cataract has existed in one eye, the symp- toms of its appearance are manifested in the other, it has been recommended (J. Bell, Stevenson, Scarpa, Weller, Himly, Tra- vers, etc.), to operate early upon the one already formed, not only for the purpose of getting rid of a positive defect, but of arresting the cataractous affection in the other. The author has operated several times under such circumstances, and in two instances with the result apparently of checking the progress of the affection in the better eye. But as such a result cannot with any positive certainty be relied on, the practice is not warrantable unless the state of the cataractous eye is such as to present the usual chances of success in the operation When double cataract exists, it is a question yet undetermined whether it is better to operate on both eyes at the same sitting, or only one, deferring that of the other to a later period, when all the disturbance arising from the first shall have completely subsided. The latter plan is attended often with an inconvenient loss of time on the part of the patient, pro- tracted anxiety, a double amount of seclusion and medical treat- ment, and exposes, at the operation upon the second eye, at least to as great a degree, that of the opposite side to the risk of sym- pathetic injury. It is, however, the practice advised by Physick, Dupuytren, Lawrence, and others, and becomes an obligatory rule when the operation is rendered more difficult and disturbing, from preternatural adhesions of the iris or the peculiar state of the ball, or when there is any infirmity of the constitution. Under other circumstances I follow the example of Beer, Sichel, Vidal, Mackenzie, and others, and operate on both organs at the same sitting, it being understood that the removal is effected by couch- ing or the process by solution : double extraction, though practised usually by Roux, unquestionably exposing the eyes to greater risk of destruction by inflammation. By this plan I have had good success in both eyes, and with little if any additional pain or inflammation. The only instance within my recollection in which any sinister consequences have occurred in my practice at all at- tributable to the double operation, was that of an elderly gentle- man of Salem, in North Carolina, who suffered on the following day with obstinate sickness and vomiting after I had couched both lenses. Such a result, however, often follows the couching of a sulgle lens ; and in this case the recovery was perfect and rapid in both eyes, and without any other untoward symptom. The propriety of the single or double operation must, however, 51 BALL OF THE EYE. 201 be determined in reference to individual cases as they come before the practitioner ; but as a rule applied generally, it would be the part of prudence to act only on one eye at a time. 2. Previous preparation.—If the patient is in good health and of temperate habits, no previous preparation will be required, except rest, if he has taken a fatiguing journey, farther than mode- rate diet for a short time previously, and some cathartic medi- cine on the day before the operation. If there be derangement of the digestive organs, any inflammatory tendency, or any serious implication of the health, they must be removed by appropriate remedies. Mr. Middlemore recommended the insertion of an issue in one or both arms before operating by extraction on a gouty subject. OPERATIONS FOR THE REMOVAL OF CATARACT. These are of three kinds :—1. Those having for their object the depression ofthe cataract below the axis ofthe vision. 2. Those for its removal by solution and absorption. 3. Those for its ex- traction. No one of these operations can by any general rule be adapted for all cases, and it is requisite for the surgeon to render himself familiar with all, to be adequate to the thorough manage- ment of this affection. Each one, it will be shown, has its ad* vantages and its objections ; and the selection of the process made should depend on the nature of the case. The order in regard to frequency in which they are in this country employed, will be that of the second, first, and third, in the above classification. The success of this delicate operation, it must be remembered, will depend, more than in most other affections, on the dexterity with which it is accomplished, and the skill of the surgeon in preventing or subduing the inflammation ofthe organ. 1. Of Depression, Couching, or Displacement, including Reversion and Reclination. There are three distinct varieties of this method, which differ from each other chiefly in regard to the place at which the instru- ment is introduced for the performance of the operation, viz: 1. Sclerotonyxis, or the posterior operation, in which the needle is inserted through the sclerotica near its anterior edge. 2. Kera- tonyxis, or the anterior operation, when it passes through the cornea ; and 3. Hyalonyxis, in which the puncture is made farther back through the sclerotic coat, and through the anterior portion of the vitreous humour. They are all commonly executed with a needle. This instrument has been extensively modified as to shape and dimensions, according to the will or caprice of different surgeons, so that more than seventy different varieties may be enumerated, of which however but a very few have received the sanction of general use. Those generally deemed most appropri- ate will be noticed in connection with each mode of operation. In each ofthe three methods of depression, the operation consists alike of four separate manoeuvres. 1. The introduction of the needle. 2. The placing of its point between the lens and iris. 3. Its action on the lens and its capsule; and 4. Ofits withdrawal from the eye. Position.—The position of the patient and the operator in all operations for cataract is nearly the same. The patient may be seated on a low chair or music stool, while the operator, occupy 802 SPECIAL OPERATIONS. ing one somewhat higher, is placed directly in front, so that he may retain between his own the knees of the patient. One foot of the operator may, according to the direction of Scarpa, be rested on a stool so as to raise the knee, in order, that it may serve as a rest to the elbow of the same side with the hand that holds the needle. This is the position recommended by the greater number of surgeons who operate much on the eye. It is the one which I have found most satisfactory, as it seems to leave the movements of the hand more free, and gives a better sense of the direction in which the lens is to be pressed. It is necessary, however, in order to act on both eyes by this plan, that the surgeon should have practise'd with both hands on the dead body, so as to be completely ambidexter. Many surgeons, however, of great dis- tinction, prefer the patient in all cases to be placed in the hori- zontal posture, with the head and shoulders elevated, shifting their own position so as to act with the right hand on the eye of either side. Others preserve the use of the right hand, by acting on the left eye in the sitting, and on the right eye in the recum- bent posture, placing themselves for the latter purpose behind the head of the patient. PLATE XLVn.—CATARACT. OPERATIONS BY DEPRESSION AND DIVISION, DEPRESSION OR COUCHING. Fig. 1.—Introduction of the needle. The upper lid is raised by the fingers of an assistant, and the lower depressed by those ofthe surgeon. A slight pressure from the pulpy extremities of the fingers, serves at the same time to fix the ball. The needle of Scarpa, held as a writing pen, is presented in the direction of the lens, (a, b, fig. 5,) so that the curve near the point shall pass perpendicularly through the sclerotic coat as seen in the drawing. If a needle of a less curve than Scarpa's is used, and which is greatly preferred by the author, the direction of the handle should of course be more horizontal. The place of puncture, according to the author's views, is represented a little too far behind the cornea. Fig. 2.—Division of the capsule. The needle, with the convex surface of the curve in front, is seen gliding between the front surface of the capsule and the posterior face of the iris, in the direction of the line c, d, (fig. 5,) so as to get at the centre of the pupil, which has been previously dilated with belladonna. The point, which is turned toward the lens, now. begins the section of the capsule. Fig. 3.—The needle is here shown resting at the top ofthe lens in the direction ofthe line e,f, (fig. 5,) after it has completed tbe division of the capsule. Figs. 4, 6.—Depression or couching of the cataract. In fig. 6, the act of depression is shown at its commencement. The concavity ofthe curve of the needle rests on the top ofthe lens, the handle is slightly raised from its position seen in fig. 3, and the point is seen descending carrying the lens before it. In fig. 4, the depression is seen completed, the handle has been raised to the direction of the lineg-, h, (fig. 5,) and the lens has been carried down out of view before the point, rendering the pupil clear. Fig. 5.—Outline drawing, showing the changes of direction in the needle above mentioned. Fig. 7.—Reclination or reversion of the lens. After the introduction of the needle, and the division of the capsule as above described, the needle, with its curve resting on the anterior surface of the lens above its middle, is seen reversing the lens, so as to make its anterior surface present upward, and its inferior margin in front. By continuing the elevation of the hand, the lens will be couched in this position. Fig. 8.—Side view of a vertical section ofthe eye, showing the same position ofthe needle in reclination as seen in fig. 7. DIVISION AND SOLUTION. Fig. 9.—Division. The delicate, sharp-pointed needle, double-edged near the point, described in the text, is represented as seen in one of the operations of the author for soft cataract. The needle has been introduced somewhat nearer the anterior margin of the sclerotic coat than in the preceding operations for depression, in order that it may act better on the face of the lens. The same place of puncture as here shown, is also chosen by many surgeons in the operation for depression. The surface of the lens has been freely divided with delicate strokes of the needle, and a few of the fragments pushed forwards into the anterior chamber. The fragments are represented lower in the anterior chamber than their actual position at the close ofthe operation, in order to leave the broken surface ofthe lens exposed to view. P/atv 47. /<-,# / P'te/ 6' ,Ju Stone by let ' .J". Phtt^./elpkui PnhltsheJ l>f C^rx., 4 Hart PS l)<,v«l.l.iM.PI,,l-* OPERATIONS ON TH The pupil should be previously well dilated with belladonna, the extract having been smeared as a paste round the brow or temple, or a few drops of a strained solution of twenty grains of the extract to half an ounce of water, introduced between the lids some hours before the period of operation. The dilatation of the pupil will serve to diminish the risk of wounding the iris, and show more clearly the progress of the point of the needle. Closing the other eye.—The eye of the opposite side should be closed with a compress and broad ribbon, or a handkerchief folded as a cravat, or with a few small strips of adhesive plaster above the lids in the manner of Professor Quadri, of Naples. Some, however, prefer to leave it uncovered altogether, as they believe by the patient directing it steadily forward, it may be made the means of keeping the one to be operated on more com- pletely in the proper direction. In children and timid persons, it is much better, however, that the opposite eye should be closed, and especially if it be capable of vision. Light.—The patient is to be so placed that the light will fall obliquely on the cornea; that of the north side of a room is to be preferred when it can be conveniently obtained, and the best way of admitting it is by a window, of which the lower half is closed. Sclerotonyxis.—Posterior operation. (Process usually employed. PL XLVII.)—The instrument usually preferred in this posterior operation for the couching or reclination. of the lens, is the lance- headed needle of Scarpa, curved at the point to the extent of about a fifth of an inch. It has been variously modified, the curve at the end for the purpose of embracing the lens being retained as the essential part of its construction. The shaft of Scarpa's instrument is made somewhat conical, in order to fill up the puncture in the sclerotica, and prevent the exit of any globules of vitreous humour from the cells divided in the operation. But the escape of a small portion of this humour from cells already lacerated, or even a somewhat larger amount, as might happen if the vitreous humour was unusually fluid, has been fairly proved to be a matter of little moment. In my own practice I give a decided preference to a needle of Scarpa's form, but of smaller dimensions, modified by taking away the crest on the concave surface of the curve, as in the manner of Dupuytren, perfectly sharp at the point and sides, and with a stalk slender and entirely cylindrical, as in the needle of Sichel. An instrument of this description will not become bound in the orifice ofthe rigid scle- rotic coat, like one of a conical shaft. It admits of the point being freely moved in all directions without producing pressure upon the punctured sclerotic and choroid tunics; is sufficiently strong for all purposes, as no force whatever is to be employed, and is seldom followed by any discharge of the vitreous humour. The straight spear-pointed needle somewhat reduced in size, cutting on. both edges near the point, is one also frequently employed, and answers an excellent purpose. It is occasionally even to be pre- ferred, when on inspection of the lens through the cornea, the operator cannot be certain of its consistence—whether it will be found so soft as to admit of being cut up for the cure by solution, which can be rather more readily done with a straight than curved needle—or so hard as to require to be couched, which may be done with either. The surgeon and patient are placed as above directed. An assistant sustains the head of the patient in a position a little BALL OF THE EYE. 203 oblique upwards and backwards, and raises the upper lid with the two fore fingers Of one hand, placing their pulpy extremities on the ciliary border, so as to be able at will, after the elevation of the lids, by a little downward pressure, to restrain the movement of the ball. But when the' patient is indocile, or there is spasm of the lids, the assistant may instead employ an elevator or spe- culum to raise the lid. The surgeon, with the same fingers of one hand, depresses the lower lid in a similar manner; and with the other hand, in which the needle is held between the thumb and two first fingers like a writing pen, he gets a point of support by resting the little finger, slightly curved, on the cheek bone. The patient is now directed to look towards the nose ; and it will be well to touch the front of the cornea with the curved back of the needle, in order to relieve the patient of the first sensation of fright at the contact of the instrument. The operator, holding the needle with the convex portion of the curve upwards, the cutting edges presenting front and back, directs the point upon the sclerotic coat, about the sixth of an inch behind the cornea, in the horizontal diameter of the ball, and with the handle ofthe instrument inclined downwards, so that the curved end shall enter perpendicularly (figs. 5, 6) at this point; the eye being at the same moment, fixed by a little pressure with the fingers of the surgeon and assistant, which should act in unison. The puncture should be made with gentle but steady pressure, the needle being directed as if it were to go behind the lens, in order to avoid wounding the ciliary processes of the choroid, which lie a little in front of the place of entry.* As soon as the curve has penetrated, the needle is to be rolled to the extent of a quarter of a circle between the thumb and finger, so as to present its convex portion forward, as indicated by the black spot placed for this pufpo'se on the handle; and at the same time the handle is to be raised to the horizontal position without the little finger leaving its place of support. The handle is next to be inclined a little backward without advancing the point, when the iris, especially if the pupil do not remain well dilated, will be bulged slightly forward by the convex portion of the curve. The needle is now to be passed on between the iris and the anterior portion of the cataract till the point shows itself * It has been directed by Mr. Tyrrel and others, to make the puncture the six- teenth of an inch only behind the cornea; but this will render the choroid pro- cesses more liable to injury, a result which is supposed to be the cause of the obstinate sickness and Vomiting that are apt to follow.depression. Scarpa, in making the puncture of the tunics, directs the needle to be held with the handle inclined to the temple, and the cutting edges vertical. In this position of the in- strument, there is much greater risk of dividing the long ciliary nerve or artery, and we might as a consequence see the anterior chamber filled with blood durin» theoperation. This, it is desirable to avoid, though when such an accident has occurred, the blood has usually been removed by absorption without injury following. Much difference of opinion exists as to whether the puncture should be made in the equator of the eyeball or at a half line above or below it, in order to avoid more surely the ciliary vessels. The more common direction is to make it just below the equator. Mr. Mackenzie and Mr. Wharton Jones have deemed it important that it should be made in the equator. It has been well known since the publication of Zinn's plates of the eye, that the long ciliary artery divides into two forking branches at the distance of two and a half to three tines from the cornea. The question, therefore, may be thus solved: if the "puncture be made near the cornea it may be made in the equator, though there is usually breadth sufficient between the forks to admit of the puncture half a line lower. At the distance of two and a half to three lines back, which is advis?d by some operators, the lower puncture is preferable. 204 SPECIAL OPERATIONS. in the pupil (fig. 2.) Then, by several slight movements with the point, the operator incises the capsule—first, at its internal semi- circumference, then across its middle—with an ascending and descending cut in the shape of the letter A, finishing by a divi- sion ofthe external circumference ofthe membrane, so as to form the letter N ; lowering the handle at this last step and raising the point so as to leave the concave part of the curve resting on the upper margin of the lens.* The handle is now to be lightly raised upwards, forwards and inwards, so as to stand at an angle of 45 degrees, without attempting to make any stress with the point. By this elevation of the handle merely, the point will descend, sinking the lens before it till both disappear behind the lower margin of the pupil; the lens being carried downwards and slightly backwards and outwards, so as to be lodged in the vitre- ous humour, (figs. 4, 6.) The lens is now couched, or displaced, and is to be held with the needle in this situation for twenty or thirty seconds to allow the vitreous humour to close around it and prevent its rising. The needle is then to be gently disengaged from the lens by slightly rolling it between the thumb and finger; tbe handle is next to be raised to the horizontal position. If the lens should be found to rise, it is to be depressed anew, (but without force, for fear of doing violence to the delicate retinal membrane,) and held for a little longer period in that position. The needle is now to be withdrawn, reversing the position in which it was entered—the convex portion being turned first towards the iris—then so as to present upwards—and the handle depressed as the curve leaves the sclerotic coat. The operation, though long in the description, is quickly performed. It must, however, be done without the least haste or nervousness. As ther lens descends, the pupil becomes clear, and if the retina be in a healthy condition, vision is instantaneously restored. The eye is not, however, to be immediately used. It should be carefully covered, or, which is better, the patient confined to a dark room. The diet must be restricted, and belladonna extract freely applied around the temple and orbit,to keep the pupil dilated and prevent any adventitious adhesions. If retinal or iritic inflammation fol- low, the antiphlogistic treatment must be freely carried out com- bined with the internal administration of calomel and opium. Remarks.—1. Some operators neglect altogether the previous division of the capsule. If it should be couched along with the lens, an occurrence which i§ not to be relied on, all might be well, though it would diminish greatly the chance of the subsequent absorption of the lens. If it should be left without being well broken up, it is exceedingly prone to become opaque and form a secondary membranous cataract, more difficult to get rid of than the primitive affection. Others follow the directions of Scarpa, first couching the lens, and then bringing the needle back so as to break away the capsule behind the pupil. But when the capsule is transparent, it cannot be well seen after the lens has been dis- placed and the point of the needle is liable by doing injury to the neighbouring parts, to increase the subsequent irritation. When cut up, as in the process described, the capsule, though • With the cylindrical needle, which moves freely in the sclerotic wound, I find it much more simple and easy to follow the practice of Sichel;—make a few Blight horizontal incisions with a sawing motion, and cross them once or twice in the opposite direction. With the conical shaft of the ordinary needle, it is better to follow the direction in the text. it does not in general become absorbed, rolls up towards its outer margin and shrinks away so as to be of no future incon- venience. 2. If the cataract should prove of the fluid kind, its liquid contents will escape on the first incision of the capsule into the anterior chamber; if the capsule should not be wholly obscured, it may still be further divided before the instrument is withdrawn— but if it should be hidden by the turbid humour, no movements of the point should be made at random, for fear of wounding the iris—it being much better to resort to a future operation for its removal if any should be needed. In several instances, however, of this description, I have found a perfect cure to follow a single semicircular cut upon the capsule. The posterior part of the cap- sule is so thin and delicate, that it is not apt to give rise to any inconvenience, unless uselessly lacerated with the needle, and it need not, except it be opaque, be interfered with. If the cata- ractous leris should be hard at the centre and soft at the circum- ference, I have several times found it advantageous to cut up the anterior soft portion, push the fragments gently into the anterior chamber, and couch the central nucleus. If it should prove alto- gether friable, the attempt at depression should be abandoned, and the cure trusted to the ordinary process by division and solu- tion. In passing the needle between the iris and lens, great care must be observed, in sweeping the curve forwards, not to spit or trans- fix the latter, which might be prematurely unseated should this happen". At all events it would serve to embarrass the movement of the instrument, "unless the accident was discovered, and the needle slightly retracted and correctly passed. This transfixion is not likely to occur unless the cataract is large, so as to render the space for the passage of the needle unusually narrow, and when suoh is the case the ciliary processes are likewise much more liable to be injured. In this state of the parts, which may be determined by careful inspection beforehand, when I use the curved needle with the expectation of couching, I adopt the precau- tion in passing the "curve forwards recommended by Mackenzie and others, that is, to raise or lower the handle so as to gain room by letting the point sweep over a more distant portion ofthe circum- ference of the lens. When the right hand is used I find it more convenient to raise the handle and carry the point below—when the left, to depress it and carry the point of the needle above. To avoid this transfixion, Mr. Mackenzie directs the needle to be passed to the centre of the posterior surface of the lens, and as the depth to which the instrument penetrates cannot be seen, he has the proper distance for insertion marked by a groove upon the needle. Then raising it to the top of the lens he divides verti- cally the posterior part of the capsule, and proceeds to act on the anterior,* by carrying the instrument underneath the lens to its front surface. But the directions for the division of the posterior part of the capsule appear to me less judicious than those given in most other instances by this experienced practitioner. 3. In case the lens should be dislodged and escape through the pupil, the operator may, in imitation ofthe practice of Dupuytren and Lusardi, follow it with the needle, replace and couch it, or, which is generally to be preferred, especially if the lens has been found hard, and therefore more likely after couching to irritate the * Treatise, page 672. OPERATIONS ON THE retina, to leave it for the moment in the interior chamber; then allowing a little time to elapse, so that the pupil may contract, and thus diminish the probability of escape of the vitreous humour, cut down upon it through the cornea as in extraction, and remove it by a small opening. 4. If the cataract be ofthe capsulo-lenticular kind, the capsule cannot readily be cut up with the needle without doing some violence to the eye, and it is better then to couch both it and the lens in one mass together. Under these circumstances it will be necessary to retain the cataract a few seconds longer than usual, and disengage the needle from it with much caution. For it is in these cases that the cataract is particularly prone to rise after couching, in consequence of its still retaining unbroken some shreds of its old means of attachment. 5. If any adhesions exist between the posterior surface of the iris and the capsule, the margin of the pupil will be deformed by the attempt to couch. If the adhesions do not readily give way, it will be necessary to divide them cautiously with the edge of the needle before depressing the lens, for fear that the traction which they would make on the iris might detach it at its outer margin. 6. Reclination. (PL XLVII. fig. 7.)—This is effected by pres- sure with the needle on the top part of the lens, so as to reverse it, making its anterior surface present directly upwards, and then proceeding to couch it flatwise below the lower edge ofthe pupil. It is difficult, however, to prevent its re-ascent without doing ex- tensive injury to the vitreous humour. This mode of couching is, therefore, but seldom practised. It may, however, be found of useful application, when the lens continues to rise after depres- sion by the usual method. For if it should, after being reclined, afterwards float up in the axis of vision, its narrow edge will pre- sent forwards, allowing the rays of light to pass by on its upper surface. In attempting to reverse the lens, however, it will sometimes be found to revolve on its axis ; in such instances the lens should be merely depressed in the usual manner. Keratonyxis.—Anterior operation.—Depression and reclination through the cornea.—It is quite easy to effect the reclination and partial displacement of the lens by a needle introduced through the cornea; the complete depression or couching of the lens is accomplished with more difficulty, and is apt to be accompanied by injurious pressure with the instrument upon the lower border of the iris. The wound of the cornea left, has also been frequently followed with opacity. The operation of depression can, there- fore, in almost all instances, be more safely and successfully accomplished by puncture through the sclerotic coat. The ante- rior operation has, however, been advised in cases where the eye is small, deeply sunken, and unsteady. A needle curved near the point like that of Scarpa, but more delicate in its structure, will in general be found best suited to this operation. Langen- beck, Walther, and other German surgeons, employ one with a greater curve. Sichel gives the preference to a needle of which the head is bent at an angle with the shaft. The needle, with its point presented perpendicularly, is to be introduced through the lower part of the cornea at the distance of about a line from it's margin, the concave side turned upwards and the convex downwards. It is then to be pushed onward to the cataract through the pupil, which should be previously dilated. 52 , BALL OF THE EYE. 205 After lacerating the capsule, the hollow part of the curve of the needle is to be rested on the top of the lens, somewhat to the inner side of the middle line. By raising the handle the lens is then carried downwards and outwards, and imbedded in the vitre- ous humour. In this position it should be held for a few seconds before the needle is withdrawn. The operation may also be accomplished by puncture either at the upper or outer portion of the cornea, and in case there be any existing opacity, it will be better to select that as the point for the introduction of the needle. Hyalonyxis*—or puncture through the vitreous humour.—This process differs but little from that of sclerotonyxis, except in the introduction of the needle, which is passed either through the sclerotic coat at the distance of two lines and a half behind the cornea—or at the usual place, giving the instrument in the latter case a more backward direction, so that it may be carried through the vitreous humour in a way to avoid all chance of wounding the iris or choroid processes, and be made to act upon the back part of the cataract, somewhat as in the operation of Mr. Mackenzie de- scribed in the preceding page. It has been praised by a traveling English oculist of the name of Bowen, as a successful method of couching secondary or membranous cataract, which may by this process be lodged so deeply in the vitreous humour as to prevent its tendency to re-ascend—a difficulty encountered in its displace- ment by the ordinary operation through the anterior margin of the sclerotic coat. Travers also accorded to it a decided preference in the operation for congenital cataract. Bretonneau and others have likewise employed it as a means of couching in lenticular cata- ract, making with the needle a previous downward incision ofthe hyaloid tissue, in which they lodged the lens in order to keep it from contact with the iris and choroid coat, and effectually pre- vent its rising. If the needle be entered far back, it necessitates, however, a puncture of the anterior end of the retina, which cannot be wholly free from the risk of evil consequences. The method has not been much employed, and scarcely deserves its peculiar name. The edge of the vitreous humour is nearly always punctured in the ordinary posterior operation, or sclero- tonyxis, which for that reason has likewise by some been deno- minated hyalonyxis, so as to lead to confusion in terms. Second method. Removal of cataract by its division into fragments, which sub- sequently disappear either by solution in the aqueous humour, or by absorption.—This is of all others the mode of operation most fre- quently practised; the one which inflicts the least injury upon the eye, it being sometimes unattended with the slightest irritation; may be safely repeated from time to time if it be necessary, and is on the whole to be considered the most successful. To cases of hard cataract, or long-standing capsular, whether primary or secondary, it is not however suited; but in ordinary congenital cataract, in that of young persons following injury, and in all the great majority of cases in which the cataract is soft or fluid, it is decidedly the most appropriate. It is not, however, always the one most immediately satisfactory to the patient, who is anxious at once to experience the benefit ofthe operation. The period at * From huahs—glass (the vitreous humour being so termed from its trans- parent appearance), and nusso—I pierce. 206 SPECIAL OPERATIONS. which the cure is obtained must depend much on the state of the lens. If this be fluid, it may be perfect in the course of a week. If it be consistent and gelatinous, several weeks or months even may elapse before vision is restored, though it may be'perfect in the end. It is not necessary, however, in these protracted cases, to wait the result of a single operation, as the process of division when properly performed may if necessary be several times re- peated, and almost with impunity, at intervals of two, three, or four weeks. It has even been observed that a sort of tolerance ofthe eye to succeeding operations becomes established, provided these are not repeated until all irritation following a previous one has disappeared. The younger the subject the more rapid in general will the process of solution be found to go on. The object of the operation is to open freely the anterior part of the capsule and expose the lens to the action of the aqueous humour, the lens being itself divided into fragments, or, in the language of Sir C. Bell, puddled or converted into a paste. If it be of such a consistence as to break into fragments, these are to be passed with the needle through the pupil into the anterior chamber, where the process of solution will be more readily effected. The operation may be performed either by the intro- duction of a needle, as by the anterior operation, through the cornea—or by the posterior, through the sclerotic coat. The posterior operation is the one most generally preferred, as better admittingthefree division ofthe lens and the dislodgement ofthe fragments. It exposes the iris quite as little to injury, and is not liable to be attended by the opacity of the cornea and the inflammation of the membrane of aqueous humour that some- times follows the puncture through the cornea. In either opera- tion the pupil must be previously well dilated with belladonna, stramonium, or hyoscyamus. If the curved needle is used for the posterior operation, it is to be introduced in front of the lens, precisely in all respects as directed at page 203. The subsequent manipulation is different; instead of attempting to couch or recline the lens, we merely, after lacerating the capsule, divide it into fragments by several horizontal and some vertical or oblique movements of the point, pushing at the conclusion the fragments a little forward with the curve of the needle. In common with many other practitioners, I decidedly prefer for this operation a slender, straight needle, flattened and lancet- shaped near the point, and with a sharp cutting edge extending back on each side for the sixth of an inch. This must be intro- duced with the flat corresponding with the antero-posteripr dia- meter of the eye, and in a direction as if it were to be passed to the centre ofthe ball. As soon as the cutting edge has penetrated the tunics, the handle should be rolled between the thumb and finger so as to present the flat surface of the needle forward, and the point which should be directed between the iris and lens, passed on till it nearly reaches the opposite side of the pupil. One of the cutting edges is then to be turned upon the cataract for the purpose of dividing it. This should be done by retract- ing the needle a little, pressing its cutting edge at the same time against the opaque mass—again pushing forward the needle, and again retracting it in the same manner, but in a different direction, until the whole cataract is divided into small portions, which are to be passed with the needle through the pupil into the anterior chamber. This is an operation peculiarly well suited to the lenticular cataract of infants, and seldom in such cases, when thoroughly performed, requires repetition. The needle is to be retained, however, but for a very brief period in the eye; and if the pupil does not remain well dilated, or the aqueous humour becomes opaque so as to mask the movement of the needle, the surgeon should content himself with doing less, recollecting that if the capsule only be freely divided, so as to let in the aqueous humour upon the lens, the latter sooner or later becomes dissolved ; and that it is much better to repeat the ope- ration at a subsequent period, than to incur the risk of injuring either the iris or ciliary processes. In operating upon an infant, several assistants will be required. The arms should be bound to the side by a piece of muslin pinned around the chest, or by a pillow-case drawn over from the feet upwards, and tightened round the neck. The child thus secured should be laid upon its back on a pillow ; one assistant, taking hold of the arms, confines the upper part of the trunk— and another embraces with his hands the side of the head and face, 'so as to keep it in the right position. The upper lid is to be raised with a speculum by a third assistant, or by the surgeon himself, if in operating he wishes to employ the right hand for the right eye, when he is to seat himself behind the child, and rest its head against his breast. Keratonyxis, or anterior operation.—This process is seldom resorted to for the cure by solution, save in those exceptional cases referred to on the preceding page. The needle should be small and delicate, and the shank, of a diameter just sufficient to fill the puncture of the cornea and prevent the escape of the aqueous humour. The straight or curved needle may be used, but the latter will be found the most efficient form. Mr. Jacobs, of Dublin, employs for this operation the common sewing needle, of the size known in the shops as No. 7, set in a cedar handle, ground or honed flat near the point, and curved. The operation is in most respects the same as that described at page 203. The pupil is to be previously well dilated; the needle, is to be passed through the cornea, and then made to lace- rate the capsule freely, and break up the structure of the lens as far as can be readily done without disturbing the iris. The needle may be entered either at the centre or near the circumference of the cornea. The practice of Saunders and Himly, of passing it through the centre, allows a freer action upon the lens without risk of injur- ing the iris, but is apt to leave a sort of gauze-like central opacity upon the cornea, as I have observed in several cases which had been operated on by Himly. Dr. Jacobs prefers to enter it near the circumference—a practice which I have followed in the few cases in which I have performed this operation. Operation by drilling when the capsule is opaque and the pupil adherent.—In cases of this description Mr. Tyrrell frequently employed with success a modification ofthe anterior operation for solution, which he denominated drilling. A fine straight needle is entered near the outer edge of the cornea, and carried through the narrowed pupil, through the capsule, and for the sixteenth of an inch into the substance ofthe lens. The handle is then rotated like a drill between the thumb and fingers, to enlarge the opening and let in the aqueous fluid to absorb the lens. The operation is to be repeated every three or four weeks, drilling at each time a new orifice in the cataract. OPERATIONS ON THE BALL OF THE EYE. 207 "I think," says Mr. Tyrrell,* " upon the average, I have had to repeat the operation seven or eight times before I have been satisfied that the lens has been removed ; consequently the cure has been extremely tedious ; but as the plan incurs very little risk, and does not confine the patient for more than three or four days after each operation, there can be no further objection than the slowness ofits effects, which is more than counterbalanced by the success of the treatment." Third method. Extraction.—This method consists in the extraction entire of the cataract through an opening in the cornea made with a knife of a peculiar shape, and is denominated Keratomy. Though apparently known to the ancients, and practised by Antyllus and Lathyrion, as would appear from the writings of Rhazes and Avicenna, this operation of extraction through the cornea was only brought into general notice by Daviel, who gave the first complete description of it about the middle of the last century. Since that time, it has been brought nearly to perfection by the labours of Wenzel, Richter, Barth, and espe- cially of Ware and Beer. Extraction of the lens by an incision through the sclerotic coat, (scleroticotomy,) as recommended and practised by B. Bell, Quadri, and others, need only be mentioned as an historical fact, as the process has with great propriety been utterly abandoned. There are three modifications of this operation for extraction through the cornea, (keratomy,) which are designated according to the part of the cornea which is divided, viz: the inferior, the one most commonly employed, in which the lowTer half of the cornea is incised; the superior, in which the upper half is cut; and the oblique, in which the outer portion is divided in a slant- ing direction from above downwards and slightly inwards. The operation in each of these modifications is divided into three stages: l,the incision through the cornea; 2, the opening of the capsule; 3, the removal of the lens. When the section ofthe cornea is made, the capsule frequently gives way before the lens, so as to allow the latter to escape. The first and second stages of the operation then appear but as one ; and in the process of Wenzel, the same result is obtained by making the point of the cataract knife during the section of the cornea act on the front of the capsule. Instruments.—The instruments required consist, 1, of a knife or keratome for the section of the cornea. Two of these should be at hand, for fear that, by some inadvertency, the point or edge of one might get blunted. Knives of various forms have been devised, but those most commonly approved are the triangular knifef of Richter and Beer, shown at Plate XLVIIL, and the elliptical one of Wenzel. The scissors of Daviel, or a small knife, shaped at the end like a probe-pointed bistoury, should be at hand. To enlarge the opening of the cornea, when the regular section has been interrupted by a fixed prolapsus of the iris before the * Practical Work on the Diseases of the Eye, &c. By Frederick Tyrrell: London, 1840. Vol. 2, p. 464. f The triangular knife of Richter, such as is shown in the drawing, may be advantageously modified by rendering it shorter, and thus increasing relatively its breadth. As thus modified, it will be less likely to wound the parts in the inner canthus, or have the iris to fall before it in a fold. edge of the knife, or from a fearj when there is great nervous agitation of the patient, that the muscles might contract too sud- denly on a free section and propel the vitreous humour. 2. One for division of the capsxde, called the cystotome. A couching needle may be employed for this purpose, or the small hooked-knife or serpette of Boyer, which has a small curette at the other end of the handle occasionally useful in the removal of fragments of the lenSi. 3. Those for the removal of the lens and capsule.—These are required in case it should not be deemed prudent, as in injury of the vitreous humour, to apply pressure to expel the lens, or if any opaque shreds of the capsule remain after the escape of the lens. A delicate hook, or cataract tenaculum, should be at hand for the extraction ofthe lens, and a pair of slender forceps for the removal of the shreds of capsule. 4. Those for separating the lids and steadying the ball.-—All the mechanical measures for this purpose have, as a general rule of practice, been discarded by modern surgeons, as the object can be much more safely accomplished by the fingers of the surgeon and his assistant. But in case the fissure of the lid be narrow, or the eye a little sunken, Pellier's elevator or Adams's speculum will be found useful, though especial care should be observed during the operation, that they do not make pressure on the ball so as to cause the escape of the vitreous humour. The chief points to be observed in the operation of extraction, are, that the incision through the cornea shall be sufficiently large, extending from a third to a little more than half of its circumfer- ence, smooth and semilunar in shape, and made in the cornea near its place of junction with the sclerotic coat,—that the opening of the capsule be effected without unnecessarily lifting the flap of the cornea, and without injury or contusion of the iris, and that the removal of the lens be effected slowly and carefully—to pre- vent the protrusion of the vitreous humour. 1. Inferior section of the Cornea. (Inferior Keratomy. PL XLVIIL fig. 1.) 1. Section of the cornea.—The patient and assistant being con- veniently placed, and the eye steadied as described above, the surgeon, holding the knife like a pen between the thumb and first two fingers, and resting the hand by the two smaller fingers on the zygomatic arch, enters the point perpendicularly to the rounded margin of the cornea, a little above the transverse diameter of the eye, and the twentieth of an inch from the anterior margin of the sclerotic coat—the handle of the knife standing in a hori- zontal direction, and the edge presenting downwards. As soon as the point becomes visible in the anterior chamber, the blade ofthe knife is to be brought in a direction perfectly parallel with the iris, and pushed by a sort of extension movement of the fingers steadily across the clear space of the anterior chamber, till the point touches the opposite side of the cornea, which it should traverse from within outward, at the same distance as before from the sclerotic margin, as shown in fig. 1. The knife is then to be carried on in the same direction, until the incision is nearly completed. But to avoid injuring with the point, the caruncula lachrymalis and other parts at the internal canthus, the handle of the instrument (the blade of which by its hold on the cornea commands the eye), is to be inclined gently during the step 208 SPECIAL OPERATIONS. last described, towards the temple, by a slight rotation of the hand over the joints of the phalanges which rest on the zygomatic arch. The incision of the cornea is now to be completed. The surgeon pushes the knife slowly on, pausing a moment before he divides the last attachment of the corneal flap in order to carry the end of a finger into the internal canthus to protect the parts, as well as to allow the contraction into which the muscles of the ball have been thrown by the incision to subside, as this might otherwise cause the sudden protrusion of the lens and vitreous body on the completion of the cut. As soon as the knife is re- moved, the upper lid is allowed to descend, and the eye kept closed for a few moments before the other steps of the operation are proceeded with. During the section of the cornea, the opera- tor must be particularly cautious not to retract or twist the blade, as this would occasion a premature loss of the aqueous humour, and bring the iris under the edge. The cut must be made with- out sawing or pressure downwards, merely by a gentle onward movement, so as to divide the inferior segment of the cornea at the same distance from the sclerotic margin at wThich the knife was entered. When the patient has sufficiently recovered from the emotion caused by the section of the cornea, we proceed to the second stage of the operation. 2. The division of the capsule. (Fig. 2.)—The assistant again raises the upper lid, observing the greatest care to avoid making any pressure on the ball. The operator depresses the lower with his fore finger, and bears softly with the end against the lower part of the ball, in order to cause a slight elevation of the cor- ' neal flap, and render easier the introduction of the instrument for opening the capsule, as seen in fig. 2. The pressure serves also to advance the cataract toward the pupil, so as to facilitate the division of the capsule. If the serpette or cystotome of Boyer is employed, as shown at fig. 2, it must be insinuated gently with its back upward, and by a slight rotatory movement under the corneal flap, so as to carry the blade flat to tbe upper part of the pupillary opening. The edge is then to be turned downwards, and the capsule divided freely with some gentle movements of the point from side to side, as well as over each semi-circumference, avoiding carefully all pres- sure upon the lens, or any lesion of the iris. If the spear-pointed needle be employed, to which a decided preference is given by the German surgeons, the neck of it is to be passed under the lower margin of the flap, "with the point di- rected towards the inner canthus, and the edges looking upwards and downwards. The needle is then to be retracted horizontally till the spear point comes opposite the pupil; the point is next turned on the capsule, so as to divide it into several square pieces. The needle is then to be withdrawn flatwise, obliquely, and with- out lifting the flap. Jiingken merely divided the capsule by a single incision—but this, though it admits readily enough the es- cape of the lens, is an objectionable practice, inasmuch as it ren- ders the patient more liable to secondary cataract. 3. Expulsion of the cataract. (Figs. 3, 4.)—If the incision in the cornea has been made sufficiently large, and the capsule freely divided, the lens is commonly dislodged immediately behind the cystotome, either by the contraction of the muscles of the ball, or the retraction of the divided capsule. If such should not be the case, the operator is to press gently against the ball, with the finger sus- taining the lower lid, until the lens stands with its largest diame- ter in the pupil, and its margin slides through, as shown in fig. 3. If deemed necessary, the scoop or curette may be introduced to favour the exit of the lens, or remove any fragments into which it may have been broken by its passage through the pupil. As a general rule, however, it is best not to employ the curette for either of these purposes, from the danger of giving rise to increased irritation. The fragments must necessarily be soft, and if they are not large, will speedily become dissolved; and the expulsion of the lens can be more safely effected by slight pressure with the handle of the cystotome over the upper lid, as shown in fig. 4. PLATE XLVIIL—CATABACT. OPERATION BY EXTRACTION.—INFERIOR SECTION OF THE CORNEA. Fig. 1.—Section of the cornea with the triangular knife of Richter and Beer. In the stage of the operation shown, the punctuation of the cornea has been made at its outer margin, and the point of the knife (e), glided across the anterior chamber in front of the iris, is brought out by a counter puncture on the side next the nose. The lids are separated by the fore and middle fingers of an assistant (a) and the fingers of the surgeon (b). The pressure of the ends of the fingers serves to steady the ball. The knife by being carried on cuts out at the lower semi-circumference of the cornea. Fig. 2.—Incision of the capsule with the cystotome or serpette of Boyer, which is introduced with the right hand ofthe surgeon. A cataract needle, as observed in the text, is very commonly substituted for this instrument. Fig. 3.— Vertical section ofthe ball, seen from the side. This drawing exhibits the tract of the lens in its expulsion from its seat, by the double influence of the pressure of the fore finger (d) on the lower lid, and the handle of the cystotome (c) on the upper. Ktf the lens is represented in its natural position, before its dislodgement. At g the same lens is represented as having left its seat, with its lower edge tilted forwards by the slight force applied by the finger (d), pressing downwards and backwards the inferior segment of the iris (h), upwards and forwards the superior segment (i), and raising the flap of the cornea as it falls from the eye upon the nail of the finger below. Fig. 4.—Expulsion of the lens.—Front view of the same process described under fig. 3. Fig. 5.—Removal of any opaque portions of the capsule, seen remaining after the expulsion of the lens. Pta/r 4c?. p/y / Fi