NLM005549703 X .. / I /t^YL^ru or becomes flexed to the extent of its weight, tends to bring back with it the lower fragment of the radius; this fragment, abutting against the projecting posterior margin of the upper fragment/(Fig. 56), is supported as a fulcrum, and the result of the weight of the hand is simply to make still more tense the aponeurosis which is attached to it behind. Thus the char- acteristic deformity is produced and maintained, while immobility of the fragments and absence of crepitus is Fig. 55. VAr,/v^ secured (Fig. 57). When the radius '----» has given way, and the force of exten- sion is no longer arrested by the inser- tion of the anterior ligament into its broad margin, this force is felt strong- ly by that portion of the ligament which is inserted into the ulna ; the whole hand, with the lower radial fragment, is caused to move backward and outward, as in supination ; a strong fasciculus of the anterior ligament, passing ob- liquely from cuneiform bone to an- terior border and base of the styloid process of the ulna, bears the most of the strain; through it, the tend- ency to supination is increased, the rounded head of the ulna is made to project strongly upon the front and inside of the wrist, its styloid process becomes approximated to the radius upon the back of the wrist, and in some cases is completely torn off. In this position the parts are firmly held, all rotation in either direction being pre- vented, as long as the backward displacement of the lower radial fragment remains unreduced. In the treatment,1 two classes of fractures must be recognized, 1 L. S. Pilcher. Fig. 57. ment. e. Dorsal periosteal pseudo-liga- /. Point of entanglement, g. Flexor tendons. THE INJURIES OF BONES. 87 namely, those without and those with displacement. The first is likely to be called a sprain and to be treated as such; for immediately upon the recovery of the hand from the over-extension which it had sustained, the corresponding surfaces of the fragments fall together, where they are held by the weight of the hand when prone; there is no tendency to displacement. The indications are: (1.) That the wrist should be supported in the prone position, with the hand hang- ing loosely, and thus maintain the fragments in apposition. (2.) That movements of extension of the hand should be limited, lest separa- tion of the fragments again occur. The first indication in the treat- ment of the second form is to overcome the displacement, which is ef- fected as follows: Bend the hand and wrist backward, approximating the position in which the parts were when the displacement took place, and relax the tense periosteum. Slight extension now in the line of the fore-arm is sufficient to disentangle the rough surfaces of the frag- ments from each other, and moderate pressure upon the dorsum of the lower fragment causes it to fall into line ; the weight of the hand is now sufficient to secure perfect apposition of the fragments; the periosteum again envelops closely the whole length of the radius; the tense inner fasciculus of the anterior ligament is completely relaxed; the radio-ulnar movements are free; the head of the ulna has ceased to project as if subluxated; all the parts have resumed their natural relations; the fracture has become one of the first class, with this difference simply, that the sprain of the soft parts is much more ag- gravated. Splints are not always necessary in the treatment, but all the measures indicated as of value in overcoming the results of sprained wrist are now of importance; as compression and support by means of a bandage encircling the joint; the snug application of a strip of strong adhesive plaster, two inches wide, so as to grasp firmly the lower extremities of both radius and ulna, to restrict effu- sion, and reinforce the radio-ulnar ligaments, and render more toler- able efforts at motion of the wrist-joint; massage, early, persistently, and skillfully applied; motion, early, regular, and decided in charac- ter ; use of the hand after the third day. As a rule, it would not be wise to discard splints altogether in this fracture, but they may in general be limited to a single well-padded splint on the dorsal or palmar surface.1 There are instances of great displacement and contusion, in which two light-padded splints, care- fully applied with adhesive strips, are useful. 6. The olecranon process separated from the ulna requires the straight position of the fore-arm. Apply a light but firm splint, ex- tending from about four inches below the shoulder to the wrist, wide as the arm at its widest part, thickly padded with cotton batting to 1 F. H. Hamilton. 88 OPERATIVE SURGERY. meet the irregularities of the arm, and having a notch cut about three inches below the olecranon; place it on the palmar surface, and apply a strip of adhesive plaster, the centre being on the process and the ends drawn firmly through the notches and fastened to the splint; retain the splint in position by a bandage or strips of plaster passed circularly around the limb and splint. The plaster of Paris is applied as follows: Place the limb in extreme exten- sion; cover it with cotton bat- ting or flannel; apply three layers of bandage, and when it is hard cut out a large fenes- trum over the olecranon; jiow apply strips of adhesive plas- ter, the centres being over the upper surface of the olecranon, and fasten the ends, drawn down firmly, to the sides of the splint (Fig. 58). 7. The radius and ulna fractured must be maintained in paral- lelism. Take two wooden splints of the length of the fore-arm, nearly or quite the width of the limb at its widest part, properly padded; apply them evenly to the palmar and dorsal surfaces, and retain them with two adhesive strips applied directly around the limb and splints. 8. The femur1 is liable to be fractured through the neck, within and without the capsule, below the trochanter minor, in the central portions of the shaft, just above the condyles, through the condyles, and at the points of epiphyseal connections. Fracture of the neck, including even cases of suspected fracture, should be treated as if in a condition favorable to bony union, in order both to save the patient from the pain and suffering caused by the irregular contractions of the muscles, due to the pressure of the broken fragments against in- flamed tissues, and to insure a longer limb and less eversion if bony union does not take place. Fractures of the shaft are generally ob- lique, and the fragments override from half an inch to two inches, owing to the contraction of the muscles ; fractures just above the condyles are in most cases oblique from above downwards, and from behind forwards. All of these forms of fracture can be treated more successfully in the straight than in the flexed position, and in nearly all cases extension is more effectually made by the weight and pulley than by any other method. The sooner the limb is put up and subjected to this method of treatment after the fracture, the better; suffering is prevented, and the sufferer made comfortable from the outset.1 Precisely the same form of apparatus is not suited to all fractures of the femur, but certain modifications are required to meet all of the indications present. In an ordinary case, provide a firm i F. H. Hamilton. THE INJURIES OF BONES. 89 bed with a suitable mattress (Fig. 61); apply a roller bandage from the toes to the ankles; next apply strips of strong adhesive plaster two and a half inches broad, and well warmed, to both sides of the leg, extending from the frac- ture some inches below the sole of the foot (Fig. 59); warm the ends and lap them over each other so as to make a loop of two thicknesses four inches below the sole of the foot; in this loop put a foot-piece of wood four inches long and three inches wide; continue the roller bandage over the limb to the groin; pass a strong India-rubber band around the foot-piece in the depres- sions cut on either side, and attach to it a rope, or make a hole in the centre of the block, through which a cord is passed and a knot tied so that it cannot escape; at the foot-board arrange a pulley on a level with the long axis of the leg; this pulley may be iron or wood, or even a large spool, and may be fastened on the foot-board of the bed, or in an iron or wood upright (Fig. 60); the weights may be obtained in sets and neatly adjusted to the rope, or they may be made to slide down one upon the other as the weights of the common scales. Now apply co- aptating splints, which may consist of several narrow strips of thin board properly padded and of such length as to extend well above and below the fracture; or four sole-leather splints may be used which do not quite touch at their margins, the external and in- ternal embracing the condyles; main- tain these splints by four to six strips of bandage knotted over the front splint, or by straps with buckles. The amount of weight to be employed must be determined by the resistance to be overcome, and the toleration of the patient; the maximum is about twen- ty-two pounds, and generally not over twenty pounds can be long endured. Counter extension is made by the weight of the body, in- creased, if necessary, by raising the foot of the bed on blocks, or by Fig. 59.1 1 A. Crosbv. 90 OPERATIVE SURGERY. a perineal band attached to the head of the bed (Fig. 61). Pre- vent eversion of the foot, especially in fractures of the neck, by long ought to remain in apparatus, but the extension may be lessened when the bones seem firm, and passive motion should be given to the knee-joint as early as the fifth or sixth week ; the amount of shortening in adults, when overlapping continues, ranges from one fourth to one and a half inches.2 The gypsum bandage should be employed only by those familiar with its use, and in a position to guard carefully against the dangers of too great compression. It is applied as follows:3 Place the patient with his nates overhanging one cor- ner of a table, or with his body, shoulders, and head resting upon a mattress elevated by blankets about one foot from the table, but terminating about two feet from its lower end; press the perineum against an iron stanchion, firmly screwed upon the lower end of the table, and wound with heavy flannel cloth; suspend the nates by a sling passed under the small of the back and supported by a wooden bar projecting horizontally from the top of the stanchion to some point of support of equal elevation beyond the head; attach compound pulleys to the foot, and give the anaesthetic; the patient being fully under the influence of the anaesthetic, make traction upon the pulleys until the shortening is over- come and the fracture reduced; the direction of the extension must be in the 1 G. Buck. 2 Resolve of Am. Med. Assoc. 3 Bellevue Hospital Reports. THE INJURIES OF BONES. 91 line of the axis of the body; envelop the limb with a dry bandage, cotton bat- ting, or old blanket, cut to fit, or drawers, and protect especially the groin and gluteal fold from excoriation; apply the bandages, saturated with plaster, over the whole limb, from below upwards, including the pelvis; occasionally rein- force the successive turns of the roller by broad pieces of flannel or of patent lint, dipped in the fluid plaster; the number and thickness of the successive layers must be determined by the apparent necessities of the case, generally four or live layers of roller being required, at least upon the thigh; the dressing being completed, continue the extension fifteen or twenty minutes, until the plaster has become hard; on the second or third day after the reduction of the fracture, the patient is allowed to move about on crutches. Fracture of the femur in children is best treated as follows:1 Pro- vide two long narrow side splints extending from near the axillae below the feet; connect them by a cross piece at the lower ends so that they are a little more widely separated below than above, to render the perineum accessible; place them upon each side of the body; secure the leg of the broken limb to the splint with a roller, and fasten the remainder of the limb, the opposite limb, and the body to the splint with broad and separate strips of cloth; the coaptation splint may be made of binders' board; it is of great importance to confine both limbs, for as long as one is free it is almost impossi- ble to secure any degree of quiet; the extended position is much to be preferred to the flexed. 9. The patella fractured transversely is effectually retained in position by the gypsum bandage (Fig. 63). Envelop the limb from the toes to the groin with sheet cotton or nicely fitting blanketing; apply the gypsum bandage from the toes to the groin, three thicknesses; when the dressing is hard, cut out a large fenestrum exposing the patella and adjacent parts ; now apply strips of adhesive plaster over the lower fragment, the centre of each resting on the patella, and the ends extending upward and fastening to the 1'1G- 63. splint; these strips should overlap each other one third from below upwards; when the lower fragment is firmly fixed, apply strips in a similar manner to the upper fragment, forcing it downward; it is well to apply a last plaster directly over the centre of the patella, to prevent the broken surfaces from tilting upwards. The following method1 is often adopted: Elevate the limb upon a well-cush- ioned inclined plane, in which is cut a deep notch about four inches below the knee; the foot-piece is at right angles with the inclined plane, and not at right angles with the horizontal floor; and perforated with holes for the passage of tapes or bandages to secure the foot. Having covered the apparatus with a 1 F. H. Hamilton. 92 OPERATIVE SURGERY. soft and thick cushion carefully adapted to all the irregularities of the thigh and leg, take especial care to fill the space under the knee; lay the whole limb upon it, and secure the foot gently to the foot-board, between which and the foot place another cushion; the body of the patient should also be flexed upon the thigh, so as the more effectually to relax the quadriceps femoris muscle. Now place a compress made of folded cotton cloth, wide enough to cover the whole breadth of the knee, and long enough to extend from a point four inches above the patella to the tuberosity of the tibia, and one quarter of an inch thick, on the front of and above the knee. While an assistant presses down the upper fragment of the patella, secure it in place with bands of adhesive plaster' each band should be two or two and a half inches wide, and sufficiently long to enclose the limb and splint obliquely; lay the centre of the first band upon the compress, partly above and partly upon the upper fragment, and bring its extremities down so as to pass through the two notches on the side of the splint and close upon each other underneath; let the second band, imbricating the first, descend a little lower upon the patella, and secure it below in the same manner; the third, and so on successively until the whole is covered, after which apply a roller from the foot to the groin. The leg should not be flexed freely, under three months.1 10. The tibia is very little displaced, when broken alone, and re- quires only a leather splint,2 or a properly adjusted plastic dressing. A very neat and simple plastic dressing may be made with flannel, plaster of Paris, and shellac,3 prepared and applied as follows : After replacing the fragments as accurately as possible, extension being maintained by assistants, bandage the limb smoothly with cot- ton wadding, prepared in the form of an ordinary roller; now soak a flannel bandage spread with dry plaster of Paris and rolled, in warm water, adding about two fluid-ounces of saturated solution of sulphate of potassium, and apply to the limb, over the wadding, by circular and reversed turns; one layer of the flannel applied in this way is amply sufficient for support; the splints should be varnished with shellac. To inspect the point of fracture, the dressing, which is only about an eighth of an inch thick, is easily cut through. To avoid the difficulty in removing plaster of Paris dressings when applied by the roller bandage to the leg, the following method of dressing is very con- venient : 3 Take a woolen or cotton stocking suffi- ciently long to reach to the knee-joint, and cut from it as a pattern six layers of coarse red flan- nel, one quarter of an inch larger, to allow for shrinkage; soak the flan- nel in water, press and lay Fig. 64. °ver the back of a chair, . , ready for use ; sew a one quarter inch cotton rope to the posterior median line of the stocking (Fig 64)- 1 T. Bryant. a F. H. Hamilton. 3 G. Wackekhagex. ' THE INJURIES OF BONES. 93 the plaster of Paris being in process of preparation; cut the stocking in the an- terior median line, apply it to the fractured limb, lace up in front, including the rope, extension and counter-extension being kept up by assistants; adjust the fracture; saturate each layer of the flannel now separately in the plaster paste, and apply three layers to each side of the limb, being careful to avoid covering the rope; after this is done, apply a layer of plaster paste to the flan- nel, and, when this has become sufficiently dry, a coating of shellac varnish, which produces an elegant finish, and also gives firmness to the splints; the varnish will dry in about fifteen minutes. Remove by loosening the rope from the plaster and cutting the thread which binds it to the stocking; cut the plain stocking surface with an ordinary pair of scissors. 11. The fibula is most frequently fractured two or three inches above the lower end; the most convenient dressing is the gypsum, which must include the foot, except the toes; the fracture must be reduced and the foot held firmly in position until the limb is dressed and the material has hardened. A useful dressing, frequently applied, is constructed as follows (Fig. 65) :l Se- lect a board, about four inches wide, of sufficient length to extend from the condyle of the femur to two or three inches be3rond the foot; upon this place a long triangular pad, the thickest portion of the triangle cor- responding to a point about an inch above the internal malleolus; the splint, with the pad resting upon it, lying along the inside of the leg, is secured by roller bandage, which must not cover the site of the fracture. 12. The tibia and fibula are usually fractured in the lower third. Apply a gypsum dressing2 made as follows : Select two pieces of flannel, suited to the length and circumference of the limb, and cut them so as to overlap slightly in front, when they resemble the leg of a stocking opened vertically; lay one over the other, and stitch them together from top to bottom down the middle line, like two pieces of note paper stitched at the fold; spread them out under the limb so that the line of stitching corre- sponds to the back of the calf; bring the two inner folds to- gether, over the shin (Fig. 66), Fig. 65. Fig. 66. and fasten them by long pins or by stitches; while the leg is held firm- ly in position, mix the plaster with about an equal bulk of water, and rapidly apply it, partly with a spoon and partly by pouring it over the outer surface of flannel covering the limb; quickly bring the two por- Dupuytren. 2 Bavarian. 94 OPERATIVE SURGERY. tions of the second layer over so as to meet, and smooth them with the hand, so as to remove the inequalities in the distribution of the plaster before it hardens; the gypsum sets in about three minutes, incasing the limb in a strong, rigid covering. To take the dressing off, open it like the leaves of a book; its edges must be trimmed, and the pins removed; maintain it in position afterwards by straps with buckles or a very firm bandage. This fracture may also be treated by leather splints, one on either side, extending from above the knee to near the tarso-phalangeal articulations. The apparatus must more or less completely envelop the limb. Sole leather cut so as nearly to inclose the limb, then softened in warm water and moulded to the leg, makes a firm dressing when it becomes dry. A very simple gypsum splint may be made and applied as follows: ' Select a piece of "house-flannel or an old, thin, shrunk blanket, or any suitable substitute; shape the pieces by measurement, taking the circumference of the limb below the knee, at the biggest part of the calf, just above the ankle-joint, from the front of the ankle-joint round the heel to the front again, and at the middle of the metatarsus; the flannel of each splint should be in width half an inch less than half the circumference at any of those points; the width of the two splints should be one inch less than the circumference of the limb at any correspond- ing part, and long enough to extend from the tubercle of the tibia to the middle of the metatarsus; four pieces are required, two for each splint; pre- pare two bandages of common muslin, each five to six yards long and two inches and a half in width; mix about a handful of good dry plaster with water to the consistence of thick cream; lay the inside pieces of flannel on the table or bed, the outer surface being upwards; soak the outside pieces in the plaster separately, and lay them out on their respective inside pieces. Whilst traction is kept up, and the ends of the broken bones are maintained in apposition, the splints are to be applied and smoothed; then the bandage is to be put on ; trac- tion is to be maintained during the hardening of the plaster; next the limb should be laid on a large soft pillow, the toes directed upwards, and the knee a little bent; in the application of the bandage great caution should be observed that it is not drawn tightly anywhere, and that no one turn of the bandage is tighter than another; the two splints should not meet by about half an inch either down the front or back; the intervals are spanned by the dry, porous muslin; at the sides the bandage is fixed to the splints by the plaster, which oozes into it from the outer layer of flannel; if it becomes necessary next day, or later, to ease the splints, or to inspect the limb at any spot, the bandage can be slit up with scissors along the middle line in front. They are hinged to- gether at the back by the muslin bandage which spans the interval there. These splints are characterized by their simplicity, stability, and economy, and therefore commend themselves strongly to the country practitioner; the surgeon can take out with him, to his case, a bag of plaster of Paris, and the muslin bandages, and perhaps the flannel; the plaster should be good, but need not be the very best; must be dry, and should be kept, when in store, in a dry, warm place; be cautious in using any flannel which has not been in some way shrunk. 1 J. Croft. THE INJURIES OF BONES. 95 II. COMPOUND FRACTURES. A fracture is compound when it communicates through a wound with the external air. These injuries have always been regarded as dangerous because such wounds commonly inflame and suppurate,1 but when they are. protected from the action of septic ferments re- covery will occur with slight inflammation and suppuration. The first question to determine is as to the possibility of saving the limb) and as a rule, the attempt should be made if the injury to the soft parts is not very great; if the bone does not largely protrude, and the skin is not extensively lacerated; if the continued warmth of the limb below the fracture indicate the escape of the main artery, and that the nerves are not implicated.2 The thorough use of disin- fectants, by which putrefactive suppuration is now prevented, adds largely to our means of saving limbs after compound fractures. The first indication is to convert the compound into a simple fracture when the opening is very slight and readily closed; this may be done with collodion, or with any dressing which hermetically seals the wound. If the bone protrude, attempt reduction by ex- tension and counter-extension; if this fail, introduce the finger or the spatula into the wound and endeavor to stretch the skin over the sharp point of bone; if all efforts fail, enlarge the wound suffi- ciently to insure return; if the bone is denuded or very sharp, saw off the projecting end; ligate ruptured arteries which can be readily found. Anaesthetics may be useful during these efforts.3 If the case is seen at once, cleanse the wound, disinfect every portion liable to contain septic ferments, secure perfect rest, and prevent the entrance of any poisons. Employ the antiseptic dressing, which best meets these indications,4 as follows: Use the spray during the dressing; if the contusion is slight, inject carbolic solution, 1 to 20, into the wound, and apply the gauze; if there is much contusion, enlarge the wound and inject the same solution freely and forcibly among the injured tissues, and dress as before; repeat the injection at every dressing when the discharge is offensive, opening the wound more freely, if necessary, to reach deeper recesses. If the suppuration has extended very deeply, and is offensive, the wound must be still more freely enlarged, and a solution of carbolic acid in wine, 1 to 5, injected, and if necessary through a tube introduced to the most re- mote recess.4 If the gauze is not at hand at each dressing, after thoroughly disinfecting all parts of the wound with the carbolic so- lution, fill the cavities and the entire open spaces with pledgets of lint saturated with carbolized oil. The plastic dressing should next be applied; if there is danger of 1 J. Hunter. 2 F. C. Skey. 8 F. H. Hamilton. * J. Lister. 96 OPERATIVE SURGERY. too much swelling, it may be applied only to the under and lateral surfaces, leaving the upper and injured surface free (Fig. 67). As early as possible, how- ever, the gypsum dress- ing should be so applied as to completely envelop the limb, a protective being placed next to the skin, as cotton batting, or thick flannel; when Fig. 67. completed and nearly dry, a fenestrum, or if necessary two or three, should be cut out so as to give full access to the wound (Fig. 68); the limb is then suspended. III. SHOT FRACTURES. Projectiles1 cause a variety of partial and complete fractures; the former are (1) removal of a portion of bone, (2) splintering off of fragments of the exter- nal cylindrical part of a bone, (3) making a hole throughout the en- tire substance of the bone, (4) driving the external cylinder into the cancellated struc- Fig. 68. ture; the latter are (1) simple when the injury is indirect, and (2) compound when the pro- jectile is brought in direct contact with the injured bone. These fractures are always serious injuries, as they frequently involve the question of resection and amputation, and are always liable to dan- gerous complications, as haemorrhage, tetanus, septicaemia, and py- aemia. The course of treatment indicated varies with the bone fractured, and the nature and extent of the injury. 1. The superior maxilla has such relations to the structure of the face that every effort should be made to preserve its symmetry when broken by shot injuries. Unless the fragments are either completely detached or but slightly adherent, they should not be taken away, but be replaced with care, as in time consolidation may take place, and very little permanent deformity be left; after care- ful adjustment of the movable fragments, close the wound with ad- hesive plaster, and apply cold-water dressings; if fragments subse- 1 T. Longmore. THE INJURIES OF BONES. 97 quently loosen, remove them.1 Bony union of these fragments usually takes place with great facility.2 2. The inferior maxilla, fractured by projectiles, is with difficulty retained in position; the fragments should be preserved and adjusted, and efforts made to retain them in apposition by the four-tailed bandage, with pasteboard cap for the jaw, and interdental splints of gutta-percha.2 3. The clavicle is in such relations with the pleural cavity and the larger vessels of the neck that serious complications frequently attend shot fractures of that bone. In the treatment of uncompli- cated fractures, remove detached splinters immediately, and necrosed fragments at the earliest practicable moment; 3 then leave the injury to nature, with as little operative interference as possible, for the less the wound and bones are manipulated the better the result.4 4. The humerus should always be subjected to conservative treat- ment, unless extremely injured by a massive projectile, or longitu- dinal comminution exist to a great extent, or a joint is also involved, or, finally, the patient's health is unfavorable.5 In cases which ad- mit of conservative treatment, proceed as follows : If the bone is much splintered, extend the wound if necessary for exploration and operation, at the most depending opening if there are two wounds, or make a fresh incision if only one exists and it is not in a favor- able position; make an examination with the finger for any foreign bodies or detached pieces of bone, and remove them; remove also such partially detached portions and fragments as are retained only by very slight and narrow periosteal connections, and saw or cut off sharp points of projecting spicula.5 Dress the wound with lint soaked in carbolized oil, and support the limb by a fenestrated splint of gypsum, or sole leather, or other material capable of being moulded to it, and which will secure rest. Immobility is securely obtained by a triangular cushion6 and axillary pad interposed be- tween the thorax and the arm (Fig. 69). This useful appliance consists of a three-cornered cushion, with rounded edges, made of horse-hair, upholstered with soft material, and inclosed with waterproof material. It is applied as follows: One of the.rounded edges is placed in the axilla, and is then fixed by a bandage, attached behind and in front by safety-needles, and passed over the opposite or healthy shoulder; the fractured arm is then laid upon the cushion, and both are maintained in position by a broad sling; the wound is now dressed with a Scultetus' bandage, the edges of the sling being drawn back for that purpose. 5. The radius and ulna, like the humerus, should be conserva- tively treated unless there is partial ablation by a cannon ball, or comminution of both bones with laceration of the blood-vessels and » J. J. Chisholm. 2 F. H. Hamilton. 3 G. A. Otis. 4 B. Beck. 5 T. Longmore. 6 F. Stromeyer. 7 98 OPERATIVE SURGERY. nerves, or extensive comminution in the vicinity of joints, with fis- sures extending; into the articulations.1 After extracting; loose fras- Fig. 69.2 ments, if no considerable deformity exists, only simple splints and bandages are required; if there is great tendency to displacement, the fenestrated gypsum dressing, applied when the arm is midway between pronation and supination, with a slightly bent elbow, is most useful.3 If but a single bone is fractured, the most simple splint dressing is required. Suspension of the fore-arm in the early stages of treat- ment is very important, and may be effected by simple apparatus, as follows (Fig. 70) :4 Select iron tubing, or other material, fasten its upright portion by clamps at the head of the bedstead, while its lower portion over- hang* the bed and holds sus- pended at its extremity a flattened strip of hard wood, on the upper edge of which a row of screw heads serves for fastening the ends of the canvas bands that suspend the limb; the strip of wood that supports the limb should play horizontally on a swivel joint at the extrem- ity of the iron tubing. 6. The metacarpal and phalangeal bones should, as far as practicable, be preserved, whatever the nature of the injury, though their functions may subsequently be greatly limited. Their wounds 1 F. Schwartz. 2 F. Esmarch. 3 H. Fischer. * G. Buck. Fig. 70. THE INJURIES OF BONES. 99 are extremely painful and troublesome in management, but are not specially liable to induce tetanus.1 In the treatment, splinters and foreign bodies should first be removed; free incisions1 through the aponeurotic layers are important in preventing accumulations of matter under fascia? and tendons, or relieving tension caused by such collections. Carbolized oil dressings pressed into the wounds in or- dinary cases, and the hot water in those liable to extensive sloughs, should be early resorted to and persistently used; the hand may be supported upon properly adapted splints. 7. The femur,2 fractured by a modern rifle-ball, is generally exten- sively comminuted, and often fissured for long distances along the shaft; an attempt to conserve the injured limb, however free from complications, and however favorable the case may appear to be, will unavoidably subject the patient to a wide variety of hazardous circumstances, owing to the prolonged treatment and attendant diffi- culties which must necessarily occur before a cure can be completed. If the femoral artery and vein have been divided, any attempt to save the limb will certainly prove fatal. In shot fractures of the upper third of the femur, especially if it be doubtful whether the hip-joint is implicated or not, the question is still open whether ex- cision of the injured portion, or removal of the detached fragments and relying on the natural efforts for union, or amputation, which is very dangerous, is best for the safety of the patient. The decision must depend upon the extent of the injury to the surrounding struc- tures, the condition of the patient, and other circumstances in each individual case. As a general rule, in fractures in the middle and lower third of the thigh, amputation is held to be a necessary meas- ure. When it is deter- mined to attempt to save the limb, the wound may be enlarged to remove spicula of bone, and oc- casionally counter open- ings should be made to prevent the accumula- tions and burrowing of pus; carbolic solutions should be injected into all the recesses, and carbolized oil on lint be introduced with forceps to avoid creating additional irritation; cold water or ice dressings may at first be applied, to be discon- tinued if suppuration occurs. The part should finally be perfectly immobilized by apparatus; for this purpose the splint should allow the limb to be swung so as to admit of dressing without change of 1 G. A. Otis. 2 T. Longmore. 100 OPERATIVE SURGERY. position. The gypsum splints or the fenestrated gypsum bandage may be employed (Fig. 71), or the cradle with a light weight at the foot (Fig. 73). A wire suspending apparatus1 (Fig. 72) has given good results: — The frame is stout wire; strips of cloth are laid across the splint from side to side, and upon these the limb is laid; the centre and upper extremity of the splint are kept asun- der by strong bows of iron wire, so arranged that they can be put on or taken off with- out disturbing the dressings; when applied, the inside wire must be bent upwards at its upper extremity, so as to make room for the pubes; extension is made by adhesive plasters, and the whole apparatus is finally suspended to the ceiling or to some point above by a rope or pulley. 8. The tibia and fibula, fractured without implication of the knee or ankle joints, are very amenable to conservative measures, and hence, as a general rule, or- dinary fractures below the knee, from rifle balls, should never cause primary am- putation.2 The treatment should consist in freeing the wound of all foreign matters and splinters, the local use of carbolized oil on lint, and Fig. 73.8 the application of the gyp- sum splint noticed in the treatment of ordinary compound fractures in this region. A very simple apparatus1 may be made, consisting of a wooden frame formed of four square bars of the length of the lower extremity, two on either side of the leg, united by a crescent-shaped piece of wood situated at the back of the knee, and by a foot-board below; the lower two serve the purpose of hold- ing the apparatus together, and making an inclined plane; the upper bars serve as points of attachment for a number of linen straps or rollers to suspend the limb, which pass from side to side and are fastened with pins; they constitute a per- fect bed, having the advantage of adapting themselves to the differences in the conformation of the limb; the foot is retained to the foot-board b}r long adhesive plaster strips, passed around the foot-board and carried upwards and secured to both sides of the leg with roller bandage, leaving a sort of loop beneath the foot-board, through which a rope is passed and attached to a little bag weighted with sand, for the purpose of keeping up extension; counter-extension is made by a perineal band, the end of which is secured to the head of the bed; a long cross-bar under the foot-board, resting on the bed, prevents the apparatus from 1 J. T. Hodgen. 2 T. Longmore. 3 G. Tiemann & Co. THE DISEASES OF BONES. 101 tilting; bricks may be placed under the legs of the bed at the foot, to give the apparatus an inclination towards the pelvis; one of the advantages of this in- strument is that each of the bands of linen may be removed separately, any wound dressed, and the band reapplied without displacing the others. CHAPTER, XIII. DISEASES OF BONE AND SPECIAL OPERATIONS. Morbid anatomy illustrates physiological processes very mark- edly in the osseous system; in every case some analogy at least may be discovered between the morbid phenomena and a normal proto- type ; in many cases there is a simple excess or deficiency of normal growth, but in the larger number there is a predominant activity of single anatomical factors whose part in normal growth is more subordinate.1 In the examination as to the condition of bone, much useful information may be obtained in obscure cases, both as to the seat and nature of the disease, by percussion;2 the instrument used should be a metallic hammer with a whalebone handle, and the bone should be firmly compressed on two sides; of the more notice- able sounds elicited by percussion of diseased bone are a high pitch when the bone is very compact, as in osteo-sclerosis, and a hollow sound when the bone is very porous, as in osteo-porosis. ■ I. RICKETS. The swellings and distortions of rickets depend on a morbid ac- celeration of those changes which usher in and prepare the way for the transformation of cartilage into bone, and the development of bone from periosteum; ossification follows at a slower pace, and hence the substance which should undergo immediate conversion into bone- tissue accumulates, forms swellings, and allows the bones to be bent and broken.1 In its various forms rickets 3 is a very common affection in children from six months to two years of age, who live in damp, dark, ill-ventilated apartments and have insufficient or improper food. Faulty digestion results in the de- velopment of acids, mainly lactic, in the blood, and the rapid elimination of the phosphates by the kidneys. The child grows feeble, peevish, melancholy, has perspiration of the head; the ends of the long bones, radius, tibia, and ribs, enlarge, and those bones subjected to pressure bend. The general treatment is (1) fresh air and sunlight; (2) cod-liver oil, and syrup of iodide of iron, or the compound syrup of the phos- phates. The mechanical treatment consists in supporting the bones 1 E. Rindfieisch. 2 A. Likke. 3 J. L. Smith. 102 OPERATIVE SURGERY. which are inclined to curve during the period of softening ; the great- est care and discretion are required to avoid doing harm by undue pressure on yielding bones; as far as possible the weight of the body should be taken from the long bones, and when curvature occurs gentle lateral support should be given by well- padded splints, making such points of pressure as will not involve other bones. Plastic appara- tus may be applied to support a weak spinal column and the lower extremities. The curva- ture of the lower limbs may be very firmly sup- ported by apparatus which protects the bones without other pressure. If curvature exists, -a much may be accomplished in straightening the limb of the child that does not walk, by firm pressure and extension with the hands, repeated several times daily. When the child is walking an apparatus may be adjusted to the tibia. (Fig. Fig. 74. 74^ Two upright steel stems are fastened below to a shoe and terminated above in the calf-band; a leather bandage is passed around the stems and tightly laced in front over the arc of the curvature (a), or a strap is passed over the arc of the curvature and fastened to a spur suspended from the calf-band behind (c) ; the points of resistance being in either case the heel of the shoe (6) and the posterior trough of the calf-band (c). When the bones of the leg and thigh are both bent, the apparatus must be so constructed as to overcome the deformity which takes different directions. The support is given by double stems of steel, secured to a shoe, carried up as high as the thigh and jointed at the ankle and knee to allow the patient perfect freedom of motion; they are kept in place by calf and thigh bands. The bow is corrected by pads being placed respectively against the ankle and knee.on the concave side of the limb, whilst a strap passed around on the highest point of the arc, inside of the outer stem, tightly buttoned to the steel bar on the con- cave side, gradually compels the leg to become parallel with it; in slight cases, or when the bow is greatest below the calf, an instrument carried up to the knee is sufficient. When the bones have become consolidated in deformed positions which impair function, they must be straightened by osteoclasis or osteotomy. II. TUMORS OF BONE. Osseous tumors are distinguished from other ossifying tumors by the uniform production of true bone as an essential element in their development.1 They are never formed altogether of bone, but there is always present an ossifying matrix, derived generally from the perios- 1 R. Virchow. THE DISEASES OF BONE. 103 teum and cartilage; the amount of periosteum, cartilage, and bone present varies indefinitely in different cases.1 In the diagnosis,2 gen- eral smoothness of surface is usually significant of a tumor growing within a bone and expanding it, unless in the case of cartilaginous tumors, which, after growing within bones, have protruded through some of their expanded walls; pulsation in a non-cancerous tumor connected with bone is a nearly certain sign of growth within bone, except in the case of myeloid epulis; if these means of diagnosis are insufficient, resort to puncture or an exploratory incision. In operations for the removal of tumors of bone, the following general rules 2 should be borne in mind : (1) Simply removing a tumor from the place in which it lies is as sufficient for the cure of one growing in a bone as for that of one growing in connective tissue ; (2) it is rarely necessary to disturb the continuity of a bone in order to re- move from it any innocent tumor; (3) the safety of removing a tumor from within a bone is greater than that of any resection or amputation that might have been performed as an alternative opera- tion; (4) innocent tumors growing on bones should be removed by excision, and growing in bones by enucleation ; (5) cancerous and recurrent tumors should generally be removed by amputation or wide excision. 1. Chondromata, cartilage tumors, are usually seated in the bones; the phalanges of the fingers and toes are more often af- fected; next, the humerus, femur, and tibia; next, the jaws, pelvic bones, and scapula; they may spring from the periosteum and from the medulla; new bone may form, layer after layer, producing a bony capsule which may continue for a long time.3 They are of slow growth, painless, rounded, nodular, and when very large prone to ulcerate. The treatment is removal when life is not endangered by the operation. Enucleation 2 is a method to be preferred when it can be effected, as in the bones of the hand, the elastic bandage being first applied to the limb; amputation is necessary when the growths are multiple or very large, or when the limb would be use- less after their removal;4 if the tumor is in the femur, disarticulation is advisable.5 2. Exostoses are manifestations of an increased physiological activity of the periosteum ; in the majority of cases some general disease, as syphilis, rheumatism, or rickets, has a part in their causation, though an injury is often the assigned cause.3 They frequently occur in the multiple or diffuse form. They may con- sist of (1) spongy bone-substance, which occurs almost exclusively on the epiphyses of the long bones, outgrowths from the epiphyseal 1 R. Moxon. 2 Sir J. Paget. 3 £. Rindfleisch. * T. Holmes. 5 T. Billroth. 104 OPERATIVE SURGERY. cartilages, but from the first being intimately connected with the spongy substance of the epiphyses; (2) compact bony substance, ivory-like, which develops on the bones of the face, skull, pelvis, scapula, great toe; (3) ossification of tendons, fascia, and muscles, where they are attached to bone. These tumors form without pain, and are inconvenient when in the vicinity of joints or on the toe, and unsightly when on the face or head. The only treatment is ex- cision, which is neither advisable nor necessary, unless the impair- ment of function be so great as to balance an operation dangerous to the joint and to life, for these tumors in time cease to grow. On epiphyseal exostoses mucous bursae are often found, usually com- municating with the joint, which are liable to be opened and lead to unfortunate results.1 These growths do not return when removed.2 When they appear on the great toe the phalanx should be ampu- tated. The ivory exostoses of the skull owing to their hardness are generally excised with extreme difficulty by means of saw and chisel, and the violence involves very great danger. As they may exist without other inconvenience than the deformity which they cause, the risk of excision should not be lightly incurred. An ex- ception must be made in the case of ivory exostoses of the orbit, as the gradual growth of such tumors displaces the eye, causing blind- ness, by stretching the optic nerve, and a hideous squint; the base, usually attached to the inner or outer angle of the root of the orbit, is often small, and when fully exposed can be partially cut with a fine saw, and then broken with the chisel and mallet.3 Exostoses of the antrum often have very small bases and are removed without difficulty on opening the front wall of the cavity. 3. Sarcomata comprise two groups, namely, the external and the internal, the former springing from the periosteum and the latter from the medulla. The periosteal growths embrace for the most part the hard forms, namely, the fibro, chondro, and osteoid sar- comata; they take their origin from the layer of the periosteum next to the bone, while the external layer often remains as a fibrous in- vestment which, by its unyielding character, retards the growth; the cortical portion of the bone is not at first involved, and if very thick, as in the diaphysis of long bones, it may become only super- ficially affected, but if the tumor appear where sponoy bone is near the surface, as in the epiphyses of long bones, the growth spreads into the medullary spaces and it is difficult to distinguish periosteal from medullary sarcomata.4 They are quite malignant 1 and usually con- tain all the varieties of sarcoma tissue, but the spindle cell-tissue predominates in most cases, especially in those enormous tumors which are developed on the ends of the great bones of the extremi- 1 T. Billroth. 2 e. Rindfleisch. 3 T. Holmes. 4 R. Virchow. THE DISEASES OF BONE. 105 ties.1 The medullary form, myeloid tumor,2 myelogenic osteo-sar- comata,8 appear especially in the jaws, as epulis; 4 next in the tibia, radius, and ulna; these tumors often contain mucous cysts and spherical or branched osseous formations, circumscribed nodules mostly forming in the medullary cavity, which gradually destroy the bone; but new bone is constantly developed from the periosteum, so that the tumor, if very large, often remains covered, entirely or partially, by a shell of bone, which appears puffed up like a blad- der; in the lower extremity they become very vascular; small trau- matic aneurisms develop in them with the true aneurismal murmur; cysts also develop in them; they are usually solitary, rarely generally infectious; they appear in the jaws at the second dentition, and in the long bones at middle age.5 When the growth is periosteal the fibrous tumor resembles it, but the sarcoma is softer, more elastic, and vascular; when Avithin bone it is difficult to distinguish sarcoma from other innocent tumors; it differs from cancer chiefly in that it is of slower growth, has a broadly rounded shape, and its seat is in the articular end rather than in the shaft of a bone; in the absence of glandular disease and of all cachexia, though three or four years may have elapsed.2 Excision is the only available remedy, and should be resorted to without delay, the base being thoroughly re- moved.2 4. Fibromata 5 springing from the periosteum are quite frequent, and are generally composed of fibres and spindle-shaped cells; the latter may preponderate, giving the growth the character of a fibro- sarcoma ; the periosteum of the bones of the skull and face, especi- ally the inferior turbinated bones, is particularly liable to this dis- ease ; in the latter position the tumors appear as naso-pharyngeal polypi ; these tumors may form in the interior of bone, especially in the upper jaw; they are most common in the young, but after puberty. They are hard, round, of slow growth, and without pain. The treatment is removal by enucleation. 5. Carcinomata occurring in bone may originate by a propagation of the infiltration from cutaneous, mucous, or glandular cancers ; but cancer apparently also appears originally in bone, though it may have an epithelial origin, as in case of those soft and quickly grow- ing cancers which spring from the upper end of the humerus and • femur, at one time from the medulla and at another from the periosteum.1 It may assume various forms, namely, encephaloid, which is most common, scirrhus, and epithelial. The diagnosis 2 in obscure cases must be made in favor of cancer (1) when the tumor commences growth before puberty or after middle age, unless 1 E. Rindfleisch. 2 Sir J. Paget. 3 R. Virchow. 4 E. Nelaton. 6 T. Billroth. 106 OPERATIVE SURGERY. it is a cartilaginous or bony tumor on a finger or toe, or near an ar- ticulation ; (2) when the tumor on or in a bone has doubled, or more than doubled, its size in six months, and is not inflamed; (3) if, in ad- dition to rapid growth, the veins over the tumor have much enlarged, or the tumor has protruded far through ulcerated openings, bleeds, and discharges matters; (4) if, though the tumor is not inflamed, the neighboring lymph glands are also enlarged; (5) if the patient has lost weight and strength out of proportion to the damage to health by pain or fever or other accident of the tumor; (6) if situated on the shaft of any bone but a phalanx. The treatment of all forms of cancer of bone must be by amputation when the disease is local; the point selected must be as far as it may be safe to operate from the seat of the malignant growth.1 III. INFLAMMATION OF BONE. The morbid changes included under the term inflammation of bone are' remarkable for their clinical diversity and singular ana- tomical uniformity; there is no deviation from the physiological type, except where pus forms, which introduces infinite complica- tions into the whole course of the inflammatory process, as repair can be brought about only by circuitous methods.2 1. Periostitis, acute, occurs chiefly in young persons, and in its typical forms almost exclusively in the long bones, as the femur and tibia; at first there is high fever, not unfrequently a chill, severe pain in the affected part; swelling without redness ; skin tense and usually oedematous; every touch or jar is very painful. The inflam- mation may resolve at this stage, or progress to suppuration, when additional symptoms appear: the swelling now increases, the skin becomes reddish, then brownish red, the oedema extends, the neigh- boring joint becomes painful and swells, and towards the twelfth day fluctuation is detected.3 The inflammation often occurs in the periosteum of the third phalanx, felon, causing great suffering, and terminating in necrosis. In the early stage of the disease in the long bones apply the strong tinct. iodine, and repeat when the vesicles dry up;3 add ice, if, when applied until the deeper parts are cold, it is agreeable and the pain subsides. When effusion takes place and is confined beneath the dense fibrous periosteal layer, free incision down to the bone gives immense relief; as the object is to relieve ten- sion, the incision should be made as soon as this condition clearly exists, though pus may not have formed ; this practice is especially important when the upper part of the shaft or the articular end of a bone is affected.4 The local applications should now be soothino-, as fomentations, and carbolized solutions should be freely used in 1 Sir J. Paget. 2 E. Rindfleisch. 3 T. Billroth. 4 T. Bryant. THE DISEASES OF BONE. 107 the wound to arrest septic changes. Pus should be freely evacuated wherever it may be found, and free drainage secured by position or drains. The general treatment should consist of anodynes, with laxatives and low diet, to relieve pain and inflammation; and tonics and nutritious food when suppuration is established. 2. Osteo-myelitis, acute, is an inflammation of the medulla of bones; it occurs in the young and is generally caused by injury ; the symptoms are, intense aching pain at the seat of inflammation which is relieved only by perforation of the bone; swelling, which begins as a puffiness but has a peculiarly abrupt margin and as the disease spreads advances up the limb; red and hepatized appearance of the marrow, seen in the bone of a stump; globules of oil mixed with the pus discharged; irritative fever with great restlessness, and in bad cases delirium.1 The symptoms so closely resemble those of suppurative periostitis that in many cases it cannot be discovered whether only the periosteum is affected or the medulla also; but if while there is great pain and fever, or complete inability to move the limb on account of pain, swelling does not occur for several days, it is to be inferred that the seat of the inflammation is the medullary cavity.2 The inflammation may induce acute periosteal abscess, thrombosis, pyaemia, necrosis, and the separation of the epiphysis by the suppuration of the epiphyseal cartilage. The indications of treatment are : removal to the open air; elevation of the part, but with depending opening for free discharge of pus; local applications of ice when agreeable to the patient; free use of disinfectants; ap- plication of the strong tincture of iodine; tonics, as quinine and iron. If antiphlogistic remedies fail and the pain increases to a violent degree, make free incision and trephine the bone to relieve the ten- sion ;8 if the integrity of the bone is destroyed, resect, or amputate. Amputation in the continuity of the affected bone is injurious, but disarticulation of the bone at an early period, before pyaemia occurs, has given good results.1 It is maintained that extensive wounds are bad in feverish patients, and pre- dispose to pyaemia, and that disarticulation is erroneous because, first, the diag- nosis is not certain, second, the results obtained are uncertain, and, third, the prognosis in exarticulation of large limbs, for acute disease of the bone, is always doubtful.2 IV. CARIES OF BONE. Periostitis and osteo-myelitis may terminate in circumscribed sup- puration, which results in ulceration or caries of bone. 1. Superficial caries corresponds to an indolent ulcer of the skin; the surface of bone exhibits a loss of substance which gradu- 1 J. A. Lidell. 2 T. Billroth. 3 L. Bauer. 108 OPERATIVE SURGERY. ally increases in depth, but remains shallow, and continually throws off small quantities of pus and shreds of decaying structures, de- rived from the denuded medullary tissue, which at a certain depth is in a state of hyperaemic proliferation, passing near the surface into an exceedingly dense corpuscular infiltration; the cells occupy all the pores of the bone tissue and leave no room for blood or blood-vessels, which are finally converted, with the cells, into molec- ular debris.1 The symptoms are tenderness, oedema, severe boring and tearing pains at night.2 The process of cure consists in the de- tachment and removal of the necrosed portions or particles of bone, cessation of the process of proliferation, shrinking together of the interstitial granulation tissue, and its transformation into cicatricial tissue.2 The indications as to general treatment are the improve- ment of the health by tonics and hygienic measures; the local treat- ment is: (1) Removal of the purulent debris; (2) arrest of the ca- rious process; (3) healing of the surface. If the caries affects the shaft of a long bone, easily accessible, as the tibia, expose the carious bone by a free incision, whether the pus is still contained in an ab- scess or is escaping from a sinus; cleanse the exposed surface of all foreign matters; very gently remove, with forceps or periosteal knife or gouge, every particle of dead bone, without injury to the living bone; apply the strong solution of carbolic acid, 1 in 20, to the surface of bone; complete the dressing by packing the wound with carbolized oil, 1 in 10; place the part in a condition of perfect rest, using plastic apparatus if necessary; renew these dressings only when required for cleanliness, and change the application to bals. Peru when granulations cover the bone. 2. Central caries usually begins in a hollow bone as an osteo- myelitis; the inflammation extends to the inner surface of the cor- tical substance, which is dissolved, and pus may form quite early in the centre of the new formation, creating what is known as a bone abscess; the periosteum is thickened, new bony deposits form from the surface of the bone, and the hollow bone is thus enlarged exter- nally at the point where the abscess forms, giving it the appearance of inflation; the central caries may be accompanied by partial necrosis of portions of bone on the internal surface of the cortical substance.2 These bone abscesses more often form in the spongy portion of long bones, especially of the tibia. The symptoms are very often uncer- tain, as the chronic inflammation may exist deep in the bone; there may be only a dull pain, with but slight impairment of function; it is only when there is severe pain on pressure and oedema of the skin, showing that the periosteum is involved, that the case becomes more apparent; but it may happen that the true state of the disease can 1 E. Rindfleisch. 2 T. Billroth. THE DISEASES OF BONE. 109 be determined only when perforation has taken place and the probe may be passed into the cavity.1 The most reliable symptoms, when present, are severe, long continued, and paroxysmal pain and local swelling, often at a single point, where there is extreme tender- ness on pressure.2 The treatment is trephining; mark on the skin the precise spot where the tenderness and pain are located; give an anaesthetic and make a crucial incision down to the bone, raise the periosteum to the requisite extent, and with the trephine open the cavity.2 If no pus is found, puncture the surrounding bone with a strong awl or drill, for the pus has been found just beside the track of the trephine.3 The abscess cavity should be cleansed and filled with pledgets of lint saturated with bals. Peru. A less severe operation is at times of equal value, namely, puncture with a drill, especially when the seat of the abscess is not well defined.4 3. Internal and external caries maybe accompanied by necrosis and by suppuration or osteo-plastic periostitis in the same hollow bone; abscesses appear at different points; rotten bone and a seques- trum may, at the same time, be felt with a probe; at one point the surface is exposed, and at another the interior; the whole bone is thickened, as is the periosteum; thin pus escapes from the fistulous openings; the surface is thickly covered with porous osteophytes; necrosed portions lie here and there; the medullary cavity is partly filled with porous bony substance, and round holes are found con- taining necrosed bone.1 The proper treatment of a bone in this condition is usually extirpation or amputation, as recovery cannot be expected by any method of treatment.1 V. NECROSIS OF BONE. The complete arrest of nutrition in a certain portion of bone, which results in its death, is usually due to suppurative periostitis as a prox- imate cause, even in traumatic cases, though not an invariable con- sequence; the pus excites a sequestrating inflammation both in the periosteum and the bone; the former being converted into a pyogenic membrane, is separated from the bone, while a fungating ostitis, fed by the medulla, is set up in the bone, which shuts off the organism by granulation tissue; the dead bone is called the sequestrum, and the fungating ostitis which separates it, demarcation; the detached periosteum develops a layer of new bone immediately under the pyogenic surface, forming a capsule, the involucrum, which incloses the sequestra.5 1. Partial necrosis of the diaphysis occurs when the outermost 1 T. Billroth. 2 C. Jackson. 3 T. Holmes. 4 T. Bryant. « E. Rindfleisch. 110 OPERATIVE SURGERY. layers of the compact substance of bone have been too long cut off from the circulation and nutrition to allow their vitality being re- stored from the medulla; the fungating ostitis does the work of a sequestrating inflammation, detaching the lamellae of dead bone and mingling them with the pus which fills the abscess cavity.1 The presence of dead tissue is recognized when it is exposed by its white appearance, with dark places if it is situated deeply. Only the probe introduced through sinuses can exactly determine its presence; in addition, there is increased thickness due to the new formation of bone. The treatment at first should be limited to keeping the fistulas clean; chemical solution of the sequestrum is liable to affect injuri- ously the new-formed bone, and thus do harm; mechanical removal of the dead bone is the only proper method; but it is important not to attempt removal until the dead is completely separated from the living bone, for the dead bone can rarely be detached without re- moving a good deal of the healthy and of the newly-formed bone; nor is the involucrum firm enough before complete detachment.2 The complete separation of a superficial sequestrum is generally easily made out with a probe. 2. Total necrosis of the diaphysis results from suppuration of the periosteum and medulla; the pus from the periosteum perforates the soft tissues and escapes, but that from the medulla falls to detri- tus or putrefies within the bone; the process of detachment is effected by an interstitial proliferation of granulations in the edges of the living bone by which a slight amount of bone is consumed; the se- questrum now lies loose in a pus cavity; this detachment of thick hollow bones requires months and sometimes more than a year; meantime the periosteum has formed a shell of new bone which in time becomes very thick, and finally compact.2 The probe is the guide to determine whether the bone is loose, but, it is difficult to decide on the mobility of a large sequestrum, especially when the bone is curved, as the lower jaw; the duration of the process and the thickness of the bony case are important aids; most sequestra are usually detached in eight or ten months, and in a year, even an entire diaphysis usually becomes detached, completely separated from its connections.2 The treatment is, in general, the same as in partial necrosis; but this distinction must be made, namely, if the formation of bone be still weak, though the sequestrum be already detached, it is well to postpone the extraction in case of the humerus, tibia, and femur, so that the formation of bone may be firmer;2 it may be necessary occasionally to resect when no new bone exists.3 1 E. Rindfleisch. 2 T. Billroth. 3 T. Holmes. THE OPERATIONS ON BONES. Ill CHAPTER XIV. GENERAL OPERATIONS ON THE BONES. I. SEQLESTROTOMY. The removal of necrosed bone may be effected by successive slight operations by which the periosteum is gradually separated from the dead mass, the indirect method, or by a single formal operation, the direct method. 1. The indirect methodx is to be preferred when the bone is superficial and it is desirable to preserve its contour,2 as in the removal of large sections of the tibia, the lower and upper jaw, the clavicle. This method consists in separating from time to time the diseased periosteum from the bone beneath with the handle of the scalpel or with a small spatula, the periosteum not being raised beyond the limits of the disease. By this means free escape for pus is constantly maintained, the new-formed bone becomes more per- fectly adapted to the space occupied by the old, and the tissue of the new structure is more firm. When at length the sequestrum is sep- arated it is readily raised from its bed with scarcely the appearance of blood, and the shape and function of the bone is largely pre- served. 2. The direct method is often tedious, and much complicated by the oozing of blood into the wound; to avoid bleeding, the ves- sels of the limb should, as far as practicable, be emptied of their blood; as the elastic bandage, so effectual in removing blood from the limb, would be liable to force infectious matters into the meshes of the cellular tissues, and the extremities of lymphatic vessels, it is better to empty the limb as completely as possible by causing it to be raised high in the air for a few moments, and then apply the elastic bandage or tubing above the point of operation.3 The operation is as follows:* If the opening in the bony case is large, and the sequestrum small, attempt the. direct removal with strong forceps through this opening; if this is impracticable, with a stout knife make an incision through the soft parts down to the bony case from one fistulous opening to another; with a periosteotome draw the thickened soft parts from the rough surface of the bony case to just sufficient extent ; remove this exposed portion with a saw,, or a chisel and hammer, or gnawing forceps; the sequestrum being ex- posed, attempt its removal by elevators or strong forceps; first move it gently in its case in different directions until free from all spiculae; 1 J. R. Wood. 2 Yon Langenbeck. 8 F. Esmarch. 4 T. Billroth. 112 OPERATIVE SURGERY. if the sequestrum is not detached, avoid forcing it out, but wait a few weeks or months until its separation is complete. After the operation the suppurating cavity is to be kept clean, and the parts maintained in a state of rest; the ossifying granulations fill the cav- ity slowly, and the fistulae may remain open for a long period, but the process of closure cannot be hastened unless the walls become sclerosed and cease to granulate, when the application of the hot iron to the cavity, or the chisel to the fistulae, may be beneficial. II. RESECTION. Extirpation of bone in part or whole is frequently required, as after injuries which have destroyed their vitality, or after diseases which have resulted in necrosis, or in the removal of tumors. But such an operation is justifiable only when it is evident that resection is preferable to every other remedial measure.1 When the opera- tion is undertaken it must be so planned and executed as to become the first step in a process of repair by which a part is restored to more or less complete usefulness that would otherwise have been sacrificed.2 1. The indications for resection must be determined by the con- dition of the patient and of the diseased part. In general the opera- tion is indicated only when the general health admits; for if the patient is suffering from a progressively wasting disease, as tubercu- losis or marasmus, which will necessarily prove fatal, resection would be unwise, as repair would not follow.8 In injuries, as gunshot, only such fragments of bone should be removed as are nearly or quite detached from the periosteum. In caries of hollow bone the ulcer may be thoroughly cleaned out with the gouge and the cavity be allowed to close by granulation,4 but if the bone is small, extirpation may be necessary to arrest the process at once.8 If a hollow bone is affected throughout, as with periostitis, external and internal caries, partial internal and external necrosis, extirpation of the entire bone may be required, as the only alternative of amputation.8 Tumors of bone,5 if not malignant, must be removed from their lo- cality, but if malignant, extirpation of the bone or wide resection is necessary. 2. The time of operating after an injury, as a gunshot, should, if possible, be within twenty-four hours of the accident, or pri- mary ; if it is delayed beyond this period it should not be performed until the intermediary stage of inflammation is passed.6 If the bone is necrosed the invariable rule should be not to attempt removal before complete detachment, because the dead bone can rarely be 1 F. C. Skey. 2 A. Wagner. 3 T. Billroth. 4 C. Sedillot. 5 Sir J. Paget. 6 G. A. Otis. THE OPERATIONS ON BONES. 113 sawed out without removing healthy and newly-formed bone; and the new bone is not firm enough before the sequestrum is detached.1 Fig. 75. Fig. 76. 3. The instruments required in resection may be few or many, both in number and variety, according to the nature of the case. (1.) The knife (Figs. 75 and 76) should be broad and firmly set in a Fig. 77.2 Fig. 78.3 Fig. 79.4 rou-1X^fo~'V to the spine, the trapezius and del- toid ; to the superior border, the omo- hyoid : to the vertebral border, the serratus magnus, levator anguli scap- ula;, rhomboideus major and minor; to the axillary border, the triceps, teres major and minor; to the glen- oid cavity, the long head of the bi- ceps; to the coracoid process, the short head of the biceps, coraco- brachialis, and pectoralis minor; it articulates with the humerus and clavicle; the subscapular artery, the largest branch of the axillary, de- scends along the outer border. («.) The body (Fig. 109) may be removed to a greater or less extent. Make three incisions, one over the whole length of the spine, a, d, and the other two extending from its extremities, one upwards to the root of the neck, a, {, the other downwards to the angle d, f; dissect the triangular flaps from the supra and infra spinatus fossae, saw through the root of the acromion, and denude the posterior and anterior surfaces of the bone; reverse the body of the scapula from within outwards, and divide the part at the proper point with the saw.3 Fig. 109. 1 G. A. Otis. 2 S. Rogers. 3 A. Velpeau. 128 OPERATIVE SURGERY. Or make a longitudinal incision extending from the superior to the inferior angle along the vertebral border, f, b, a second parallel incision extending from the neck of the acromion to the middle of the external border, a, e; a trans- verse incision unites these along the spine; dissect the flaps, detach the muscles posteriorly and anteriorly, and divide the bone with the chain saw or forceps. For a tumor, make an incision commencing at the superior angle of the scap- ula in a direction obliquely downwards and inwards; a second incision five inches below the upper end of the first, having a curvilinear direction termi- nating about the same distance from its lower end ; dissect the integuments to- wards the axilla and spine, detach the muscles, separate the acromion and the neck of the scapula, and remove the bone.1 (b.) The spine, acromion process, and angles may be separately re- sected. The spine may be readily exposed, owing to its superficial position, by an incision made parallel to its border (c, d) ; if required, the incision may be curved downwards so as to raise a flap; the bone being denuded, the diseased portions may be removed with a strong cutting forceps. To resect the acromion2 make a semilunar incision at the posterior part of the shoulder with the convexity downwards; pass the chain saw under the narrow part of the neck of the acro- mion, divide the bone at this part, and disarticulate ; or make a cru- cial or T incision, or follow the track of sinuses which may exist. An angle of the scapula may be resected by a transverse, or a V, or a crucial incision over the part. In resection of a border, make the incision parallel with the part to be removed. (c.) The entire scapula is removed as follows 8 : Make an incision from the acromion process to the posterior edge of the scapula (/, e,) and another from the centre of this one downwards (c, g); reflect the flaps thus formed, separate the scapular attachment of the del- toid, and divide the connections of the acromial extremity of the clavicle ; to command the subscapular artery, divide and tie it with- out delay; next cut into the joint, and round the glenoid cavity, hook the finger under the coracoid process, so as to facilitate the division of its muscular and ligamentous attachments, then pulling back the bone forcibly with the left hand, separate its remaining at- tachments with rapid sweeps of the knife. The sub-periosteal re- section may be made by the same incision. The scapula may be removed by any of the methods given for the excision of a part of the body; other methods have been adopted, namely, a flap formed by the incisions a, b, and b, h; or a, d, joined at the extremities by b, h, and A, E. 8. The clavicle" has such immediate relations to the upper walls of the thoracic cavity that operations for its extirpation must be cautiously performed.4 In shot fractures, detached splinters should always be immediately extracted; but extirpation of the bone for 1 S. D. Gross. 2 E. Chassaignac. 3 J. Syme. * V. Mott. THE OPERATIONS ON BONES. 129 such injuries will seldom be required, though when the wound is un- complicated by serious injury of the lung, nerves, or great vessels, it does not appear that the operation is necessarily fatal.1 Necrosed bone should be cautiously removed in order not to injure neighbor- ing parts. The removal of morbid growths involving the clavicle is sometimes the most serious operation in surgery.2 (a.) The scapular extremity is broad and flat, and gives attachment on its posterior part to the trapezius, and on its anterior to the del- toid; it is bound to the acromion by a superior and inferior ligament, and to the coracoid process by the coraco-clavicular, or coracoid and trapezoid ligaments. Resection is as follows : make a crucial incis- ion, of sufficient length; raise the flaps, cut the attachments of the deltoid and trapezius muscles and acromio-clavicular ligaments.3 Or, make a curved incision, with its convexity forwards and a little outwards, which, reflected backwards, completely exjwses the bone; divide with the chain saw, seize it with the forceps, and divide the ligaments, raise the bone, and detach.4 For a tumor, make a crucial incision through the integuments and the plat- ysma uiyoides, one limb nearly in a line with the clavicle, and the other at right angles, and dissect the flaps and facial coverings successively, down to the ex- ternal basis of the tumor ; carefully detach the pectoralis and deltoid muscles from their clavicular origin, avoiding the cephalic vein, and divide on a direc- tor the fibres of the trapezius and the cleido-mastoid muscles. Disarticulate the scapular extremity of the bone, and the mobility thus communicated to the mass facilitates the completion of the operation; pass a director beneath the bone, as near to the sternal articulation as practicable, and with a pair of strong bone nippers divide it; detach the subclavius muscle and rhomboid ligament.5 Or, make an elliptical incision from the middle of the clavicle backwards, over the most prominent part of the tumor.6 (b.) The entire clavicle may be resected for necrosis: Make an in- cision parallel to its inferior border extending a little beyond its extremities ; or add two vertical incisions, of one to two inches in length, one on the outside, the other on the inside of the first in- cision- the flap resulting from which divisions, on being raised up, completely lays bare the bone; then disarticulate either the sternal or acromial extremity, and grasp it with the left hand in order to raise it up, while with the right detach with the bistoury the ad- hesions upon its lower border; or saw the bone through its middle, and remove the two halves separately. For a tumor operate as follows : Make an incision from the acromial extrem- ity of the clavicle to the external extremity of the clavicle of the opposite side; cross this by an incision at right angles with it, beginning just below the middle of the sterno-mastoid muscle, and extending to the face of the pectoralis muscle below the middle of the clavicle; dissect the four flaps from the surface of the 1 G. A. Otis. 2 V. Mott. 3 A. Velpeau. 4 E. Chassaignac. 5 B. Travers. 6 J. Syme. 9 130 OPERATIVE SURGERY. tumor; dissect the deltoid muscle from its anterior edge, and the trapezius from its posterior edge, and divide the coraco-clavicular ligament; pass the chain saw and divide the bone; seize the fragment with the forceps, and detach the soft parts with the point of the knife, the edge being kept constantly turned to- wards the bone, in order not to make the slightest wound of the soft parts.1 (c.) The sternal extremity is of a triangular form, and has the fol- lowing important relations: — On its postero-superior surface to the sterno-mastoid and sterno-hyoid mus- cles, and on its anterior surface to the pectoralis major muscle; poste- riorly it is in near relation with the pleura, internal mammary artery, subclavian vein, and transverse cer- vical artery; the innominata is on the right, and the thoracic duct on the left side. Resect as follows : Make (Fig. 110) an incision curved downwards, the degree of the curvature depending upon the size of the bone, but always so arranged as to enable the ope- rator to raise it by dissection to the upper part; after rais- ing the flap, instead of sepa- rating the muscles, pass a chain saw at the point where the bone is to be divided; remove the frag- ment by carefully disarticulating it with the point of the knife, and avoid wounding the important parts posteriorly. For a large tumor, the following operation was performed : A semilunar in- cision, exposing the pectoralis major muscle, was made from the sterno-clavicu- lar articulation, the extent of the tumor, and an incision was made from the outer edge of the external jugular vein, over the tumor, to the top of the shoul- der, the platysma myoides and a portion of the trapezius divided, the bone ex- posed external to the coracoid process, and divided with the chain saw; another incision was made over the tumor from the sternal extremity of the clavicle to the termination of the first incision at the external jugular vein; in the subse- quent dissection, owing to the large size of the tumor, the external jugular was tied, and the outer portion of the sterno-mastoid muscle was divided; the hami- orrhage was excessive.2 Fig. 110. BOXES OF THE LOWER LIMBS. The lower limbs are employed in support and progression, and hence resections should be so performed as to preserve stability of the bones. 1. The phalanges of the toes may be resected by the methods 1 J. C. Warren. 2 y. Mott. THE OPERATIONS ON BONES. 131 given for the corresponding bones of the fingers. Resection of the shaft of a phalangeal bone may be by a straight incision on the dor- sum, the extensor tendon being drawn aside; or the incision may be on the lateral surface of the joint and curved downwards ; the bone may be divided with the forceps. The great toe is of the utmost value in progression, and in removing diseased bone every effort must be made to retain periosteum, with a view to the preservation of its function. 2. The metatarsal bones may be partially or entirely removed. (a.) In resection of the phalangeal extremity of the metatarsal bones, make a straight incision on the dorsum of the toe, over the part to be removed, avoiding the extensor tendons, divide the bone with forceps or saw, and disarticulate; in operating upon the first and fifth, the incision may be upon the free lateral surface, and it may be straight, or curved.1 Resection of the extremity of the first metatarsal bone is made by an incision on the outside of the joint; denude the bone to the point at which it is to be cut, and saw it perpendicularly to its axis; then detach it from the soft parts, pro- ceeding from behind forwards and complete the resection by sepa- rating it from the phalanx, (b.) In resection of the shaft of meta- tarsal bones, the same incisions are practiced on this part of the metatarsal bones as at the extremities; in removing the body of the first and fifth, a curved incision more completely exposes the bone (Fig. Ill); the chain saw should be used to divide the shaft of the first metatarsal bone, (c.) The resection of the tarsal extremity of. the metatarsal bones requires the same incisions as have been given for resections of the phalangeal extremities of the metatarsal bones. The chief obstacles in the disarticulation are the interosseous liga- ments which unite the metatarsal bones together. The incision should freely expose the articulation, and the bone being divided, it should be raised with the forceps, and disarticulation effected with the point of the knife, (f/.) The resection of entire first and fifth metatarsal bones requires a curved incision with its convexity down- wards a, b, c (Fig. Ill), and ex- tending beyond the articulation; the bone being exposed, the middle of the shaft should be divided with the saw, and the fragments separately disarticulated. In the removal of the three middle metatarsal bones, a long straight incision should be made, the bone divided in its centre, and the operation completed as in the preceding case. 1 E. Chassaignac. 132 OPERATIVE SURGERY. 3. The tarsal bones are very liable to be involved in the artic- ular inflammations of that region, or to be separately affected by caries ; in either case they may require removal, singly or in groups. The results have been in the highest degree favorable, both as to mortality and the usefulness of the limb. These operations have never been performed according to any prescribed rules, but each operator has adapted his incisions to the exigencies of the individual case in hand ; in many cases the bones have not been resected entire, but the portion of bone diseased has been removed with a gou"-e. In the resection, care should be taken not to involve the synovial membrane of adjacent articulations, which do not commu- nicate with the joint involved; and, whenever practicable, the peri- osteum should be preserved. The individual bones may be resected by the following methods, and by a combination of these incisions two or more bones may be removed at a single operation. 1. The cuneiform or wedge bones are placed at the fore part of the tarsus; they articulate behind with the scaphoid, and in front with the metatarsals of the three inner toes; the second bone is the smallest, and does not reach as far for- wards, so that the second metatarsal is more deeply set in the tarsus. Resec- tion1 is as follows: Make an incision on the outer side of the foot, extending from the centre of the outer margin of the plantar surface of the os calcis to the middle of the metatarsal bone of the little toe, 1, 1 (Fig. 112); make an- other incision on the inner side of the foot from the neck of the astragalus to the middle of the metatarsal bone of the great toe, 1, 1 (Fig. 113); carefully Fig. 112. Fig. 113. dissect off the dorsal and plantar surfaces from the outer and inner sides until the bones to be removed are completely exposed, the thumb of the left hand being the guide to the point and edge of the knife in keeping close to the surface of the bones, and avoiding injury to the important structures contained in the soft parts; insert between the soft parts and the bones a curved probe-pointed bistoury across the line of articulation between the astragalus, scaphoid, cal- caneum, and cuboid, first upon the dorsal, then upon the plantar surface, and open up these joints; now introduce a key-hole saw between the plantar soft parts and the shafts of the metatarsal bones and cut them through, the handles of forceps or other body being inserted between the metatarsal bones and the dorsal soft parts to protect the latter. The wound must be firmh' plugged with pledgets of lint, and the foot supported with properly applied splints. 2. The cuboid is situated on the outer side of the tarsus, wedged in between 1 P. H. Watson. THE OPERATIONS ON BONES. 133 the os calcis and fourth and fifth metatarsal bones; internally it articulates with the third cuneiform equally with the scaphoid; the inferior surface is grooved for the tendon-of the peroneus longus.1 Resect as follows: Make two incisions, 3, 3 (Fig. 112), one from the posterior extremity of the fifth metatarsal backward about two inches, the other of the same length from the same point along the dorsum inclining slightly forwards; raise this flap, and drawing aside the ten- dons of the peroneus longus and brevis, open the joints, and raise the bone with strong duck-bill forceps introduced from the free margin. 3. The scaphoid presents posteriorly a concave surface, as part of the socket of the head of the astragalus, anteriorly it has three facettes for the three cunei- form bones, externally it has a small facette for the cuboid, and internally it presents a free surface having a small tubercle.1 Resect thus: Recognizing the tubercle, make a curved incision, the convexity downwards, extending from one inch posteriorly to the same distance anteriorly, 2, 2 (Fig. 112); raise this flap, and separate the soft tissues from both surfaces of the bone; with a strong knife, separate the joints anteriorly and posteriori}'; seizing the bone with strong duck-bill forceps, raise and depress the bone, meantime detaching the ligaments with the knife. 4. The astragalus has most important connections; above it articulates with the tibia, laterally with the malleoli, and below with the calcaneum by two sur- faces. It is attached to the calcaneum by the interosseous, posterior, and ex- ternalligaments; and to the scaphoid by a ligament passing from its anterior extremity. Resection may be made with slight injury to the tendons which pass over that region or by their destruction. The former methods are very tedious, but, unless sloughing occurs, give the best results. Resection is as follows: Make a superficial incision2 from the tendon of the tibialis anticus, curved forwards and outwards to the middle of the scaphoid, thence backwards to a point below the external malleolus; raise the tendons and draw them aside, except the ex- tensor brevis which should be cut; expose the bone, seize it with forceps, sep- arate its attachments with the point of the knife, while the foot is strongly inverted. By the latter method, proceed as follows 3: Make a curved incis- ion from one malleolus to the other; lay the ankle joint freely open, exposing the whole upper part of the diseased bone; sever the ligaments attaching it to the scaphoid; raise the bone with a lever, and divide the interosseous ligament uniting it to the os calcis; clear the back part of the bone carefully to avoid injury to the tendons and vessels which lie near. 5. The os calcis has been frequently removed, and with marked success, as regards the mortality; the part remains very useful for walking and stand- ing.4 The bone articulates above with the astragalus by two articular surfaces having an interosseous ligament; in front with the cuboid, to which it is firmly bound by four ligaments, two plantars, which are very strong, a dorsal and in- terosseous. Resection has been made by numerous methods, but the plantar flap (Fig. 114)s gives ready access to the bone, and removes the cicatrix from the plantar surface. The patient lying upon his face, make a horse-shoe incis- ion; carry it from a little in front of the calcaneo-cuboid articulation around the heel, along the sides of the foot, to a corresponding point on the opposite side ; dissect up the elliptic flap thus formed, the knife being carried close to the bane, and thus expose the whole i L. Holden. 2 L. Oilier. 3 T. Holmes. « M. Polaillon. 5 J. E. Erichsen. 134 OPERATIVE SURGERY. under surface of the os calcis; then make a perpendicular incision about two inches in length behind the heel through the tendo-achillis in the mid line and into the horizontal one; detach the tendon from its insertion, and*dissect up the two lateral flaps, the knife being kept close to the bones from which the soft parts are well cleared; then carry the blade over the upper and posterior part of the os calcis, open the articulation, divide the interosseous ligaments, and then bv a few touches with the point, detach the bone from its connections with the cuboid. Or, make an incision clown to the bone from the inner edge of the tendo-Achillis horizontally forwards along the outer side of the foot, somewhat in front of the calcaneo-cuboid joint, midway between the outer malleolus and the end of the fifth metatarsal; it should be on a level with the upper border of the os calcis; make a second incision vertically across the sole of the foot from the anterior end of the former incision to the outer border of the grooved or internal surface of the os calcis. 4. The fibula may be resected in whole or in part with the best results. («.) The lower extremity articulates through the malleolus exter- nus with the astragalus; it also articulates with the tibia by a convex surface, the joint being continuous with that of the ankle. The ligaments are, the interosseous, which passes between the two bones, and is continuous above with the interosseous membrane; a flat triangular band ex- tending between the two bones, anteriorly; the inferior ligament occupying the same position posteriorly; the transverse ligament extending from the external malleolus to the tibia. Resect thus (Fig. 115): Make a straight incision over the bone the entire length of the diseased part; separate the periosteum, pass the chain saw, and divide bone; seize the frag- ment with the forceps, and resect. (&.) The shaft of the fibula gives at- tachment to muscles by all its surfaces, and by its internal border to the in- terosseous membrane; expose the bone by a straight incision, pass the chain saw, and divide the shaft at proper points above and below the disease. (c.) The upper extremity of the fib- ula articulates with the external part of Fig. 115. the head of the tibia; this articulation communicates with the knee-joint. Its ligaments are the anterior superior ligament, two or three flat bands, which pass obliquely upwards from the head of the fibula to the outer tuberosity of the tibia, and the posterior superior ligament, a single thick and broad band which passes from t'he back part' of the head of the fibula to the back part of the outer tuberosity of the tibia. THE OPERATIONS ON BONES. 135 The resection is effected by the straight incision; divide the bone with the chain saw, raise the diseased part with the forceps, and effect the resection with the point of the knife. ((/.) In resection of the entire fibula make an incision parallel with the bone its entire length, separate the soft parts with the periosteum, and divide the bone in the centre with the chain saw; now disarticu- late each fragment separately. 6. The tibia is subjected to resection more frequently than any other long bone, owing to its subcutaneous situation. The results are most favorable, as new bone is readily reproduced when the periosteum is well preserved.1 The tibia is bound to the fibula by the following ligaments: the anterior, a flat band of fibres; the posterior, somewhat triangular; the transverse, long and narrow, and below the posterior. The internal lateral ligament unites the lower border of the internal malleolus to the astragalus, os calcis, and scaphoid. (a.) The lower extremity forms the upper and internal part of the ankle-joint; it is closely invested with tendons, and upon its pos- tero-internal border the posterior tibial artery and nerve pass to the foot. Resection by the subperiosteal method of the entire diaplr\>is and lower epiphysis has resulted in reproduction of the bone removed and a useful limb.2 Make a straight incision along the crest to the ankle-joint; saw the bone at the requisite height; raise the bone from its periosteal bed by carefully separating the periosteum; dis- lodge the tendons from their grooves, divide the ligamentous struc- tures, and complete resection by detaching the bone from the articu- lation. (b.) The shaft of the tibia is subcutaneous on the anterior and inner part; exsection of this portion is a comparatively simple opera- tion ; on the posterior part it gives attachment to muscles, and along its external border is attached the interosseous ligament connecting it to the fibula. The operation will depend upon the extent of the disease, and the location of the sinuses if the disease is necrosis. The incision should be along the subcutaneous borders of the bone, and extend beyond the diseased portion; the periosteum should be thor- oughly separated from the shaft, and the bone divided with a chain saw at either extremity; the fragment is then easily separated. Or, make a long curved incision in the length of the bone, having its convex- ity backwards; dissect this flap up and turn it outwards; divide the bone at the proper points, and raise the fragment with forceps. As excision of the shaft of the tibia is generally undertaken for necrosis, the gouge is found useful in separating dead bone, and the mallet may be used freely; it is also frequently desirable to use the trephine. (c.) The upper extremity of the tibia is broad, and presents upon 1 L. Oilier. 2 D. W. Cheevers. 136 OPERATIVE SURGERY. its upper surface two cup-shaved cavities for articulation with the condyles of the femur. The ligaments which are attached to it are, anteriorly, the ligamentum pa- tellae, internally, the internal lateral, posteriorly, the posterior ligament, or the ligamentum posticum Winslowii, and within, the anterior and posterior crucial ligaments. The operative process is entirely subordinated to the degree, actual situation, and form of the disease; so that there may be occasion for the crucial, or the elliptical, or simple incision, and also for a va- riety of saws and bone-cutting instruments.1 When practicable, subperiosteal resection should always be performed. 7. The patella, though in immediate relation with the knee-joint, may be excised with good results. Make a crucial incision, the trans- verse branch being over the base of the bone, or a second transverse incision may be made near the apex; dissect the flaps off cautiously, and remove the bone or its fragments; the tendinous expansion sur- rounding the bone should be separated, and not divided, as far as possible. The antiseptic method should be strictly pursued. 7. The femur is the largest bone of the skeleton. Resections of different portions of the bone are very frequent and give satisfactory results, especially when the periosteum is preserved, as new bone is reproduced.2 (a.) The lower extremity is rarely removed, except in exsections of the knee-joints. "When it is necessary to operate for necrosis in this region, the sinuses are the safest guides to the dead bone. If, however, a formal operation is required, make a long straight or slightly curved incision on the external aspect of the knee, isolate the femur a little above the condyles, preserving the periosteum, and make section of the bone by the chain saw; the fragment is then made to protrude at the wound, seized with forceps, and disarticu- lated. (b.) The shaft of the femur gives attachment to muscles through- out nearly its entire extent, and to reach it without injury to the soft parts, the muscular septa must be followed, either along the antero- external region of the limb, or as indicated by the seat of the disease; the curved incision and the semilunar flap raised up from without inwards, and from behind forwards, may sometimes be necessary to lay bare the bone to a sufficient extent. The limb must be well supported by the gypsum or other dressing during the after treatment. (c.) The trochanter major gives attachment to the gluteus medius and minimus, and by its fossa to the external rotators. In resection make a free crucial incision through the skin and tendon of the glu- teus maximus, and when the surface is sufficiently exposed, use the 1 A. Velpeau. 2 T. Holmes; J. Bell. THE OPERATIONS ON BONES. 137 gouge to scoop away the affected parts; if the disease prove exten- sive, divide the attachments of the glutei to the upper and fore part of the process, and then remove the entire trochanter with saw and forceps. (d.) The upper extremity of the femur enters so largely into the exsections of the hip-joint that the methods of removal are essen- tially the same. BOXES OF THE TRUNK. The bones of the trunk form the walls of cavities containing vital organs, and give support to the limbs; resections are, therefore, gen- erally partial, and must be performed with such care and by such methods as will not impair these functions. 1. The vertebrae have been subjected to frequent partial resec- tions. The removal of loose fragments after severe injuries, as from shot, are perfectly rational, and have resulted in a fair measure of success.1 Resections of the arches or trephining the spine, is one of the most difficult2 and fatal operations in surgery, and practically without benefit. Eighty-five per cent, of terminated cases have proved fatal, and there is no well authenticated case of complete re- covery.3 The conclusion is inevitable that without much more posi- tive favorable evidence, resection of the arch cannot be accepted as an established operation.1 If resection is attempted, proceed with the operation as follows : 4 make a long incision above the ridge of the spinous processes, the middle of which is opposite the displacement; divide all the attachments of the muscles to the ar- ticular processes; as one end of each muscular bundle is separated from its attachment, it retracts and needs little holding back; the saw or the nippers are generally sufficient to divide the vertebral arch; in sawing or cutting out the arch, grasp the spinous process, if it be not broken, with a pair of stout tooth forceps, which are to be preferred to the elevator for lifting the detached bone from its natural connections ; a small crowned trephine may be used to cut through the vertebral arch, or Hey's saw. 2. The sacrum may be partially resected for the relief of pressure upon nerves as follows: Make a crucial incision; remove the spinous process of the bone with forceps and Hey's saw; apply a trephine, and make an opening, through which introduce bone nippers, and re- move the bone.5 3. The coccyx may be excised in whole or part for necrosis, fracture, and a painful affection, coccydinia, thus: place the patient on the side, the thighs flexed, and the hips close to the edge of the bed; the buttocks being separated, make an incision in the median line, extending from the extremity of the coccyx upwards to the 1 G. A. Otis. 2 P. F. Eve. 3 J. Ashurst, Jr. * J. F. South. 6 G. C. Blackman. 138 OPERATIVE SURGERY. requisite extent; remove the diseased bone either with the gouge, or the drill, or the bone may be divided with the cutting forceps. The forefinger in the rectum determines the progress and extent of the resection. 4. The ribs are closely invested on their internal surface by the pleura, and along the groove on the lower border runs the intercostal artery. The only admissible primary interference when the ribs are fractured by balls is the extraction of loose fragments, and the smoothing off of sharp-pointed ends.1 Resection for necrosis should be made by opening existing sinuses and carefully separating the thickened periosteum with the pleura. In the removal of mor- bid growths, portions of ribs may require resection; great care must be taken to separate the pleura with the periosteum without wound- ing the former. Proceed as follows: Place the patient upon the sound side, and expose the bone by an incision along the middle of the rib, or the incision may be curved downwards; divide the inter- costal muscles and disengage the intercostal artery from its groove in the inferior border of the bone; separate the pleura cautiously with the handle of the scalpel, or similar instrument, and pass a thin piece of pasteboard or other substance behind; divide the bone with the chain saw. Section of the posterior part of the rib may be first made to avoid wounding the pleura; scrape carefully each border of the bone, and do not incline the point of the knife tow- ards the intercostal space. In removing the false ribs, support the free extremity while the rib is divided posteriorly. Or, make a curved incision having its convexity downwards, exposing the diseased bone, two or three days before resection; after having cut the flap pass two threads firmly united, by means of a curved needle along the internal face of the rib at the point where the bone is to be divided; replace these threads after twelve or twenty-four hours by a drainage tube; these tubes prepare the way for the passage of the chain saw; on the second or third day saw the bone and remove the fragment.'2 5. The sternum has been frequently partially resected for shot injuries, and with very favorable results, the mortality being very slight.3 When subperiosteal resection has been made for necrosis, new bone has been reproduced.4 The incision for resection may be crucial or vertical, according to extent of injury or disease, and the parts may be removed by the trephine, gouge, or forceps. BONES OF THE FACE. 'In resection operations on the bones of the face it is important to avoid, as far as possible, incisions which will leave unsightly scars, and the removal of bones which destroy the symmetry of the fea- tures. When practicable, perform intra-buccal resections without 1 G. A. Otis. 2 E. Chassaignac. 3 0. Heyfelder. * L. Oilier. THE OPERATIONS ON BONES. 139 external incision;1 make incisions along the natural folds of skin and preserve the borders of the mouth from division;2 in all cases that admit of subperiosteal resection, this method is to be preferred. 1. The inferior maxilla is very liable to injury and necrosis, and to be the seat of morbid growths. In comminuted fractures the frag- ments should be preserved unless quite detached, as they have great .vitality, and are important in the preservation of the contour of the jaw. For necrosis the resection should as far as possible be sub- periosteal and intra-buccal, and both objects may often be accom- plished by occasionally aiding the slow process of separation of the necrotic bone from its attachments to bone and periosteum with the elevator, or the handle of the scalpel, or a spatula.1 By de- grees the sequestrum is loosened, new bone forms around it from the periosteum, and eventually the dead bone may be lifted from its bed with perhaps slight incisions of the gum; by this method large portions of the jaw, and even the entire jaw, may be reproduced during the process of sequestration, and not only its contour but its function be preserved.1 This method is preferable to early resec- tion, which is liable to be followed by great contraction of the parts, even if the periosteum is preserved and new bone is produced.3 In resection for tumors ample external incisions are often required, and large portions of the bone must be sacrificed. But small tu- mors, involving only the alveolus, may be removed with bone forceps without incision of the skin.4 A considerable portion of the central part of the jaw may be removed without incising the lip, if the mu- cous membrane is freely divided between it and the bone, and the lip is drawn well down.4 (a.) When the entire central part is to be resected proceed as fol- lows : Pass a stout ligature through the tip of the tongue to hold it in position when the muscles are incised; an assistant standing behind the patient holds his head firmly, and compresses the two facial arteries at the points where they cross the lower jaw; standing in front, seize with the left hand one of the angles of the lower lip, while an assistant holds the other angle from the bone; and the whole in a state of tension; divide the lip with a vertical incision through the median line down to the os hyoides; or, if practicable, make a single curved incision along the lower margin of the jaw; raise the periosteum from the bone to be removed; extract a tooth opposite to each point where bone is to be sawn through ; use a small Hey's saw, or the chain saw ; the bone being sawn through on both sides, divide the muscles attached to it, as closely as possible to their insertion, carrying the knife along the concave surface. 1 J. R. Wood. 2 Sir W. Fergusson. 3 Von Langenbeck; M. Rizzoli. * C Heath. 140 OPERATIVE SURGERY. Unite the two flaps with silver wire sutures passed through to the mucous membrane adjusting the margins of the lip; or use the hare- lip pins with figure-of-eight suture, if there is much tension; at- tach the ligature holding the tongue to a fold of adhesive strip firmly fastened. Commence the incision at the angle of the mouth opposite the healthy portion of jaw ; extend it down to the place at which the saw is to be applied; then along the base of the jaw past the middle line to the other point of section.1 (b.) The horizontal portion has the following anatomical parts to be considered: — Attached on its internal surface is the mylo-hyoideus muscle, beneath which is the fossa for the submaxillary gland ; on its external surface along its lower margin is the attachment of the platysma myoides muscle, and along its alve- olar margin the buccinator; the facial artery mounts over its lower border, just anterior to the insertion of the masseter muscle. Resect as follows:2 Make an incision commencing behind and a little above the angle, avoiding the facial nerve and parotid duct alone the border of the jaw, terminating from a quarter to half an inch below the symphisis menti; raise and reflect the flap on the face, tying both ends of the divided facial artery; the bone being denuded, or the periosteum raised, divide with a chain saw passed at the proper point anteriorly, a tooth being removed if necessary; seize the end of the fragment with strong forceps, and divide with the chain saw at or near the angle, as may be required; close the wound firmly with silver wire sutures, care being taken to compress the surfaces of the incised mucous membrane closely to secure prompt union. (c.) The half of the lower jaw has the following additional rela- tions : — The rami terminate in two processes, one for articulation, and the other to give attachment to the temporal muscles; the articulation is supported by an external and internal lateral ligament, and the capsular; the stylo-maxillary passes from the styloid process to the angle of the jaw; the internal maxillary artery passes behind the neck of the condyle in such proximity as to render care necessary to avoid wounding it in disarticulation of the jaw. Resect as follows (Fig. 116) : Place the patient with the shoulders raised and head turned to the opposite side; commence the incision at the zygomatic arch behind the condyle, carry it downwards be- hind the ramus to the angle, and under the body of the bone to a point one quarter of an inch below the symphisis menti if the oper- ation is for an old necrosis,2 but through the centre of the lip (Fig. 116), if for the removal of bone for other affections; in the former case incise the periosteum and raise it from the bone throughout, 1 J. Bell. 2 J. R. Wood. THE OPERATIONS ON BONES. 141 but otherwise for the removal of a tumor;x the facial artery must be cautiously divided and secured ; sub-periosteal resection may now be rapidly performed for necro- sis, the bone being divided with the chain or small straight back saw, and the cut end used as a lever to raise it from its position during the process of enuclea- tion ; if the periosteum is not saved, having divided the bone d, seize the cut extremity, with forceps, raise it from its bed, carefully separating all tissues adherent to the body and ra- mus ; carry a probe pointed Fig. 116. bistoury or curved scissors beneath the zygomatic arch, and behind the coronoid process, and with it divide the tendon of the temporal muscle while depressing the bone to disengage the process and luxate the condyle; pull the bone c, strongly outwards, as far as possible from the vessels, in order to avoid especially the internal maxillary artery, e, and complete the operation by dividing the pterygoid muscles and the articular ligaments. Secure every bleeding vessel, and close the wound by carefully adjusting the margins of the integ- ument and of the mucous membrane. When the tumor is large and completely wedged in the upper part of the bone so as to hinder the freeing of the coronoid process, and prevent dislocation, cut off the tumor as high as possible with the bone forceps or saw, and then remove the remaining portion of the jaw only in case the disease is malignant.1 (c?.) The entire lower jaw is removed as follows: Pass a ligature through the anterior part of the tongue, and intrust to an assistant; make an incision commencing opposite the left condyle downwards towards the angle of the jaw, ranging at about two lines in front of the posterior border of the ramus, thence along the base, to termi- nate at the median line a little posterior to the most prominent part of the border of the jaw. Dissect 2 upwards the tissues of the cheek, and reflect downwards, for a short distance, the lower edge of the incision; separate the tissues forming the floor of the mouth, situated upon the inner surface of the body of the bone, from their attach- ments from a point near the median line, as far back as the angle of the jaw; next divide the attachments of the buccinator ; secure by ligature the facial artery, the sub-mental and the sub-lingual; expose the external surface of one branch of the jaw, and of the temporo- maxillary articulation, by dissecting the masseter upwards as far as 1 C. Heath. 2 J. M. Carnochan. 142 OPERATIVE SURGERY. the zygomatic arch; seize the ramus and pull the coronoid process downwards below the zygoma; divide the insertion of the ptery- goideus internus, grazing the bone in doing so; carefully avoid the lingual nerve, here in close proximity; divide the dental artery and nerve; separate the tissues attached to the inner face of the bone, as high up as a point situated about a line below the sigmoid notch, between the condyle and the coronoid process; detach the tendon of the temporal muscle by means of blunt curved scissors, a probe- pointed bistoury keeping close to the bone; make use of the ramus, now movable, as a lever to aid in the disarticulation of the bone; to effect safely the disarticulation of the condyle, penetrate the joint by cutting the ligaments from before backwards and from without in- wards; the articulation thus opens sufficiently to allow the condyle to be completely luxated; blunt scissors may now be used to cut care- fully the internal part of the capsule, and the maxillary insertion of the external pterygoid muscle; by a slow movement of rotation of the ramus upon its axis the condyle is detached and the operation completed. To effect the removal of the other half, make the same incision on the opposite side, so as to meet the first on the median line; the dissection is similar. 2. The superior maxilla has the following important anatomical features:1 — It is attached to other bones in but three principal points: first, by its as- cending process and articulations with the os unguis and ethmoid; second, by the orbital border of the malar, as far as the spheno-maxillary fissure; third, by the articulation of the two maxillary bones with each other and palate bone; there is a fourth point of contact behind with the pterygoid process and palate bone, which yields easily by simple depression of the maxillary bone into the interior of the mouth; in attacking these different points no large vessel is in- jured; the trunk of the internal maxillary artery may be easily avoided, or in any case tied after the removal of the bone; moreover, in case of unforeseen haemorrhage during the operation we have a resource in compression of the car- otid; only one important nerve trunk, the superior maxillary, need be divided. Resection of the bone is performed for the extirpation of malig- nant growths and to gain access to naso-pharyngeal tumors ; in the former case it is justifiable, only where the disease is limited to the upper jaw and its corresponding palate bone, owing to the certainty of recurrence if the disease extends beyond.2 The methods of pro- cedure are numerous, and give great and desirable latitude 3 to the operator. Early operators cut boldly through the cheek,4 1 (Fig. 118), but, to avoid unsightly scars, the rule now obtains of making the incision in the course of natural folds of the skin, 2 (Fig. US)3, and 25 and 46 (Fig. 117). Subperiosteal resection may be made by 1 J. F. Malgaigne. 2 j. Bell. 3 Sir W. Fergusson. * Lizars. 5 E. Nelaton. 6 A. Guerin. THE OPERATIONS ON BONES. 143 these incisions, but a more formal operation is made bv dividing the cheek, 1 (Fig. 117).1 Fig. 118. Resect the superior maxilla below the floor of the orbit2 (Fig. 119), by the following operation : Make an incision slightly convex back- wards commencing at the ala of the nose, and terminating at the cor- responding commissure of the lip, following the naso-labial fold or fur- row, 4 (Fig. 117) ; dissect up the two flaps resulting from this incision until the nostril is exposed, and the malar process is completely denuded; with a small saw held in the right hand, a, saw through the malar process from above downwards, and a little from within outwards ; the soft palate hav- ing been detached from the posterior border of the palatine bone by a trans- verse incision made at the posterior border of the last great molar, and an incisor tooth having been extracted, divide the horizontal portion of the maxilla from before backwards with cutting forceps c, one branch being in the mouth, and the other in the nares; make a section of the bone from the divided malar process to the nares by the forceps b: seize the bone with strong forceps, and remove, fracturing the pterygoid process. The entire maxilla or portions may be resected as follows:3 Ex- tract the incisor teeth of that side ; divide the upper lip in the median line to the nostril; continue the incision around the ala and up the 1 L. Oilier. 2 A. Guerin. 3 Sir W. Fergusson. Fig. 119. 144 OPERATIVE SURGERY. side of the nose, towards the inner canthus of the eye, thence con- tinue it in a slight curve below the orbit, 2 (Fig. 117 a), or, to the malar bone, 2 (Fig. 118) ; reflect the skin from the bone, and with a narrow saw passed into the nostril divide the alveolus and hard pal- ate ; incise the mucous membrane of the mouth as far back as the soft palate ; with a narrow saw passed into the nostril divide the alveolus and hard palate ; cut partially also the malar process of the maxillary bone, or, if necessary, the bone itself, and the nasal pro- cess of the superior maxilla, and complete the division of these bones with the forceps; grasp the bone with the lion forceps, and detach it forcibly from the pterygoid process and palate bone; when the bone is loose, raise the fascia of the orbital palate, separate the infra- orbital nerve, the soft palate, and any adhering tissues. The hem- orrhage must be suppressed by ligatures and the actual cautery, and the wound adjusted at the lips by hare lip-pins and in other parts by the wire suture. Resection may be necessary by an incision through the cheek2: Make an in- cision with its convexity downward, 1 (Fig. 118) from the commissure of the lips to the temporal fossa; dissect this large flap from below upwards, and turn it back upon the forehead; cut through with the forceps the external or- bital process at its juncture with the malar bone, the zygomatic arch, the os unguis, and the ascending nasal process of the upper jaw; divide the soft parts which connect the ala of the nose to the maxillary bone, and separate the max- illae in front with a chisel and mallet, or a small saw; detach the soft parts from the floor of the orbit, divide at once the superior maxillary nerve, and the con- nections of the bone with the pterygoid process; conclude the operation by cut- ting through with the bistoury, or curved scissors, the velum of the palate, and the remaining soft parts which still adhere to and retain the bone. The chain saw may be used to divide the processes. Resection without external incision may be made as follows3: The head being thrown back in position, and the mouth kept open by the gag placed between the back teeth of the opposite side, place a sponge cut so as to completely fill up the passage to the throat, and hold it in position on the soft palate by a sponge-holder to prevent the blood passing into the throat during the first part of the opera- tion, the patient being allowed to breathe only through the nose; make two internal incisions from behind, half an inch on each side of the fangs of the molars forward to the central incisor of the op- posite side ; denude the periosteum with the elevator by commen- cing externally at the central incisor, and passing backward to the internal pterygoid process, and upward to the malar bone; then in- ternally from the same point to and a little past the centre of the palate ; the sponge now being of no further use, remove it; denude the tensor-palati muscle from its attachment to the posterior part of 1 E. Ni-laton. 2 A. Velpeau, J. Syme, R. Liston. 3 D. H. Goodwillie. THE OPERATIONS ON BONES. 145 the hard palate ; care being taken not to injure the posterior pala- tine vessels and descending palatine nerve that pass at this point for- ward on to the hard palate through the posterior foramen and along a groove ; now extract the lateral incisor of that side, and by its socket though a little to the right of the centre of the hard palate, so as to save the vomer, make a section with a saw, dividing the superior maxillary bones; change this saw for one much shorter, the teeth of which have a different angle and the cheek falls into a U shank which allows the saw to play freely; make a section up between the tumor and the internal pterygoid process to % the malar bone, then forward through the canine fossa, dividing also the inferior tubinated bone, to meet the other section at the ala nasi; after the saw has entered the antrum in this last section, the handle should be advanced more rapidly than the point; this pre- vents the point from piercing the vomer. By these two sections a tumor with adjacent bone may be removed clean. 3. The superior maxillae may be removed at a single operation by an incision, 3 (Fig. 117), along the centre of the nose and through the upper lip ; additional incisions may be made, if required, under the orbit laterally. Or, a four-cornered flap may be made by an in- cision on either side from the angles of the mouth to the external angles of the eye, 1 (Fig. 117). III. TREPHINING. This operation is required for the removal of a circular piece of bone, as in opening into cavities in bone. The instruments neces- sary are the trephine and elevator (Fig. 120). The trephine, b, c, d, is a cylindrical saw, with a cross handle like a gimlet, a, and a centre-pin, the perforator, around which it re- volves until the saw has cut a groove sufficient to hold it ; the centre-pin is then retired. The handle is fast- ened to the shaft by a screw, with a button affixed to the end of the1 shaft; or the screw may be on one end; when the handle is placed on the shaft this screw is tightened, Fig. 120 and its extremity reaches the shaft and fastens it firmly in its place; the advantage of this arrangement is that the upper surface of the handle is smooth, and the palm of the hand is not bruised as it is by the handle of the old instrument. The conical trephine, c, has the peculiar advantage of dividing the osseous walls without any 10 146 OPERATIVE SURGERY. danger of wounding the structures within. It is a truncated cone, with spiral peripheral teeth, and oblique crown teeth; when applied, the peripheral teeth act as wedges so long as counteracting pressure exists on the crown teeth; upon removal of that pressure of the bony walls its tendency is to act on the principle of a screw; but owing to its conical form and the spiral direction of its peripheral teeth its action ceases. In the construction the trephine is made of different sizes to meet the various conditions in which it is used, as on the cranium, b, c, or for opening the antrum, d. Trephining is performed as follows: Make an incision down to the bone, having the form of a V, T, or -|-, or of a semicircle; the bone being scraped, take the handle of the trephine in the right hand, and fixing the perforator by its screw so that it protrudes slightly beyond the teeth, place the perforator in the centre of the bone to be removed; work the instrument alternately backwards and for- wards, until the teeth have cut a groove sufficiently deep to receive them; then loosen the perforator and fix it in the shaft, to avoid wounding the membranes; great care should be taken to maintain the instrument in a position perpendicular to the part operated upon, in order to avoid its penetrating more deeply on one side than the other, and thus suddenly and unawares wound the cerebral membranes. It is important to examine the depth of the groove frequently with a probe, to ascertain how nearly the instrument has completed the section of the bone; the teeth of the trephine may occasionally re- quire cleaning with a small brush or wet sponge. The disc of bone should be raised with the point of the elevator e, and the edges smoothed with the lenticular knife at its other end. , IV. OSTEOPLASTY. The transplantation of bone consists in raising bone, covered with its periosteum, and placing it in a new position for the purpose of filling ga'ps created by disease or operations. The superior maxilla has been resected so far as to permit the removal of naso-pharyngeal polypi, and been replaced with perfect restoration of its integrity;1 portions of the hard palate have been cut away and placed in appo- sition with similar sections from the opposite in staphyloraphy;a the chasm between the fragments of ununited bone has been success- fully filled by dividing the long axis, and turning it down so that it filled the space. The requisite to success is the preservation of the fibrous and periosteal attachments of the fragment removed to the bone from which it is separated. 1 Von Langenbeck. 2 Sir W. Fergusson. INJURIES OF JOINTS. 147 CHAPTER XV. INJURIES OF JOINTS AND SPECIAL OPERATIONS. Joints are composed of the two ends of bones covered with car- tilage; of a sac frequently containing many appendages, pockets, and bulgings; of a synovial membrane, a fibrous capsule, and the strength- ening ligaments.1 It is owing to the intimate relations of these com- plicated structures that the injuries and diseases of joints are pe- culiarly serious. I. WOUNDS. On account of their exposed positions joints are specially liable to wounds of various forms and degrees of severity. 1. Contused -wounds may be so severe as to be followed by ex- travasation of blood into the tissue around it, or even into its cavity. Examine first for a fracture, then apply apparatus to secure perfect rest, and the ice-bag to prevent inflammation; the gypsum dressing with a suitable fenestrum at the joint is the best apparatus for the injury of joints of the lower extremity. 2. A punctured wound is dangerous, owing to the tendency to suppurative inflammation and the retention of the pus. That the joint is involved is known by the escape of synovia. Pursue tire fol- lowing treatment : Place the patient in bed, close the wound with collodion or adhesive plaster, if it is slight, but with sutures accu- rately applied if it gape; secure perfect rest to the joint by immov- able apparatus, and if any application is made, use cold. In favor- able cases all excitement about the joint will subside in a few days, and when the dressings are removed at the end of four to six weeks, recovery will be complete.1 3. An incised wound is also recognized as having penetrated the joint by the appearance of synovia. Such a wound must be treated and dressed antiseptically; close it accurately with sutures, apply immovable apparatus to the limb, and locally use ice-bags; give cooling regimen. If the case proceed favorably, retain anti- septic dressings until union is firm, then commence passive motion, but restrict it for at least one month. 4. A lacerated wound should be treated as follows: Cleanse the wound of all foreign matters under the spray, pare the edges of all, contused tissues, and if possible close the wound with silver wire sutures and treat it as an incised wound; if large, gaping, and cannot be closed under the carbolic spray, enlarge the opening wherever it 1 T. Billroth. 148 OPERATIVE SURGERY. is necessary to gain free drainage of the cavity of the joint, inject carbolic solutions, 1 to 20, to destroy septic ferments which may have entered the joint; introduce the drainage tube or a horse-hair drain, carbolized; apply antiseptic dressings and immobilize the joint by apparatus ; renew the dressings within twelve hours, and repeat them as often as necessary to prevent accumulation of secretions in the wound.1 However favorably the case proceeds, the joint must be retained in a state of perfect rest for at least two weeks, when pas- sive motion may be begun, but if it produce any swelling of the joint or tenderness, all motion must cease for several days, when it may be renewed. II. DISLOCATIONS. A joint is dislocated when one bone is displaced from another at its place of natural articulation; there may be no other injury than rupture of the capsule, simple dislocation, or there may be a wound of the integument entering the joint, compound dislocation. The signs of dislocation are, preternatural immobility, and tendency, when reduced, to remain; but with free motion without crepitus. The treatment required is immediate reduction; anaesthetics must be used for relaxation; when reduction is possible by manipulation this method should always be preferred; if more force is necessary, make extension and counter-extension with the hands, aided with bandages tied in the form of the clove- hitch (Fig. 121); if more power is required, re- sort to mechanical contrivances, as the pulley. Compound dislocations are among the most seri- ous accidents which can befall a limb;2 but it must be borne in mind that by the proper use of antiseptic dressings these injuries may now be treated without suppuration, and are therefore far more amenable to conservative measures than formerly. The treatment must depend upon the amount of injury in each case; if slight, reduction maybe effected by suitable en- largement of the wound, followed by thorough cleansing and dis- infection; resection should be made when the bones are destroyed, the antiseptic dressings being employed; amputation will be necessary when the principal artery of the limb is ruptured, or there is destruc- tion of the tissues about the joint, or the patient is old or feeble. 1. The temporo-maxillary joints are dislocated by the displace- ment of the condyles of the lower jaw forwards, one or both, the lat- ter being more frequent. Reduce as follows: The patient seated on the floor with the head between the knees of the operator, place a 1 J. Lister. 2 t. Bryant. INJURIES OF JOINTS. 149 couple of pieces of cork, gutta percha, or pine wood as far back be- tween the molars as possible; now draw the chin steadily upwards, taking care not to draw it forward at the same time; or, sitting or standing in front depress the condyles by means of the thumbs pro- tected by pieces of leather placed on the tops of the molars; if this method fail, reduce one side at a time, or give an anaesthetic; after reduction support the jaw with a bandage. 2. The vertebral articulations are rarely displaced without frac- ture, especially in the lumbar and dorsal regions. In the cervical region forward and backward luxations may occur with or without fracture. Reduction should always be attempted. If the lumbar or dorsal vertebra? are displaced make forcible extension with judicious lateral motion and direct pressure upon the spine. If a cervical ver- tebra is displaced raise the head firmly by the chin and occiput, and if reduction does not follow, add slight rotation in the direction of dislocation to disengage the process, or place the patient on the back and make extension in the same manner. 3. The sterno-clavicular joint may be dislocated by the displace- ment of the end of the clavicle forward, upwards, or backwards. Reduction is effected by elevating the shoulder in pushing upward at the elbow, or by drawing the shoulders backward and upward with the knee pressing against the spine between the scapula. Though frequently it is difficult to retain the clavicle in position, the function of the arm is rarely impaired. For the first and second forms, the pad in the axilla, the sling for the elbow, and a pad upon the displaced bone, retained by adhesive straps, are most useful; for the third form, rest on the back, or such appliance as will retain the shoulder upwards and outwards, are required. 4. The acromico-clavicular joint may be luxated by the upward or downward displacement of the end of the clavicle ; reduction is ef- fected by drawing the shoulder outward and backward. The retain- ing apparatus for the upward luxation should be applied as follows:1 Place a compress over the articulation, and retain it by two strips of adhesive plaster, the edges being glued to the skin by collodion ; bandage the hand and forearm with a flannel roller; apply a loop of elastic bandage2 five feet long and one inch and a half wide, passed under the elbow of the injured side; draw the ends snugly over the compress, carrying the anterior one around the axilla of the sound side, as in a spica of the shoulder, to join the other between the clavicles, where they are fastened with strong pins. Complete and permanent restoration rarely follows any treatment.3 5. The shoulder joint dislocations consist of the displacement of the head of the humerus ; first, downwards into the axilla; second, i W. T. Bull. 2 H. A. Martin. 3 F. H. Hamilton. 150 OPERATIVE SURGERY. forward under the coracoid process; and third, backwards under the spine of the scapula. The reliable sign of these displacements is the projection of the elbow from the chest when the hand of the dislo- cated arm is placed upon the opposite shoulder. The method of reduc- tion in the first two varieties is the same; proceed as follows: Flex the forearm upon the arm, and while the arm is elevated to a right angle with the trunk, rotate gently forwards by depressing the hand and forearm; or place the knee in the axilla to press the head outward and serve as a fulcrum, and use the shaft as a lever; or laying the patient down, place the heel against a pad in the axilla, and grasp- ing the wrist and elbow, make steady traction, meanwhile prying the head outward with the heel; failing, give an anaesthetic.1 Reduction may also be effected by manipulation: grasp the shoulder with one hand and the flexed elbow with the other, make extension at the elbow, drawing it from the side (Fig. 122) with slight rotatory motion outwards; when extension is fully made, raise the elbow and with the arm describe a semicircle towards the sternum and face, then suddenly depress the elbow upon the thorax, rotating the head of the humerus inwards and with the thumb of the right hand giving the proper direction to the head (Fig. 123); this manoeuvre may be re- peated if necessary.3 In the subspinous form make extension towards the joint, or resort to the last method, stand- ing behind the patient and drawing the elbow back- ward and rotating the bone while the thumb of the fright hand guides the head to the joint. In com- pound dislocation the question as to the propriety of reduction or resection should be decided as follows: In a healthy patient, without complications, reduction is preferable; but if the patient is weak or old, or the exposed bone is badly injured, or the parts are much lacerated, saw off the exposed head of the bone.4 Antiseptic dressings should be scrupulously applied. 6. The elbow joint may be dislocated by displace- ment of the ulna and radius backwards, forwards, inwards, outwards, the last two being partial. Examine carefully to determine whether there is a transverse fracture of the humerus, or of one condyle, or of the olecranon. Reduce the first form thus : the patient seated in a chair, press the knee in the bend of the elbow and flex the arm forcibly but slowly around it.5 Other methods are as follows: the pa- 1 F. H. Hamilton. 2 T. Bryant. 3 H. H. Smith. * T. Holmes. 5 Sir A. Cooper, F. H. Hamilton. Fig. 122.2 Fig. 123.2 INJURIES OF JOINTS. 151 tient being seated, carry the arm and forearm directly backwards, the scapula being pressed forwards;1 extension of the forearm from the hand or wrist downwards ;2 extension of the forearm from its middle by an assistant, while the surgeon seizes upon the olecranon process with the fingers of one hand and placing the palm of the other against the front and upper part of the forearm pulls forcibly back- wards.3 The second form may be reduced by forced flexion aided by pressure; the lateral displacements are restored by moderate extension combined with lateral pressure.* The head of the radius may be dis- placed separately forwards, outwards, and backwards, the first being far the most frequent; reduction is effected in all forms by extension aided by pressure upon the head of the radius made in the right direc- tion.4 In compound dislocations in healthy patients, reduce the bones and close the wound antiseptically, unless there is much comminu- tion, when excision of the bones involved should be performed; in general, a useful limb results from these excisions of the joint surfaces. 7. The wrist joint is luxated by displacement of the carpus for- wards or backwards; reduction is made by extension in a straight line with slight rocking or lateral motions if necessary.4 8. The phalangeal joints may be dislocated and are generally easily reduced. The displacement of the first phalanx of the thumb upon its metacarpal bone is an exception; the difficulty of reduction is due to the escape of the head of the metacarpal bone between the two tendons of the flexor brevis, where it is lodged as in a button- hole.5 Reduction is effected by first pressing the metacarpal bone firmly to the centre of the palm to relax the short flexor, then put- ting the displaced phalanx in a state of extreme extension to relax the tissues of the button-hole and to push up those which form its distal part over the projecting head of the metacarpal bone; this is done by dragging the hyper-extended thumb downwards or away from the wrist, and then acute flexion will restore it to its place.6 If this method fail, with a very narrow bladed tenotome divide the insertions of the flexor tendon and repeat the manoeuvre. 9. The hip joint7 is protected and strengthened by the ilio-fem- oral, or inverted Y ligament, which is inserted above into the front and outside of the inferior spinous process of the ilium, and below into the anterior inter-trochanteric line; it has two main branches, extend- ing, the outer to the trochanter major, and the inner to the trochan- ter minor; in regular dislocations this ligament is unbroken and controls largely the movements of the head of the femur. The several positions of the head of the bone with reference to the socket may be reduced to the following, namely, (1.) The dorsal, including 1 R. Liston, J. Miller. 2 F. C. Skey. 3 J. Pirre. ■» F. H. Hamilton. 5 Fabbri. 6 T. Holmes. ' H. J. Bigelow. 152 OPERATIVE SURGERY. that on the tuberosity, the dorsal, the everted dorsal, the anterior oblique, and the supra-spinous. (2.) The thyroid, including that on the perineum and on the thyroid foramen. (3.) The pubic, the pubic and sub-spinous. Though the head of the bone may be primarily luxated in various directions, yet the downward dislocation is by far the most common, as the capsule is thin and weak at this part, and flexion, by which the ligament is relaxed, with adduction or abduc- tion, is the habitual attitude of the thigh in action and self-defense. From this position the head of the bone readily passes to the dorsal, or thyroid, or pubic regions; thus all regular dislocations may be sec- ondary. These several positions are sufficiently well recognized for reduction by the following sign, namely: the head of the femur al- ways faces the same way as the internal condyle. As a preliminary to reduction, etherize the patient to relaxation, and place him re- cumbent on the floor. The best general rule for reducing a recent dislocation is to get the head of the femur directly below the socket by flexing the thigh at about a right angle, and then to lift or jerk it forcibly up into its place. This rule applies to all dislocations except the pubic, and even to that when secondary from below the socket; the reduction by the lifting method is usually instantaneous, and flexion is the basis of its success (Fig. 124). If after one or two trials it appears that the bone cannot be jerked into place, enlarge the rent in the capsule a little by moving the flexed thigh from one side to the other so as to sweep the head of the femur across below the socket; and again repeat the act of lifting. The following rules for reduction of the Fig. 124. femur from its several positions, should be observed : (1.) In dorsal dislocations, flex and forcibly lift; if this effort fail, flex and lift while abducting. If this fail it will be found that abduction has carried the head of the bone from the dorsum nearly or quite to the thyroid foramen, and that the capsular rent has been so enlarged that the first method may now prove successful. (2.) In thyroid dislocations, adduction of the flexed thigh reverses this movement and carries the head from the thyroid foramen to the dorsum, and also enlarges the opening, making the first rule effective. (3.) The pubic dislocations may generally be brought down without difficulty from above the socket, after flexion, especially if they are secondary, and may then be reduced from that position like the thy- roid. A fulcrum made by rolling one or more sheets into a firm band, two or three inches in diameter, may aid the manipulator. Place the centre of the band in the groin, and while assistants raise the ends by pressure at the knees, the head INJURIES OF JOINTS. 153 is lifted into the socket.1 "The same result is secured by requiring an assistant to lift the head of the bone by means of a stout sheet in the groin and over his shoulders. 10. The patella may be displaced outwards, inwards, or on its own axis; reduction is made by laying the patient on the floor, lifting the limb with the heel upon the shoulder so as to relax completely the quadriceps muscle, and pushing the patella into position ; if this effort fails in the last form flex the thigh and straighten the leg while pressure is made on the patella.3 11. The knee joint is dislocated by displacement of the tibia backwards, forwards, outwards, and inwards, but in general the lux- ation is incomplete. Reduction is generally effected without much difficulty. If backward, use forced and extreme flexion ; if forward, reverse the movement; if lateral, make extension and pressure. 12. The ankle joint is luxated by the displacement of the tibia forwards and backwards. Reduction is effected by extension and counter-extension combined with pressure. Division of the tendo- Achillis has been found necessary in cases of backward luxation. Dislocation outwards or inwards is a rotation of the astragalus, accom- panied usually with a fracture of the fibula and rupture of the inter- nal lateral ligament.2 Compound dislocations are not infrequent at the ankle-joint, and always demand the most judicious care; as in other compound dislocations the conditions present must determine the course of procedure. By conservative measures in young and healthy persons, where the vessels have escaped damage, and there are no other serious complications, the limb and joint may often be saved. The wound should be cleansed of all foreign matters, carbolic solutions, 1 to 20, should be injected into all its recesses, and antiseptic jute or cotton, soaked in carbolized oil, applied to the opening; the joint must be immobilized by the fenestrated gypsum bandage, unless there is great swelling, when the splint must be used. Anchylosis will en- sue, but the increased mobility of the transverse tarsal joint will in a great measure compensate for this loss.8 When there is much com- minution removal of the fragments is necessary, or excision of the joint may be required, followed by the dressings already given. In a cer- tain proportion of cases, the injury, or health, or age of the patient, renders amputation the only safe course. 13. The tarsal bones may be luxated from their positions, but generally the great violence which causes such displacement does severe injury to the tarsus. Luxations of the astragalus are far the most important; the dislocations of this bone may be forwards, back- wards, outwards, and inwards, or it may be rotated on its axis. As a rule, if the dislocation is simple,attempt immediate reduction; if 1 G. Sutton. 2 F. H. Hamilton. 3 T. Holmes. 154 OPERATIVE SURGERY. the luxation is complete and reduction impossible, resect; if the lux- ation is compound, resect; if there is severe laceration, or other in- juries complicating these conditions, amputate. Reduction is effected by extension from the foot, grasped as in removing a boot, and counter- extension from the knee, with such pressure upon the displaced bone as may be required. If the astragalus is displaced from the scaphoid and calcaneus the treatment is the same. CHAPTER XVI. DISEASES OF THE JOINTS AND SPECIAL OPERATIONS. It may be stated as a general truth that diseases of a joint com- mence either in the synovial or osseous tissues, and that they origi- nate for the most part in an acute or chronic inflammation; in the progress of any case both tissues may become eventually involved; practically there is no primary disease of articular cartilages, and when they undergo a change it is secondary to some other affection, either of the synovial membrane or of the bone; when the disease commences in the synovial membrane or in the bone, and disorganiza- tion of the joint follows, it is in that tissue in which the disease began that the gravest change will be seen.1 I. INFLAMMATION. Injury in some form is generally the cause of inflammation of the joints. The various wounds already mentioned are liable to ter- minate in inflammation, announced by swelling and heat of the part, pain on pressure, and fever. 1. Serous synovitis2 commences with swelling, heat, and pain of the joint, but slight fever; the synovial membrane is slightly swollen and moderately vascular; the cavity is full of serum with sy- novia, and the remainder of the joint is healthy. The symptoms rapidly subside with rest, painting with the tincture of iodine, or applying compresses of wet bandages, or blisters; the patient soon begins to use the joint without difficulty, the fluid is gradually ab- sorbed and function is restored. 2. Parenchymatous or purulent synovitis 2 begins with a chill, high fever, extreme tenderness of the joint which is fixed, swollen, and hot; there is no fluctuation, but the whole limb is oedematous; the synovial membrane much swollen, red, and puffy; there is a lit- tle flocculent pus in the cavity, and the cartilage looks cloudy; the difference between the serous and purulent varieties is that in the 1 T. Bryant. 2 t. Billroth. DISEASES OF THE JOINTS. 155 former the synovial membrane is simply stimulated to secretion, while in the latter it is deeply affected. The treatment at this early stao-e is: (1) fixation of the joint by apparatus, in the most favorable position for subsequent use if anchylosis occur, anaesthetics being given if necessary; the gypsum is generally the most available, the limb beino- well protected by wadding to avoid strangulation; (2) the continued application of ice-bladders so as to effectually cool the entire joint. Before applying these dressings the parts may be thor- oughly painted with tr. iodine. Opium and quinine should be given in such measure as will secure relief from the effects of pain and fever. If the disease subsides months may elapse before the inflam- mation entirely disappears, and great care is necessary to avoid a renewal of the disease by cold or injury. If the disease continues to progress abscesses form, the joint becomes more swollen, the fever is hi^ ? sternum to fix the part firmly; \ sS ] if the bandage is weak at any point wet the part and dust it with plaster (Fig. 134). The abdominal pad may be dispensed with, and firm support given by the ban- dage to the lower part of the region, if an opening is cut in the dressing, corresponding with the stomach, after the bandage is firm (Fig. 135).1 Additional fen- estra? are often required as at the curvature, or where sinuses are discharging. The compensative curves of the spine may be more completely straightened by inducing profound anaesthesia before suspension, and experience proves that there is no danger during anaesthesia, either in the position of the patient or in the compression of the thorax by the gypsum, even if the patient remains suspended, as is usual, until the dressing becomes firm.2 If the diseased vertebrae are in the lumbar or lower dorsal regions the bandage need not be applied higher than the axillae, but if the caries exist in the upper dorsal region there must be additional sup- port of the upper part of the thorax, and this is obtained bv continu- ing the bandage over the shoulders, and thus encasing the entire 1 Bellevue Hosp. Records. 2 Von Langenbeck. Fig. 134. Fig. 135. DISEASES OF THE JOINTS. 165 trunk in the common dressing (Fig. 135). When this form is used the arms must not be in the sling but should hang by the side. By this means the spine can be permanently maintained erect. When the caries attacks the cervicals, means must be used to so support the head that the contiguous vertebrae may not be compressed. This may be accomplished by supporting the chin, or by lifting the head entire. The chin may be sustained by extending the plaster of Paris jacket (Fig. 135) up- wards as a cravat, well lined with cotton batting, or other soft material (Fig. 136). Or, the head may be raised entirely from the column by an appliance (Fig. 137) so incorporated in the plaster bandage that it has a firm basis of support, and by a sling which accurately fits the chin and occiput and lifts the head directly up- wards (Fig. 137). FlG. 136< To apply the apparatus the patient is suspended in the usual way, from the axillae, chin, and occiput, and the plaster bandage applied, as usual, over a tight-fitting knit or woven shirt. After the bandage has been accu- rately applied,, the patient is removed from the suspending apparatus and carefully laid upon an air bed until the plaster has hardened or " set." The patient can then stand up, and the apparatus for sus- pending the head is applied in its proper position, over the back of the plaster jacket, and the lower por- tion of it bent and moulded until it accurately fits all its various curves. The loose tin strips, being very flexible, can then be smoothly moulded around the jacket which has already been applied to the trunk, and another plaster bandage, having been wetted in water, is to be carefully and tightly applied over the apparatus and jacket first applied, in sufficient num- ber of layers to make it perfectly secure. The tin being rough and perforated, a sufficient amount ,of plaster will be incorporated into its holes and meshes to pre- vent any possibility of displacement. We have now a secure point of support from the pelvis and trunk, and the head can be sustained by properly adjusting the movable rod and securing it by screws. The gypsum dressing may be worn without change from two weeks to two months, accord- ing to the effect which it produces; when renewed, the patient should be thoroughly washed, but without assuming the upright posi- tion. The final cure is rarely completed in the most successful cases in one year. There are several kinds of useful apparatus for spinal caries more or less complicated in their mechanism, and requiring great experi- ence and care in their successful management. Fig. 137. 166 OPERATIVE SURGERY. A very neat and efficient spring corset1 may be so constructed and applied as to protect the diseased vertebrae from injury, and allow great freedom of mo- tion of the trunk; the springs are brass, of a serpentine form, especially tem- pered, elastic and, by a little manipulation, readily adapted to any surface, how- ever irregular or uneven, to which they are applied; in their spring-like action exists an elevating power, an auxiliary to the local and general support rendered, the tendency of which is to take off the superincumbent weight of the body from the diseased vertebrae. A spinal brace2 may be so applied as to take the weight of the trunk above the point of disease from the bodies of the vertebrae and throw it on the articu- lar processes. There are two pieces or levers passing up the back, not over the spine, but each side of it, so that it is firmly held from lateral deviations; to the upper end of these, two curved pieces of steel are fastened diagonally on both side's of the neck; they pass directly for- ward and around the shoulder, and thus prevent a great loss of force by diagonal action. This ar- rangement entirely obviates the painful and inju- rious ligaturing of the arms, which would occur if the straps passed forward from one point. At the part opposite the point of disease, the point where the fulcrum pads are placed is made of chamois skin or Canton flannel, filled with cork filings, which have no felting qualities, or, if desirable, can also be made of hard rubber; the shoulder- straps and the band around the hips are likewise provided with similar pads to protect the skin from pressure and abrasion; the instrument, like the spine itself, acts like a double lever with a common fulcrum at the curvature; this action is directly backward at the hips and shoulders and directly forward at the middle of the back, or wherever the diseased part is located; thus the posterior portion, the only healthy portion of the diseased vertebrae, is made to support a part of the weight of the body and the intervertebral car- tilage and bodies of the vertebrae, where the disease exists, are relieved of pres- sure. The abdomen is still further sustained in the upward direction by an apron in front which is fastened on each corner. If the disease is in the upper dorsal or cervical region, an apparatus is constructed for such cases with an attachment for sustaining the head; the effect and form of this attachment is that of a lever, acting backwards to raise the head and neck. 3. Spinal abscesses,3 whether they appear in the lumbar region or below Poupart's ligament, should be opened antiseptically, as fol- lows: While the spray covers the region of incision, make a suffi- ciently free opening at the most dependent part to allow of the com- plete escape of the contents; after the pus has ceased to flow inject carbolic solution thoroughly into all parts until the fluid returns clear; with the last injection cause hyperdistention of the cavity by holding: the edges of the wound firmlv to the nozzle while the fluid is Fig. 138. 1 J. A. Wood. 2 C. F. Taylor. 3 J. Lister. DISEASES OF THE JOINTS. 167 injected; if the deep sinus can be found pass a tube, as a catheter, as far as practicable without injuring the parts, and throw the injection as nearly as possible up to the carious vertebrae; insert two or three drainage tubes, rubber tubes with holes cut in at different points Fig. 139. (Fig. 139), and cover with the gauze or carbolized dressings ; change these dressings under spray as often as the discharges require, wash- ing the cavity out with carbolic solutions whenever there is any indi- cation of putrid matters present; continue these dressings until the abscess has closed or is reduced to the condition of a sinus. Treated in this manner, spinal or other congestive abscesses may be freely opened, their contents removed, and a healthy granulating surface established and the sinus often closed without incurring the ordinary risks of profuse suppuration and systemic poisoning. If antiseptics are not employed, the following advice cannot be too carefully heeded: If the abscess comes from a bone on which an operation is impossible or undesirable, do not meddle with it, but be thankful for ever}' day that it re- mains closed, and wait quietly until it opens, for thus there will be relatively the least danger.1 III. LOOSE BODIES. These bodies in the knee-joint are outgrowths of cartilages in chronic rheumatic arthritis, or in the dendritic growth of synovial fringes accidentally detached, or portions of the proper articular car- tilage with or without some subjacent bone which has been exfoli- ated into the joint.2 The symptoms are slight pain in knee with weakness, and often moderate dropsy, and at length sudden pain and inability to walk while the knee stands between flexion and ex- tension, due to the loose body being caught between the bones form- ing the joint, or the semilunar cartilages, or in one of the synovial sacs; it may at times be detected and fixed by external manipulation.1 When very troublesome, it must be removed by the antiseptic method under the spray; fix the body as firmly as possible and make a free incision upon it; apply the antiseptic dressing and secure perfect rest; if there is much effusion, drainage tubes should be introduced.3 If antiseptics are not used, the utmost care must be taken to protect the joint from the entrance of air; force the body tightly under the skin at one side of the joint, press the skin strongly upward, and put it still more on the stretch, then cut through the skin and cap- sule down upon the body, and let the latter spring out, or lift it out 1 T. Billroth. 2 Sir J. Paget. 3 J. Lister. 168 OPERATIVE SURGERY. with an elevator; instantly close the wound with the finger, extend the leo1, let the skin return to its normal position so that the cut in it lies lower than in the capsule, and the two wounds do not commu- nicate directly ; close the skin wound with sutures and plasters; ex- tend the limb on a splint, or apply the gypsum dressing before the operation, and make a large opening over the joint.1 The sub- cutaneous incision may be made, and the body forced into the con- nective tissue, where it is allowed to remain or is subsequently re- moved. CHAPTER XVII. GENERAL OPERATIONS ON THE JOINTS. 1. EXCISION. The excision of a joint is the more or less complete removal of the articular surfaces of the bones which enter into its formation. 1. The indications for the necessity of excision are: for shot in- juries, the comminution of the joint ends of the bones, or the impac- tion of a ball in the end of the bone in such manner that it cannot be removed without destruction of the bone ; in compound disloca- tion with extensive injury of the soft parts, or complicated with fracture; in caries which has destroyed the articular surface, and continues to progress in spite of well-directed efforts to control it. 2. The time of excision should be immediate in all injuries which undoubtedly necessitate its performance, but for caries it should be delayed until the appropriate measures for its arrest have been thor- oughly applied without success. 3. The method of operation should aim (1.) to remove all diseased structures without needlessly sacrificing parts; in children, especially, the epiphyses of bones must be preserved with the most scrupulous care, to insure their future growth; in adults the amount of bone re- moved will always have regard to the future usefulness of the joint; (2.) to preserve the functions of the joint; the fibrous structures which strengthen must be saved in their proper relations; ,the peri- osteum must be preserved with the attachments to the capsule ; the muscular attachments must be separated uninjured, or with the bony fragments of their insertions to insure their future usefulness; the bones must be so shaped and placed in position as to maintain their special movements, preserving even a useful hinge-joint at the el- bow 2 and at the knee.3 1 T. Billroth. 2 H. J. Bigelow. 3 C. Hiiter. OPERATIONS ON THE JOINTS. 169 JOINTS OF THE UPPER LIMBS. 1. The phalangeal joints should be excised by an incision along the side, slightly convex downwards; through a single incision the extremities of the bones may often be reached and excised by turn- ing them outwards. In the treatment make sufficient extension by means of a palmar splint to keep the bones apart, and begin passive flexion as soon as repair is established. 2. The metacarpo-phalangeal joints should be excised by dor- sal incisions along the margin of the extensor tendons, which must be drawn one side; the articular surfaces being cleared, excise them with cutting forceps, a fine saw, or chain saw. The treatment is the same as after excision of the phalangeal joints. 3. The wrist joint is properly limited to the articular end of the radius, and the first row of carpals. But excision at the wrist in- cludes the removal, not only of the radius and first row of carpal bones, but of a part or whole of the ends of the radius and ulna, a part or whole of the carpus, the proximal ends of the metacarpal bones, or all of these at once.1 The radio-carpal articulation is formed between the radius and triangular fibro- cartilage above, and the scaphoid, semilunar, and cuneiform bones below; the carpal articulations are arthrodial; the synovial sacs are so arranged that their communications are limited; this anatomical peculiarity should be remembered in the effort to remove portions of the carpus, as it is desirable not to open these cavities farther than is absolutely necessary; the ligaments are dorsal, palmar, and interosseous. In the radio-carpal and common carpal articulation, there is allowed not only flexion and extension, but a certain amount of lateral bend- ing.2 The per cent, of mortality' of all exsections at the wrist is, for disease, 7; and for shot injuries, 15; the per cent, of usefulness of the wrist in the cases which have given determined results is, for disease, 7 perfect, 45 useful, and 24 worth- less; for injuries, 28 perfect, and 57 useful; for shot injuries, 1 perfect, 28 use- ful, and 17.5 worthless, or requiring amputation; the effect of the extent of ex- cision upon the per cent, of usefulness is, for partial 62.9, and for complete 83.3 The following are the definite end results after various excisions for shot in- juries at the wrist;4 in five complete excisions the functions of the hand were much impaired, but preferable to amputation; in four excisions of the extremities of radius and ulna, there was lateral distortion of hand and stiffness of fingers; in twenty-one excisions of the lower end of the radius nearly all had anchylosis and extreme deformity; the hand generally being strongly deflected to the ra- dial side, often at right angles, the fingers rigidly fixed in flexion or extension, the end of the ulna projecting, and the integument over it irritated and exposed to accidental iujuries; in fourteen excisions of the ulna, nearly all had anchylo- sis and deformity, the hand was generally less displaced, but there was an equal 1 R. M. Hodges. 2 Quain's Anat. 3 H. Culbertson. 4 G. A. Otis. 170 OPERATIVE SURGERY. proportion of cases of ridigity of the fingers, and more examples comparatively of paralysis and of neuralgic suffering; in six cases of excision of the end of the radius with one or more carpals, there was anchylosis and deformity; in eight cases of excisions of the end of the ulna with adjacent carpals, or carpals and metacarpals, two had very useful hands, but the remainder had anchylosis, con- tracted fingers, and other deformities; in eight excisions confined to the carpus, three retained valuable mobility of the hand, and five had anchylosis with much deformity ; from this record it seems probable that recovery unattended by an- chylosis is seldom to be anticipated, yet that this result is not disastrous provided the hand is in good position, and the functions of the fingers are in some degree preserved. But these imperfect extremities are far more useful, especially when supported by suitable apparatus, than stumps after amputation.1 Excision for caries has hitherto been unsuccessful chiefly owing to the recur- rence of the disease, and the impaired functions of the hand; but these results are largely due to partial excisions, and hence the necessity of complete removal of the wrist when affected with caries. Even bones -which appear sound in a carious joint seem apt to be affected in an insidious, incipient degree, and if left behind may lead to recurrence of the complaint.2 The indications for excision are; for shot injuries, if there is com- minution of the bones of the carpus, or of the carpus and epiphy- ses of the bones of the fore-arm, especially if the missile is lodged, and cannot be removed otherwise; if subsequently infiltration cannot be controlled by incision and threatens to spread to the fore-arm;3 in injuries, as compound dislocations, all displaced and fractured bones which must eventually become detached should be at once re- moved ; in crushing injuries when vessels, nerves, and soft parts are not so much involved as to render amputation necessary ; in sec- ondary excisions for injuries to the carpus the entire wrist should be removed; in caries involving the carpus extensively, and which has resisted other treatment, excision becomes necessary. Excision of the entire wrist consists of a series of operations each of which must be executed with scrupulous care, as follows:2 Break down adhesions of tendons by freely moving all the articulations of the hand; commence the first incision at the middle of the dorsal as- pect of the radius, 2 (Fig. 140), on a level with the styloid process ; carry it towards the inner side of the metacarpo-phalangeal articula- tion of the thumb, running parallel in this course to the extensor secundi internodii ; on reaching the line of the radial border of the second metacarpal bone, carry it downwards longitudinally half the length of the bone, the radial artery lying farther to the outer side of the limb; detach the soft parts from the bone at the radial side of the incision, the knife being guided by the thumb nail; divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal bone, and raise it along with that of the extensor carpi radialis brevior previously cut across, and the ex- 1 E. D. Hudson. 2 J. Lister. 3 Von Langenbeck. OPERATIONS ON THE JOINTS. 171 tensor secundi internodii while the radial is thrust somewhat out- wards ; separate the trapezium from the rest of the carpus by cutting forceps applied in the line with the longitudinal part of the incision ; leaving the trapezium in po- sition until the rest of the carpus is taken away, dissect the soft parts on the ulnar side of the incision from the carpus as far as convenient, the hand being bent back to relax the extensor tendons of the fingers; commence the second incision, 3 (Fig. 140), at least two inches above the end of the ulna, immediately anterior to the bone, and carry it downwards between the bone and flexor carpi ul- naris, and on in a straight line as far as the middle of the fifth metacarpal bone on its palmar aspect; raise the dorsal lip, cut the extensor carpi ulnaris at its insertion into the fifth metacarpal Fig. 140. bone, and dissect it from its groove in the ulna without isolating it from the integuments ; separate the extensors of the fingers from the carpus, and divide the dorsal and internal lateral ligaments of the wrist-joint; leave the connections of the tendons with the radius undisturbed; now clear the anterior surface of the ulna by cutting towards the bone, avoiding the artery and nerve; open the articulation of the pisiform bone, and separate the flexor tendons from the carpus, the hand being depressed to relax them ; clip through the base of the process of the unciform bone with pliers, but avoid carrying the knife farther down the hand than the bases of the metacarpal bones; divide the anterior ligament of the wrist-joint, separate the carpus from the metacarpus with cutting pliers, and extract the carpus with sequestrum forceps through the ulnar incision, dividing any ligament- ous attachments; the articular ends of the radius and ulna may be protruded at the ulnar incision and excised; divide the ulna obliquely with a small saw so as to take away the cartilage-covered rounded part over which the radius sweeps while the base of the styloid pro- cess is retained ; clear the radius sufficiently to remove the articular surface; if the caries is slight remove a thin slice without disturbing 172 OPERATIVE SURGERY. the tendons in their grooves on the back of the bone; clip away the articular facet of the ulna with bone forceps applied'longitudinally; if the caries is extensive remove freely all the diseased bone with pliers and gouge ; examine the metacarpal bones and excise the artic- ular surfaces only if they are sound, and more extensively if diseased; next seize the trapezium with strong forceps, and dissect it out with- out cutting the tendon of the flexor carpi radialis, and excise the end of the metacarpal bone; clip off the articular facet of the pisiform bone, and, if sound, leave the remainder in position; close the radial incision firmly throughout with sutures, and also the ends of the ulnar incision; but the middle must be kept open by pieces of lint in- troduced lightly to give support to the extensor tendons, and afford free escape of pus. The incision 1 may be made from the middle of the ulnar border of the meta- carpal bone of the index finger upwards to the middle of the dorsal surface of the epiphyses of the radius, 1 (Fig. 141), crossing to the ulnar side of the extensor carpi ulnaris at its insertion into the base of the third metacarpal bone, and dividing the dorsal ligament of the car- pus between the tendons of the long extensor of the thumb, and the exten- sor indicis; the soft parts being raised through this incision by careful manipu- lation of the hand, the carpal bones may be removed one by one by dividing the ligaments which bind them together and to other bones. Various other methods of partial and complete excision have been devised (Fig. 141). A common method has been by parallel incisions, one on the radial, b, and the other on the ulnar border, e, joined by a transverse incis- ion on the dorsum of the carpus.2 The great defect in this method, as in simi- lar incisions, variously curved, c and/, is that the extensor tendons are sacri- ficed; though these incisions may be adopted in exceptional cases, they do not offer the advantages of the method8 given. The after treatment3 must be pursued with due recognition of the fact that the new joint at the wrist is produced by an approximation of the bones of the fore-arm and of the metacarpus, partly by short- ening of the limb and partly by the growth of new bone from the divided ends; with proper care, perfect symmetry of the hand can always be insured; for as the radius and ulna above, and the meta- 1 Von Langenbeck. 2 Sir W. Fergusson. 3 j. Lister. Fig. 141. OPERATIONS ON THE JOINTS. 173 carpus below, are divided in parallel lines, the shrinking of the new material between them draws the hand equally upwards towards the forearm; the surgeon should aim to maintain flexibility of the fingers by frequently moving them, and at the same time to procure firm- ness of the wrist by keeping it securely fixed during the process of consolidation. These indications are met by placing the limb on the splint (Fig. 142),1 which consists of an obtuse- angled piece of thick cork attached to a splint, with a cross-bar of cork at- tached to the under sur- face about the level of the knuckles ; on the splint the hand lies semi- flexed, its natural posi- tion, the fingers midway between the extremes of flexion and extension into Fig. 142. which it is necessary to bring them in the daily passive movements; the thumb is to be kept from the index-finger by a pad of cotton maintained between them; flexion and extension of the fingers should be commenced on the second day, whether inflammation has subsided or not, and con- tinued daily, each finger being flexed and extended to the fullest de- gree possible in health, care being taken that the metacarpal bone concerned is held steady; pronation and supination must not be neg- lected, and as the wrist acquires firmness, flexion and extension, ad- duction and abduction, should be occasionally encouraged; passive motion must be continued until there is no longer a tendency to con- tract adhesions.1 2. The elbow-joint has two motions, flexion and extension, which are limited to the locking of the coronoid and olecranon pro- cesses in the respective fossae of the humerus which receive them ; the path of motion is in nearly a vertical plane with a direction slightly outwards; the inner lip of the trochlea being prominent be- low, forms an expansion which corresponds to an inward projection of the coronoid part of the ulnar surface, and is only brought into use in flexion; the outer lip of the trochlea being everted at the upper and back part, forms a surface which is only in use in complete ex- tension, and which then corresponds to a surface on the outer aspect of the olecranon, which comes in contact with no other part of the humerus; in flexion and extension, the radius moves by its cup- 1 J. Lister. 174 OPERATIVE SURGERY. shaped head upon the capitulum, and on the groove between that process and the trochlea by a ridge internal to the cup.1 The per cent, of mortality from excision for shot injuries is 19, for injuries 15, for disease 10; for deformity, no deaths in 13 cases; for all classes, 15.69 per cent, in 1.075 cases.2 The results of other treatment may be thus stated: for shot injuries the expectant plan gives deaths 10.3 per cent. ; amputation in the arm, 24.3 percent.;3 for injuries, amputation of the arm gives 34 per cent.;4 and for disease, 26 per cent, mortality.3 Complete excision is more favorable to life than partial, in shot injuries and disease, the per cent, of mortality of the former being, for shot injuries, 25; for diseases, 9 ; the latter, for shot injuries, 26.7; for diseases, 11; for injuries proper, entire excision is more fatal than partial, the mortality being, for the former, 21 per cent., and for the latter 7.4 percent.; of the vigorous 33, of the exhausted 66 percent, die after excision; the most favorable age is, for shot injuries, 20-25 ; for injuries, 30-40; for dis- ease, 10-20; the most favorable period is, for injuries, the primary, and for disease, between 9-12 months from the origin.2 The usefulness of the joint after excision depends upon the perfec- tion of the hinge, or antero-posterior motion. The extreme conditions in which it may be left are anchylosis, and a flail-like, or dangle-joint action. Though in both cases the limb is often very useful, yet every effort should be made to avoid such results. While it is true that after-treatment has much to do with the prevention of anchy- losis, yet, in general, the extent of exsection determines the degree of mobility, and also the power of controlling it; if too little is taken away there will be more or less complete anchylosis, and if too much, there will be such relaxation of the muscles as to prevent their efficient action; excisions which have given the best results have been at the commencement of the condyloid projections of the humerus, and at the base of the coronoid process of the ulna.6 The periosteum should be carefully preserved, whatever method is adopted. It may be established as a rule, that excision for injury should be partial and conservative, and for disease it should be entire, or limited only by the removal of the diseased bone.6 When the disease or injury is limited, it is of doubtful propriety to inflict ad- ditional injury by section of healthy bone, for excellent results have been ob- tained when the joint ends of either the upper or fore-arm have been removed after complete exposure of the joint, and the uninjured portions of the articula- tion have been unmolested.3 The method of operation may be by an incision made longitudinally, or by the H,7 the T,8 the h- , the -h, the -f- shaped. The results, both as to mortality and usefulness, prove that absolute preference should not be given to either method in all cases, but that the in- cision should be selected on anatomical grounds, or in relation to 1 Quain's Anatomy. 2 H. Culbertson. 3 G. A. Otis. 4 S. D. Gross. 5 J. E. Erichsen. 6 C Hiiter; Von Langenbeck. 7 Moreau. 8 J. Roux. OPERATIONS ON THE JOINTS. 175 Fig. 143. convenience, or facility of execution.1 In general, the longitudinal incision, by giving sufficient exposure of the joint, and enabling the operator to avoid easily the transverse division of muscular attachments, ligaments, and fibrous struc- tures, should be preferred.2 Subperiosteal exsection is as follows: Make an incision, 2, 2 (Fig. 143),3 two or three inches long on the posterior surface of the joint, a little internal to the middle of the olecranon, beginning about an inch above the tip of the olecra- non, and extending an inch and a half or two inches above that point, upon the border of the ulna, and through muscle, tendon, and periosteum to the bone ; with the elevator, raise the periosteum of the ulna towards the inner side, and detach the inner half of the tendon of the triceps in connection with the per- iosteum, by means of short, parallel, longitudinal in- cisions ; with the left thumb nail, draw the soft parts which cover the internal condyle and enclose the ulnar nerve towards the epicondyle, and detach them by means of curved incisions until the epicondyle is entirely uncovered ; the last incisions separate the origins of the flexor, muscles and the internal lateral ligament, their connections with the periosteum being retained; now draw the outer portion of the triceps tendon outwards and separate by short incisions from the olecranon, maintaining, however, its con- nections with the periosteum of the outer side of the ulna, which is raised from the bone with the insertions of the anconeus; by repeated incisions along the bone, loosen the fibrous capsule of the joint from the margin of the humerus, first over the trochlea, until the internal condyle appears; detach the external lateral ligament and origins of the extensor muscles, so that all remain in connection with each other and the periosteum; now forcibly flex the arm, protrude the articular surfaces through the wound, and saw them off; if the ulna is sawn off below the coronoid process, separate the upper fas- ciculi of the brachialis anticus without disturbing the union of the tendon with the periosteum. Subperiosteal resection may be so performed as to retain the origins of mus- cles, as follows: 4 Make parallel incisions over the external and internal con- dyles, of proper length ; raise the soft parts from the internal condyle, separate the attachments of the flexors with the lainelhe of bone, by means of the chisel; raise the periosteum on both surfaces with the elevator, and divide the lateral ligament; repeat the same operation on the external condyle; now divide the humerus above the condyles, separate the attachments of the triceps with peri- osteum and lamellae of bone; detach the coronoid process from the ulna; divide the extremity of the ulna and remove it. 1 H. Ctilbertson. 2 Von Langenbeck; R. M. Hodges. 4 Voiet. 3 Von Langenbeck. 176 OPERATIVE SURGERY. The J- incision 1, 1,1 (Fig. 143) may sometimes be preferred; the arm being semiflexed, make an incision three or four inches long on the inner aspect of the dorsal surface of the joint, commencing about two inches above the internal condyle, and external to the ulnar nerve, which must be carefully drawn inside when exposed; make a second incision at right angles, dissect up the two flaps to the requisite extent; remove the olecranon with strong cutting forceps and expose the interior of the joint; divide the lateral ligaments; detach the peri- osteum from the surface of the humerus; pass the handle of a scalpel under the bone, and saw upon it; turn back the fragment cut off, and detach it from the joint; separate the head of the radius from the neighboring soft parts, pass a compress under it, and cut it off, preserving all or part of the attachment of the biceps; then lay bare the ulna, prolonging downwards the internal incision; if necessary, isolate the portion to be cutoff from the peri- osteum; put it aside from the soft parts with a compress or protecting guard, and saw it, preserving, if possible, the attachment of the brachialis anticus. If the condyles are not diseased the hinge motion may be preserved by operating as follows :1 After the median incision is made and the ulna cleaned, saw partly through this bone about an inch and a half from the olecranon, and complete the section with forceps; now dis- locate the humerus backward and saw obliquely into the olecranon depression, first from the bed of the ulnar nerve, which is drawn to one side, and similarly from the external condyle; break out the in- cluded mass; (Fig. 144) divide the or- bicular and lateral ligaments, dislocate the forearm back- ward, and saw off the radial extremity. The limb must be placed in a trough splint, semiflexed at the elbow, made of wire or tin, having a large fenestrum cut out at the joint to admit of easy access to the wound. The gypsum dressings may be applied with steel or iron bands curved at the joint so as to leave the wound perfectly free, and fastened above and below in the gypsum. Complete drain- age must be secured by position or drain tubes, and freedom from all sources of irritation. As the cure progresses, passive motion must be early begun and persevered in until the cure is complete. 3. The shoulder joint consists of the large and hemispherical head of the humerus, opposed to the much smaller surface of the 1 H. J. Bigelow. OPERATIONS ON THE JOINTS. 177 glenoid cavity of the scapula; the bones are not retained in position by the direct tension of strong ligaments, which would have too much restricted the movements, but by surrounding muscles and at- mospheric pressure; the ligaments are the capsular, which invests the joint, the coraco-humeral, a broad bundle of fibres extending over the upper and outer part and attached to the root of the coracoid process, and the glenoid, which surrounds and deepens the articula- tion ; the function of the joint is to give support to the arm and great freedom of movement, which is restricted only superiorly and posteriorly by the margin of the acromion.1 The general mortality from excision is 29.84 per cent, distributed according to the causes as follows : shot injuries, 34 ; injuries, 27; disease, 18.2 The mor- tality of shot injuries, according to the methods of treatment pursued is: ex- pectant, 25 per cent; excision, 36; amputation, 29 per cent.3 Various circum- stances influence the mortality, namely, the vigorous give 10, and the exhausted 27 per cent, of deaths; complete excisions are less fatal than partial; those in- volving a portion of the head of the humerus are not so fatal as those involv- ing the entire head ; excision of the head and limited portions of the scapula is less fatal than removal of the entire head; the mortality is no greater in the removal of more or less of the upper fourth of the humerus than of the head alone, and is even less when the upper fourth is removed with a portion of the scapula, though the mortality increases when the upper half of the humerus is removed; yet it is diminished to that of excision of portions of the head, when a part of the scapula is also excised; when more than half of the humerus is excised the mortality is still more diminished.2 The usefulness of the limb after excision is given as follows: After excision for disease, 9.4 per cent, had perfect results, and 70.5 per cent, useful limbs; for injuries, 12.5 per cent, had perfect results, and 62.5 useful limbs; for shot injuries, 2.7 per cent, had perfect results, and 22.2 per cent, useful limbs.2 The amount of motion is generally very satisfactory, but is not greater than that after recovery with anchylosis; the arm cannot be elevated beyond the horizontal line, and in many cases hangs down without any power in the deltoid; but the movements of flexion, exten- sion, and adduction are generally free, and there is usually sufficient power in the forearm to carry heavy weights and perform many of the ordinary domes- tic tasks; recovery with anchylosis, therefore, gives as favorable results as regards the usefulness of the limb as the most successful excision.4 The indications for excision are: In caries, when a cure by natural processes has failed to follow judicious treatment, either from the extent of the disease in the bone, or the general feebleness of the patient's powers; 5 in compound dislocation;6 in compound fracture with protrusion of the shaft through the wounds, and rupture of the capsule with destruction of the periosteum;7 in extensive shot in- juries, as the impaction of a ball in the head of the humerus, or comminution of the epiphysis.8 The method of operation has little or no influence upon the mortality, but it has a marked relation to the 1 Quain's Anatomy. 2 H. Culbertson. 3 G. A. Otis. 4 T. Holmes. s T. Bryant. 6 F. H. Hamilton. " E. Chassaignac. 8 G. A. Otis; Von Langenbeck. 12 178 OPERATIVE SURGERY. usefulness of the limb, e. g., the longitudinal incision gives 8 per cent, perfect, and 45.6 per cent, useful limbs; the various other in- cisions give but a fraction over 1 per cent, perfect, and at the high- est 11 percent, useful limbs.1 The straight incision should, there- fore, be preferred in ordinary excisions. Subperiosteal excision of the humerus should, as far as possible, be practiced in order to secure greater length of limb, for while the degree of shortening ordinarily bears a certain relation to the extent of bone excised, in subperiosteal exsections this law does not hold good, the shortening being com- paratively vastly less in the latter, e. g., 3.93 inches removed with periosteum gave 3 inches shortening, while 4 inches removed, sub- periosteal, gave only one-half an inch shortening.1 Exsection may be performed by the methods given (pp. 127, 128). or as follows:2 The patient lying on the back, the shoulder raised on a cushion, and the external condyle looking forward, make an incision commencing at the border of the acromion near the clavicu- lar articulation, and carry it directly downwards through the deltoid muscle to the capsule and periosteum (Fig. 145); draw aside the margins of the wound with retractors, and recognize the tendon of the long head of the biceps; run the point of the knife along the outside of the tendon, opening the groove and cap- sule to the acromion; draw the tendon one side, and while the arm is rotated out- ward, with a circular sweep of the knife, held perpendic- ularly to the bone, divide the capsule and the attachment of the subscapularis to the lesser tuberosity; then rotate the arm inwards, and in the same manner sever the capsule and the insertions of the supra and infra spinatus and teres minor from the greater tuberosity; the head of the bone is now thrust out of the wound and removed by a narrow back saw passed behind it. Any portion of the glenoid cavity mav be exsected through this wound. If larger space is required, as in necrosis of the acromion, make additional incisions (Fig. 146). 1 H. Culbertson. 2 yon Langenbeck. Fig. 145. Fig. 146. OPERATIONS ON THE JOINTS. 179 Subperiosteal resection may be effected by this method as follows:1 divide the periosteum along the incision and raise it from the bone, first on the inside while the arm is rotated outwards, detaching with it the insertions of the sub- scapularis; then on the outside, while the arm is rotated inwards, separating the insertions of the external rotators; this part of the operation is difficult in primary resection owing to the thinness of the periosteum; the head of the bone being now exposed it may be turned out and excised. The treatment consists in fixing the arm upon the triangular cush- ion 2 and inserting a suitable drainage-tube ; in primary exsection the tube may pass out at an opening made posteriorly, the wound being firmly closed by sutures.1 JOINTS OF THE LOWER LIMBS. 1. The phalangeal joints should be exsected by incisions on the side of the joint, convex downwards. The treatment is the same as the similar operation in the upper limb. 2. The metacarpo-phalangeal joints should be excised by dor- sal incisions along the extensor tendons, which must be preserved and drawn aside; the treatment is extension and passive flexion. The metatarso-phalangeal joint of the great toe may be removed by a lateral semi-lunar incision over the joint. 3. The metacarpo-tarsal joints have been exsected with good results thus,3 make a semilunar incision on the dorsum of the foot and dissect the flap upwards ; expose the first row of tarsal bones and exsect their surfaces with a saw; now expose the articular surfaces of the metacarpal bones and excise them. 4. The tarsal joints generally become carious in connection with such extensive caries of the tarsal bones as necessitates the extirpa- tion of entire bones. Single joints may, however, be excised when the disease is limited, as the astragalo-scaphoid, the calcaneo-sca- phoid, the calcaneo-astragaloid. The incision should be made over the affected joint and curved, and the articular surfaces should be removed with a fine saw or gouge. 5. The ankle joint is a hinge joint; the inferior extremities of the tibia and fibula united form a kind of arch which embraces trans- versely the superior articular surface of the astragalus so as to render lateral movements impossible when the ligaments are tense.4 The mortality5 in the total excisions at the ankle-joint is 12.9 per cent., and for each class as follows: for disease, 8.5 per cent.; for injuries, 12.5 per cent. ; for shot injuries, 12.6 percent.; between the ages of 1 and 15 there were no deaths; the mortality was greatest in the following order of age periods, 20-25, 15-20, 25-20, 30-40, 50-60, and greatest from 40-50 years. In excision for disease the largest number of deaths are found at the period 30-40, and in excision for injuries the least number; the cause of death attributable to the operation is 1 Von Langenbeck. 2 Fig. 68. 3 T. Holmes. 4 Quain's Anatomy. 5 H. Culbertson. 180 OPERATIVE SURGERY 9.7 per cent., and to the disease or injury, or other diseases, 58.8 per cent.; the mortality increased in proportion to the extent of bone excised as fol- lows : excision of the tibia gave 4.7 per cent.; of the fibula 8.6 per cent.; of the astragalus, 13 per cent.; of the tibia and fibula 18.4 per cent.; of the tibia, fibula, and astragalus, 24.4 per cent.; no deaths occurred when excision for disease and injuries was not practiced until after eight months from the attack, from which it is inferred that other joints gradually became involved, rendering the operation more and more dangerous by delay. , The usefulness of the limb was recorded as follows: in excision for disease, 5 5 per cent, were perfect, 60.1 per cent, useful, and in 12 per cent, the extremities were amputated; for injuries, 6 per cent, were perfect, and 59.3 per cent, were useful, for shot injuries 6 per cent, were perfect, 42 per cent useful, and 6 per cent, were amputated, from which it is concluded that a large proportion of these excisions result in more or less usefulness of the limbs. The indications for the operation are as follows : (a.) In compound fractures and dislocations of the ankle-joint, with large, lacerated wounds, and protrusion of the bones, immediate excision greatly in- creases the chances of saving life and limb;1 (p.) in neglected com- pound fractures at the joint, originally produced by severe destruc- tion, combined with extensive laceration of the ligaments, attended with suppuration, formation of fistulae, partial dislocation, excision is the only remedy to produce rapid healing, and to gain a useful limb;1 (c.) in acute suppuration, due to osteo-myelitis, with abun- dant fetid discharge, and destruction of ligaments; (rf.) in cases which have recovered with so much deformity that the foot cannot be made useful with mechanical appliances;x (e.) in chronic caries limited to the articulation of the tibia, fibula, and astragalus.2 The indications against the operations are: (a.) marked constitutional cachexia;3 (b.) chronic caries of the ankle-joint, especially in chil- dren, which is curable by drainage, removal of carious portions of bone with the gouge, and immobile apparatus,4 and in persons ad- vanced in years, in whom amputation at the ankle-joint is more speedy and safe;1 (c.) extension of the caries to the ankle-joints and bones, or upward along the shaft of the tibia.3 The operation which best preserves vessels, nerves, and tendons, as well as the periosteum, is by two longitudinal incisions, one over the external and the other over the internal malleolus, and extended above and below sufficiently to give free access to all of the diseased bone.5 All transverse incisions involving the vessels, nerves, and tendons should be avoided.6 Excise as folkrws:5 The limb being turned on the inner side upon a firm pillow, make an incision two or three inches long on the middle of the fibula down to the point of the malleolus, and sufficiently deep to divide the periosteum; from the extremity of the malleolus con- 1 R. Volkman. 2 L. Oilier. 3 T. Holmes. 4 L. A. Sayre. 5 Von Langenbeck. 6 H. Hancock. OPERATIONS ON THE JOINTS. 181 tinue the incision about a third of an inch, but merely through the skin, so as not to injure the tendons, but to permit of their being raised from behind the malleolus; at the point where the bone is to be divided, separate the periosteum with the raspatorium, and turn down as much as circumstances will permit; introduce the point of the index finger, or a spatula, into the interosseous space to protect the soft parts during the act of sawing; incline the saw slightly to- wards the joint, so that the part to be removed will be external at the point of division; seizing the upper extremity of the fragment with very strong forceps, separate its connections with the raspa- torium and knife when necessary; now turn the foot upon the ex- ternal surface, and make the same incision as upon the fibula; the periosteum is more easily separated than from the fibula; saw the tibia in place with a fine-bladed saw, when the parts are unyielding from chronic inflammatory infiltration ; in recent injuries, and acute suppurations, it may be possible, after the periosteum has been sepa- rated and the ligaments incised, to gradually dislocate the foot out- wards with the aid of the knife, and remove the tibia with the saw.1 To gain more complete access in many cases, the incisions made along the centre of the malleoli may be extended laterally along the margins of the extremities of these bones, 3 (Fig. 148). Or, the Fig. 147. Fig. 148. same result may be attained by extending the incisions made along the posterior margins of the tibia and fibula, around the lower and anterior margins of the malleoli, 3 (Fig. 14 7). Remove the carious parts of the astragalus with a gouge in chronic disease; resect only traumatic cases. Modifications of the longitudinal incisions are as follows : Continue the ex- ternal incision from the point of the malleolus downwards and forwards to within half an inch of the base of the outer metatarsal bone, making a flap; re- flect this flap forward, expose and divide the fibula, and dissect out the frag- ment; now reverse the foot, and continue in like manner the internal longitu- dinal incision from the point of the malleolus to the projection of the inner cuneiform bone; reflect the flap, divide the internal lateral ligament close to the bone, and by twisting the foot outward the tibia and astragalus will appear at the wound; introduce a narrow-bladed saw between the tendons through to the external wound; saw off the end of the tibia and top of the astragalus.2 1 R. Volkman. 2 H. Hancock. 182 OPERATIVE SURGERY. Fig. 149. Fig. 150. A convenient method of suspending the limb is as follows:1 Make a splint of wood or metal fitted to the anterior surface of the leg and ankle (Fig. 149), with rings in- -o-—v serted at three points for suspension: J in its application, the splint is well padded and laid on the front part of the leg and the limb fixed by the ordinary bandage, the ankle being free (Fig. 150); or the gypsum bandage may be applied over the splint and around the leg, a layer of old flannel being first adapted to the leg, and the ankle left ex- posed. 6. The knee-joint may be regarded as consisting of three articulations conjoined; namely, that between the patella and femur, and two others, one between each condyle of the femur and the tibia; the ligamentum mucosum is an indication of the original distinctness of the synovial membranes of the inner and outer joint; the crucial ligaments may be regarded as the external and internal lateral ligaments of those two joints respectively; each portion of the articular surface of the femur belongs either to one or other of the three component joints of the knee, and no part is common to any two of them.2 The knee is a hinge-joint, having free motion in but two directions; it is sup- ported principally by the lateral, the internal, and the posterior lig- aments, and in front by the patella, and its ligamentous attachments; it has also a capsular ligament; the articular face of the tibia has a semilunar fibro-cartilage, which deepens the articular surface for the condyles of the femur. The mortality3 following excision is, for disease, in 603 cases, 29.8 per cent.; for injuries, in 28 cases, 39.2 per cent., and for shot injuries, in 61 cases, 75 per cent. The modifying conditions are as follows: the age most favorable for excis- ion is for disease and injuries, 5-10; for shot injuries, 15-20; the period of the disease most favorable, is 3-6 months, and the most unfavorable 15-18 months, for shot and other injuries, secondary operations are most favorable; traumatic influences greatly increase the mortality in excisions for disease; complete ex- cisions for disease give a higher per cent, of mortality (29) than partial (25), but for shot injuries it is the same (75); in general the mortality increases in propor- tion as less than 2| inches are removed; from 2 £ to 4 inches the mortality is least; above 4 inches it reaches its highest rate; removal of the patella increases the mortality from 2.34 percent., not removed, to 27.3 per cent.; in excision for disease the greatest per cent, died from the operation (37), a less per cenUfrom 1 R. Volkman. 2 Quain's Anatomy. 8 H. Culbertson. OPERATIONS ON THE JOINTS. 183 other diseases (28.6), and the least per cent, from the original disease (20.2); in excision for shot injuries an equal number die from the injury and the operation; in excision for shot injuries the mortality is mainly attributable to the character of the injuries sustained, 42.2 per cent., and to the supervention of other diseases, 15.5 per cent., the deaths traceable to the operation being but 4.4 per cent. It is noticeable that exsections at the knee-joint for disease are becoming more and more successful; for example, before 1850 the mortality was 53.48 per cent.; 1850-60 it was 30.73 per cent.; 1860-70 it was 21.0; 1870-4, 16.9 per cent. The usefulness of the limb is thus recorded: In excisions for disease in 420 cases, 14.3 per cent, were perfect, 42.4 per cent, were useful, 4.6 per cent, not useful, and 17.8 were amputated; for injuries, in 17 cases, 17.6 percent, were perfect, 64.7 per cent, were useful, and 11.7 per cent, were amputated; for shot injuries, in 17 cases. 58.8 per cent, were useful, and 23.5 per cent, amputated; in 46 cases of excision for deformity, 19.5 per cent, had perfect, and 67.8 per cent, had useful limbs; the amount of bone removed varied from ^ an inch to over 4 inches, but the usefulness did not depend upon the extent removed; the removal of the patella secures a greater degree of usefulness than its re- tention in the proportion of 76.9 per cent, of the former to 31.4 per cent, of the latter. From these facts it would appear that this excision gives a large percentage of useful limbs; but those who believe that the value of the limb depends upon a permanently firm, unyielding, osseous union of the femur and tibia, will conclude that the recorded results must be taken with some allowance, for too often the union proves to be fibrous and has been followed by amputation,1 or the limb bends under constant use, or bows outward or inwards, or disease recurs.2 But great prii portant: The patella should not be removed, unless diseased, as the preceding facts show a large per centage of recoveries when it is un- disturbed ; it is also essential to the formation of a firm, well applied flap;6 if carious, the diseased part may be removed with the gouge or forceps ; in excision of the knee-joint in children, remove at first a thin slice of bone, and, in case this should not suffice, with the gouge scrape out carefully the softened and broken-down osseous tis- sue, leaving the much thinned cortical substance with the periosteum, behind; the epiphyseal cartilage is often by this means laid entirely bare from the side of the joint; if perforated with fistulous openings a small spoon must be introduced and every particle of diseased tissue removed ; in very young children it will often even not be necessary to remove any part of the tibia with the saw, it being practicable to remove the diseased part with the spoon; if the epiphyseal cartilage can be saved only in part, no more should be sacrificed than is actually necessary.6 The method of operation will depend upon the kind of joint sought to be obtained; if union of the excised bones is necessary, the U- shaped incision is in general preferable to others, as it permits the removal of any necessary amount of bone without injuring the soft 1 T. Holmes; J. Ashurst, Jr. 2 J. Ashurst, Jr. 3 T. Bryant. 4 L. A. Sayre. 6 J. Ashurst, Jr.; T. Bryant. 6 \\. Vo'lkm'an. OPERATIONS ON THE JOINTS. 185 parts, and both corners of the wound are situated as low as the ana- tomical conditions will allow.1 If an attempt is made to retain mo- tion, a lateral incision 2 is to be preferred, which admits of exsection with the least destruction of the ligamentous tissues of the joint. In exsection designed to secure union, the articular surfaces should be so divided as to give a forward angle at the point of union; this is secured by saw- ing the bones in the lines h, k, and i, j (Fig. 151); the amount of bone removed must of course depend upon the extent of the disease. Exsect as follows:3 The leg being slightly flexed on the thigh, make a curved incision, commencing at the insertion of the internal lateral ligament into the inner con- dyle of the femur, and passing just below the lower extremity of the patella, terminate it at the same point on the external aspect of the joint; the lateral incisions should not be made lower than the insertion of the lateral ligaments, to avoid division of the articular arteries; carefully remove all diseased and degenerated tissues ; reflect this flap upwards (Fig. 152); re- move the patella, if diseased, if not, leave it un- disturbed and divide the lateral and in- terarticular ligaments; pass a fold of cloth through the joint, and draw it firmly under the extremity of the bone to be sawn, thus completely isolating the soft parts behind; apply the saw first to the extremity of the femur, and then to the articular head of the tibia; cleanse the wound, and wire the bones together. The wire selected should be the an- nealed iron-wire, and it should be inserted at two points corresponding to the inser- tion of the lateral ligaments. Subperiosteal resection, with lateral curved incision, is made as follows:2 1 R. Volkman. 2 Von Langenbeck. 3 J. R. Wood. 186 OPERATIVE SURGERY. 2, 2 (Fig. 153) Extend the knee and make a curved incision five to six inches long on the inner side, beginning two inches above the patella, at the inner bor- der of the rectus femoris muscle, its convexity looking back- I 1 wards, passing over the posterior edge of the internal con- i ! J dj^le and ending on the inner side of the crest of the tibia, two • i I or three inches below the patella. In the upper part of the j j I wound is the vastus interims, beneath which the tendon of I i j / the adductor magnus presents itself; in the lower portion the \ \ i / tendon of the sartorius muscle is seen; these tendons must \ L ': / not be injured; cut through the internal lateral ligament in I / Si\ / *ne ^ne °^ *'le Jom'-> separate the internal insertion of the Iri V / capsule from the anterior surface of the internal condyle as l\ >.._•]/ / high as the vastus internus; detach the internal alar liga- \ f*Jr. Ik ment from the anterior border of the tibia to the middle \pSJi(/•%, line; flex the knee, and, as it is again slowly extended, by \/i ft' \ a powerful effort luxate the patella outwards; divide the cru- • s ' \ cial ligaments, and to separate the posterior crucial ligament I i I from the spine of the tibia rotate the internal condyle of the i i J tibia forwards; divide the external lateral ligament together | i I with the adjoining portion of the capsule, by a free cres- / cent-shaped incision, carried several lines below the tip of Fig. 153. the external epicondyle ; the joint now gaps widely ; cut the posterior wall of the capsule; push the articular heads of the femur and v tibia successively forward, and saw them off; if it is necessary to remove the patella, cut around it with the knife at the border of its cartilaginous surface, and then, by means of the periosteal knife, peel it out of its periosteum, so that the latter continues in connection with the ligamentum patellae and the extensor tendons. Before the wound is closed, a strong drainage-tube is inserted, and allowed to protrude at the most depending part. It is also useful to make a counter-opening out of which the other end of the drainage-tube is allowed to hang, as also one through the upper attachment of the capsule of the joint. The after-treatment is generally very prolonged and tedious, for the average time in excision for disease in recovered cases is one hun- dred and seventy-eight days, and in fatal cases fifty-eight days. The conditions to be secured and maintained, of the greatest importance for success, are, (1) proper coaptation of the cut surfaces, and (2) complete immobility of the parts. These conditions are secured by apparatus which fixes the limb immovably, and yet leaves the excised parts so exposed that dressings may be renewed without disturbance of the bones. The gypsum splint and bandage, when judiciously applied, give the most satisfactory results. Of several forms the following meets all the indications most perfectly;1 provide a compress by folding a strip of firm cloth, or lint, extending from just below the tuber ischii nearly to the heel, twelve times together, and of such width as not to touch the angles of the incision; dip it in a solution of plaster of Paris, and apply it to the posterior sur- face; retain it by gypsum bandages, so applied as to leave the front part of the knee uncovered; an iron brace may be added over the 1 P. H. Watson; F. Esmarch. OPERATIONS ON THE JOINTS. 187 knee for strength.1 Or, make a wooden concave splint to the calf of the leg and back of the thigh, but narrow at the knee; also an iron rod for suspension, apply the dressing thus: Pad the posterior splint with lint or cotton-wool, and cover that part corresponding to the site of the wound with gutta-percha cloth, or hot paraffine; place the limb in position and carefully adjust it; place the iron rod on the front and lay folded lint between it and the limb at the groin, at the upper part of the tibia, and at the bend of the ankle; apply an open woven roller bandage around the whole dressing from the toes upwards except at the site of the wound ; over this apply the gypsum band- age in two or three layers; when the dressing is firm, suspend the limb by the hook; the wounds may now be dressed without disturb- ing the part. 6. The hip-joint is a large ball-and-socket joint, in which the globular head of the femur is received into the acetabulum or coty- loid cavity of the innominate bone; the articulating surface of the acetabulum is formed by a broad, ribbon-shaped cartilage occupying the upper and outer part, and folded round a depression which, ex- tending from the notch, is hollowed out in the bottom of the cavity, and is occupied by delicate adipose tissue covered with synovial mem- brane; the articulating surface of the femur presents a little beneath its centre a pit in which the round ligament is attached; movement is allowed in every direction, extension being limited by the anterior fibres of the capsular ligament, and flexion by the contact of the neck of the femur with the acetabulum.2 The results of excision are as follows: For shot injuries the mortality is 89 per cent, in a total of 121 cases; at the different periods it is as follows: pri- mary, 36.7 per cent; intermediate, 48.1 percent.; secondary, 15.2 per cent.,3 giving a large preponderance in favor of the secondary operation. For disease, the mortality is 45 per cent, in a total of 426 cases; the most favorable age is 1 to 10 years; the most favorable period is when the disease has existed 12 to 15 months; the general mortality is greater in complete than in partial excisions. There is but little difference in the mortality when the head and neck, or the head, neck, trochanters, or the head, trochanters, and upper part of the shaft are removed, provided the amount of pelvic bone excised is limited; the mortality centre is the head of the femur, the rate diminishing as the bone is removed outwards to the shaft and increasing as it advances upwards upon the pelvis.3 The usefulness of the limb after excision for disease is equivalent to 93.8 per cent, of the recovered cases; complete excision gives a better result in re- 1 R. Volkman. 2 Quain's Anatomy. 3 H. Culbertson. 188 OPERATIVE SURGERY. covered cases than partial, the former having 45.8 per cent, and the latter 35.8 per cent, perfect limbs, and the former having 48.6 per cent, and the latter 56.G useful limbs; after excision for shot injuries 3.9 more or less useful limbs and 5 imperfectly useful limbs are recorded in 119 cases.1 The indications for exsection are as follows: In compound disloca- tions2 in shot injuries when the head is shattered by the ball, or the ball is impacted in the head ; 3 in disease, when suppuration and dis- organization of the textures of the joint continue unrelieved by or- dinary treatment, and the patient's health is in fair condition.4 Superficial or limited acetabular disease does not interfere with the performance and good results of excision of the head of the femur; even when the acetabulum is much involved, or pelvic suppuration ex- ists, it is important to afford a free escape to the pus by the removal of the head, neck, and great trochanter of the femur.5 It should not be attempted in cases in which abscesses form with little or no fever, the nutrition of the patient remaining satisfactory; nor when anchylosis is complete, though free suppuration is present.8 In gen- eral, the following conditions should guide in deciding to exsect for disease: (1) in chronic coxitis with formation of abscesses and fistu- lous openings, the suppuration being abundant, with fever at night, and progressive weakness ; (2) when an acute suppurating coxitis, with high increase of temperature, supervenes upon a chronic one in which dry granulations without suppuration have filled the acetabu- lum ; (3), when an iliac abscess which is forming shows that pus has perforated the acetabulum and entered the pelvic cavity; (4) when during suppuration, the head of the femur has separated and left the acetabulum.3 The period of operating should be primary in compound disloca- tions and shot fractures. In disease it has not yet been accurately decided what is the earliest stage of its course in which the opera- tion is justifiable, but the evidence 6trongly corroborates the opinion that usually it is delayed too long.5 The surgeon cannot commit a greater error than by delaying excision too long in severe cases, and operating only when the patient is excessively debilitated.8 Though the mortality would seem to diminish in proportion as the shaft is removed, yet there can be no doubt that, as a rule, the extent of the incision should depend upon the amount of disease; if limited to the head, that part alone should be removed;6 if the neck is carious, the trochanter may still be preserved; but if the latter is involved, the bone must be divided at the trochanter minor. The methods of operation are numerous, but the single incision along the axis of the trochanter, with subperiosteal removal of the 1 H. Culbertson. 2 p. H. Hamilton. 8 R. Volkman. 4 L. A. Sayre; T. Annandale; L. Verneuil; C. Hiiter. 5 T. Annandale- 6 Von Langenbeck ; Sheede; C. Hiiter. OPERATIONS ON THE JOINTS. 189 bone, most nearly meets the anatomical indication of the part. Of the several arteries distributed to this region, namely, the gluteal, sciatic, obturator, external and internal circumflex, and the superior perforating by anastomosis, the only one which approaches the line of this incision near enough to be incised before dividing into branches of distribution too small to give rise to noticeable haemor- rhage, is a twig of the internal circumflex, which, at one eighth to one fourth of an inch from the insertion of the obturator externus, breaks up into its terminal divisions ; this branch may be avoided by keeping the point of the knife well against the bone, and dividing the tendon of the obturator externus muscle in the digital fossa.1 Exsect as follows2: (Fig. 155) The pa- tient lying on the sound side, with a strong knife commence an incision, 1, 1 (Fig. 155), at a point midway between the anterior in- ferior spinous process of the ilium and the top of the great trochanter; carry it in a curved line over the ilium, in contact with the bone, across to the top of the great tro- chanter ; extend it not directly over the cen- tre of the trochanter, but' midway between the centre and its posterior border; com- plete it by carrying the knife forward and inward, making the whole length of the in- cision four to six or eight inches, according to the size of the thigh; if the periosteum has not been divided by the first incision, carry the point of the knife along the same line a second or third time; an assistant sep- : ; / arating the wound with the fingers or retract- FjG ]55 ors, the great trochanter (Fig. 157), is exposed; with a narrow thick knife make a second incision through the periosteum only at right angles with the first at a point an inch or an inch and a half below the top of the great trochanter, opposite or a little above the lesser trochanter, and extend it as far as possible around the bone,making sure that the periosteum is freely divided; at the junction of the two incisions of the periosteum introduce the blade of the periosteal elevator, and gradually peel up the periosteum from either side with its fibrous attachments until the digital fossa has .been reached; with the point of the knife applied to the bone divide the attachments of the rotator muscle, and continue to elevate the peri- osteum, carefully avoiding rupturing it at any point; when the perios- teum is removed as far as necessary, adduct the limb slightly, de- 1 J. A. Wyeth. 2 L. A. Sayre. 190 OPERATIVE SURGERY. press the lower end of the femur sufficient to allow the head of d bone to be lifted out only so far as is requisite to permit its re- moval with the saw g : divide the bone just above the trochanter minor, and remove the fragment; if the head of the bone cannot be raised before division on ac- count of the involucrum, saw the bone first and then remove the head; if the shaft at the point of section is necrosed, expose and exsectmore; examine the acetab- ulum and if found diseased re- move all dead bone; if perforated, the internal periosteum will be found peeled off. making a kind of cavity behind the acetabulum, and all diseased bone must be very carefully chipped off down pIG 156 to the point where the periosteum is reflected from sound bone; all sinuses must be thoroughly cleaned of particles of bone and false membrane; cleanse the wound thoroughly, fill it with Peruvian bal- sam, and stuff it with oakum, always avoiding cotton or lint, and close only the extremities with stitches.1 Or, make an incision 2, 2 (Fig. 155),2 commencing about three inches below the crest of the ilium, and the same distance posterior to the anterior superior spine, downwards to the trochanter major, and then along the centre of the shaft of the bone. An exploratoiy incision may be made by entering the knife immediately above and in a line with the posterior margin of the great trochanter, and making an incision sufficiently long and deep ta allow the finger to explore the joint; extension of this in- cision upward or downward two inches will admit of excision of the head of the femur.3 The following method4 is approved: Make a longitudinal incision over the great trochanter 2| to 4 inches in length, in a line Fig. 157. with the axis of the femur, and directed to the posterior superior spine of the iliac bone; two thirds of the incision is made in the glutei muscles above the trochanter, and one third on the trochanter; 1 L. A. Savre. 2 L. Oilier. 8 T. Annandale. 4 Von Langenbeck. OPERATIONS ON THE JOINTS. 191 separate the muscles down to the neck of the femur, in the direction of the longitudinal incision until the neck of the femur and the margin of the ace- tabulum are entirely free; incise the capsule in a longitudinal direction, and notch it slightly on both sides at the margins of the acetabulum; while the fin- ger is passed into the wound, cause rotation of the femur, which enables the operator to separate all the muscular attachments on either side of the incision; the head may be dislocated and sawn off, or the bone may be divided in place and the fragment removed (Fig. 157). The operation 1 by a horizontal incision at the front part of the joint has been advised; the incision commences external to the crural nerve, and involves the sartorius, rectus, and tensor vagina femoris muscles. It is not well adapted for real excision of the joint, as it admits only of an operation on the neck of the femur, unless the incision is very large; as the wound is in front of the joint it . does not favor free discharge of matter; the incision is, however, well adapted for simply dilating fistula? situated in front of the joint, or for gouging out the joint by means of sharp spoons, or for the extraction of the head of the femur when separated.2 The after treatment requires great care and unwearied patience; in order that the excised joint may be kept at rest, the wound must be so placed and exposed that the dress- ing and cleansing may be accomplished without moving the part; during the first weeks it is necessary to keep the acetabulum and the surface of the fe- mur well apart, and the soft parts well stretched, as in excision of the elbow, shoulder, and the ankle-joints; by this means healthy granulations make a more rapid progress, and the pelvis and femur come into close contact by the contraction of the granulations and their formation into cicatricial tissue.2 The wire cuirass is the best apparatus to meet these indications, especially when the patient is a child (Fig. 158). Apply it as follows : The cuirass being properly padded, place the patient in it so that the anus is opposite the opening and free from any obstruction; dress the well leg as follows: make it perfectly straight, then screw up the foot-rest until it is brought firmly against the heel; place a pad between the rest and the foot to absorb perspiration; cover the instep with cotton or blanket, and cany a roller firmly round it and the foot- Fig. 158.3 rest, and thence up over the limb; before applying it, place a piece of paste- board, leather, or several folds of paper, over the leg, knee, and thigh to pre- 1 Rozer. 2 R. Volkman. 8 C H. & Co.; \V. F. Ford. 192 OPERATIVE SURGERY. vent the slightest bending of the knee ; carry the roller around the perineum, and over the outer arm of the instrument, and several times back through the perineum, and then across the pelvis, by which means the well limb is made a firm counter-extending force; dress the operated leg as follows: apply two strips of adhesive plaster, two to four inches in width, according to the size of the leg, one upon either side, extending above to the sinuses, and below suffi- ciently to admit of their attachment to the foot-rest where extension is made; screw up the foot-rest to meet the heel, and bring down the ends of the plaster and fasten them securely around it; then extend the foot-rest slowly and grad- ually by means of the screw, until the limb is brought down to its full extent; if, by long contraction, the adductors and tensor vaginae femoris do not yield, divide their tendons and fasciae subcutaneously; now apply a bandage from the toes over the entire limb to the wound; place a mass of oakum around the wound to absorb the discharge, and continue the roller firmly over it to the body; this dressing will probably not require to be changed for from forty-eight to sixty hours, or until the dressings are moistened with the discharges, when the oakum must be removed, the wound cleansed with carbolic solution, and again filled with Peruvian balsam, and dressed as before; after this, change the dress- ings once or twice daily according to the discharge, and remove the patient from the entire instrument as often as may be necessary; the well leg should be removed at least once a week, and free movement given to all the joints; the cuirass should be used for a month or two, when a long or short hip splint may be substituted, and the patient allowed to exercise.1 In the absence of this apparatus, the limb may be placed in ex- tension, supported by sand-bags or pillows,2 or it may be encased in plaster of Paris, with suitable openings for the discharges. The gypsum bandage is best adapted to adults, and is most ser- viceable when applied with a strip of iron spanning the joint, and maintaining the thigh and pelvic portions in position (Fig. 159) ;8 this stirrup of steel may be movable by means of a bracket, making extension pos- sible ; its construction and application are apparent. With chil- dren, extension by the application of weights and proper positions of the limb are the best means; the patient may be placed on a divided mattress, of which the two different parts, exactly corre- sponding to the spot where the excision was made, are separated by an interstice of several inches.4 1 L. A. Sayre. 2 T. Annandale. 3 C. F. Stillman- 4 R. Volkman. III. THE MUSCULAR SYSTEM. THE MUSCLES; THE TENDONS; THE FASCIAE; THE BURSJE. CHAPTER XVIII. INJURIES OF THE MUSCULAR SYSTEM, AND SPECIAL OPERATIONS. I. MUSCLES. 1. Ruptures of muscles may be partial or complete. The former are sprains, and occur in severe wrenches of the limbs or back; they are restored by rest and soothing applications, and when the soreness is relieved, by gentle movements, massage and galvanism. A muscle may be completely ruptured subcutaneously when the whole force is thrown in a violent and unexpected manner upon one or two muscles, or in violent paroxysms of muscular spasms, as in tetanus ; the point of separation is commonly at the junction of the muscle with the tendon ; the accident is attended with extreme pain, resembling that occasioned by a smart- blow from a stick, and often by a distinct sound like the snapping of a cord; all motion of the part is either impossible, or is accompanied by such severe pain, with spasmodic twitching, as to cause the patient to desist; deep in- dentations are found at the seat of rupture by retraction of the di- vided ends, and often considerable swellings; there is always extrav- asation of bipod with discoloration of the skin. Simple subcuta- neous ruptures of muscles are not serious injuries.1 Place the part in a position most favorable for relaxing the muscles, and bringing the surfaces in apposition, and support it with splints and other appli- ances; maintain the extremities of the separated muscle in contact by evenly applied flannel bandages or laced belts, aided in some 1 T. Billroth. 13 194 OPERATIVE SURGERY. cases by a strip of leather or gutta percha. At first there is a con- nective tissue intermediate substance which soon undergoes such shortening and atrophy that a firm tendinous cicatrix forms; func- tional disturbances rarely remain of any considerable amount, though there may be some weakness of the extremity and loss of delicate movement.1 If the rupture involve the skin also, the injury is grave in proportion to the extent of the laceration; if the muscle protrudes at the wound, it must not be cut away but reduced to position; if necessary, enlarge the wound of the skin, and after replacement close the wound with antiseptic dressing and treat it with a view to secure union without suppuration. 2. Incised wounds cf muscles are followed by retraction of the cut ends. There is always observed a peculiar inversion, subsid- ence, or tucking in of the muscular fibres at the divided parts, so that nearly all the fasciculi direct their cut ends towards the subja- cent bone or fascia; in repair, new muscular fibres are never formed, but the retracted portions become inclosed in a tough, fibrous bond of union; in some cases the cut ends of the muscle are imperfectly united, but the action of the muscle is not lost, for one or both of its" ends, acquiring new attachments to the subjacent parts, still act, though with diminished range.2 Whether the wound is open or sub- cutaneous, approximate the cut extremities of the muscle as perfectly as possible both by position and dressings, and retain them in this condition by absolute rest; if the wound is open, employ deep su- tures to muscles and skin, with bandages above and below fastened over the wound so as to give uniform support and prevent separa- tion. II. TENDONS. 1. Rupture of a tendon is caused by a sudden action of its mus- cles, as of the tendo-Achillis in springing upon the toes; or violence from accidents, as in dislocations; the tendon yields more frequently than the muscle, the point of separation being at the junction of the tendon to the muscle, or at the attachment to the bone; the rupture occurs with a snap and a shock as if the part had received a sharp blow, with sudden and complete loss of function. In treatment, the divided ends must be as accurately approximated as possible, and retained until firm union is established; though close adaptation can not be hoped for, yet a perfect union, with recovery of the action of the muscle, usually takes place, for the severed ends are brought closer and closer together by the contraction of the new material as it becomes perfected, and the remaining deficiency is fully compen- sated by the accommodating nature of the muscle. The appliances 1 T. Billroth. 2 Sir J. Paget. INJURIES OF THE MUSCULAR SYSTEM. 195 in the treatment of ruptured muscles and tendons are the same. The following muscles and tendons are more frequently ruptured : — (a.) The triceps extensor eubiti usually ruptures at the insertion into the olecranon; bandage the arm from above downwards, with a splint in front to keep it extended; or apply adhesive strips over the body of the muscles, and allowing them to cross over the olecranon, make firm traction and fasten the ends over the splint on the anterior surface. (6.) The biceps flexor eubiti is liable to have the tendon of its long head ruptured, the other usually ruptures at a later date;: bandage the arm up- wards, and fix the limb with the hand upon the opposite shoulder; union rarely occurs. (c.) The quadriceps extensor cruris may be ruptured near the patella; place the limb on a straight splint, the foot elevated; fix the patella with ad- hesive strips so that it cannot descend ; apply adhesive strips over the entire compound muscle, each commencing at the upper limits of the thigh; but all converging to the patella; to the combined strips united, attach a rope passing over a pulley, and add a weight sufficient to maintain the parts in apposition. {d.) The tendo-Achillis may rupture, or be detached from its insertion into the os calcis; immediately apply a bandage to the leg from above downwards, over the calf, but stop short of the point of separation, lest the tendon be forced down to the bone and form attachments. Extend the foot on the leg, flex the leg on the thigh, and fix the parts in this position by attaching a belt placed above the knee to the heel of a stout slipper on the foot, if detached from its insertion. 2. Incised wounds of tendons are followed by contraction of the muscle or the displacement of the attached part. They are rec- ognized by loss of function, and the depression at the point of separa- tion. This is one of the few structures of the body capable of com- plete reproduction, and the extent of the new part varies within given limits, according to the separation of the cut tendon.2 The obstacles to perfect union of tendon are : failure to maintain the parts in apposition, too early use of the limb, division in dense fibrous sheaths, the extremities becoming adherent to the inner sur- face of the sheath. Place and maintain the limb in such position as to secure easy apposition of the cut extremities ; if the wound is open, first unite the cut extremities of the tendon by suture, as car- bolized catgut, and then close the external wound; avoid putting the tendon on the stretch for several weeks. III. BURS.E. Wounds of bursae are liable to lead to inflammation and suppura- tion; and secondarily, involve the neighboring joints. Cleanse and disinfect the wound, and endeavor to secure immediate union; if pus form, open the abscess under carbolized spray, and apply antiseptie dressings. 1 T. Bryant. 2 W. Adams. 196 OPERATIVE SURGERY. CHAPTER XIX. DISEASES OF THE MUSCULAR SYSTEM AND SPECIAL OPERATIONS. I. MUSCLES. 1. Inflammation of muscles, myositis, is rarely an idiopathic dis- ease ; it may occur, however, in the tongue, psoas, pectoral, and gluteal muscles, and in those of the thigh and calf of the leg; the acute form usually terminates in abscess, although resolution has been observed.1 After an injury, the symptoms usually appear sev- eral weeks later, and result from some lack of repair in the injured part, due to the want of the necessary rest which an injured muscle so much requires in the process of healing.2 It begins with parenchy- matous swelling of the muscular fibres, and passes rapidly into sup- puration and abscess; the bellies of entire muscles, as the psoas, may be converted into pus; but more commonly the abscess is limited to a spot varying in size from a pea to a walnut, according to the cause in each particular case; the most trifling inflammation affecting the striped muscles of the trunk and limbs occasions the most violent dis- turbance of function; the muscle rests in a state of contraction, and any attempt to extend it is most strenuously opposed by the patient on account of the intense pain to which it gives rise.3 In large ab- scesses which are compressed by strong fasciae there is contraction of the muscles in the substance of which the abscess develops, as in psoitis; but in small and not very painful abscesses, and in traumatic inflammations of the muscles, there is usually no contraction.1 Reso- lution of the inflammation should be attempted by rest and the ap- plication of ice-bags. When pus forms, warm moist applications must be made, and as soon as abscess is detected it should be opened, and with antiseptic dressings if a large muscle is involved. II. TENDONS. 1. Inflammation of tendons, and their sheaths, is liable to follow sprains, or other injuries. The sheaths may inflame, with exudation of fibrinous serum, which often induces temporary or permanent ad- hesions of the sheath to the tendon; or suppuration may occur with necrosis of the tendons; there is now fever beginning with a chill; if the inflammation and suppuration extend, the fever becomes con- tinued and remittent in form; if intermittent chills occur, there is great danger. Inflammation of the sheaths, arising from unknown 1 T. Billroth. 2 T. Bryant. 3 e. Rindfleisch. DISEASES OF THE MUSCULAR SYSTEM. 197 causes, begins as an acute phlegmon, the cellular tissue participates, and the limb swells greatly.' The symptoms at the first are pain on motion, and slight swelling; sometimes a friction sound is present, or grating in the sheath perceptible to the ear or hand. Resolution may occur without suppuration, the limb remaining stiff a long time, as the adhesions between the sheath and tendon do not break down until after months of use; if extensive suppuration follow, the ten- dons usually become necrosed and escape from the abscesses as white threads or shreds, followed by permanent stiffness of the fingers. The treatment of slight inflammation of the tendons, with crepitation, is rest on a splint and local application of tincture of iodine, or add a blister.1 If the symptoms are more severe, elevate the limb and apply ice ; if this is painful, use hot fomentations over a large sur- face ; if the inflammation extend, with throbbing, and hardness, make a free incision along the centre of the sheath, to relieve the tensely strangulated tissues, even though no pus is present.2 If pus is detected, make numerous openings, and secure free drainage from position or tubes; if the disease still progresses, and the patient sinks, amputation of limb may be necessary to save life.1 In the more chronic states, where abscesses burrow, though free openings have been made, resort to pressure with pads of lint soaked in liquor plumbi acetat., and combine tonics and good diet.2 The synovial sheaths suffering chronic inflammation may be- come distended with a fluid, jelly-like and containing white bodies. The sheaths in the hand are most frequently affected; there is a gradual formation of a swelling in the hollow of the hand and the lower end of the volar side of the forearm, and the fluid may be felt passing in the sheath to the forearm under the ligament of the wrist; the fingers are generally flexed and cannot be fully extended; the movements of the hand and fingers are somewhat limited, but there is no pain; the fluid is jelly-like, with white bodies. In other cases there is a partial hernia of the sheath, with dropsy, a ganglion forming a kind of sac-like protrusion about the size of a pigeon's egg, and filled with synovia; it appears most commonly on the dorsal surface of the wrist, in connection with the extensor tendons; it also contains thick mucus, and white bodies, like melon seeds.1 In treatment avoid any operation which might cause suppuration. In dropsy of the sheath, open the sheath antiseptically, using the spray continu- ally until the carbolized dressings are fully applied, and insert a long tube for drainage. If the antiseptic method cannot be applied, avoid operating as long as possible, and then proceed cautiously, as follows: Open the sheath either by incision or puncture, and inject iodine ; if puncture is made, select a medium-sized trocar which will 1 T. Billroth. 2 J. L. Clarke. 198 OPERATIVE SURGERY. allow the escape of the fibrinous bodies; inject tepid water through the canula to force out these bodies; when all has been removed, in- ject slowly a syringe full of a mixture of equal parts of tr. iodine and water, or add an equal quantity of iodide of potassium; remove the canula, cover the wound with a small compress, bind up the hand and forearm carefully and place it on a splint; if the tension subse- quently becomes severe, remove the dressings, close the puncture with plaster and paint with iodine.1 In the case of ganglia, attempt rupture with the thumbs pressed firmly upon it; failing, open it anti- septically, or by subcutaneous free incisions of the sac, and evacua- tion of its contents into the connective tissue; the limb should be kept at perfect rest during the treatment. III. BURS.E. Bursae are deep-seated or subcutaneous sacs to prevent friction; the former are interposed between a muscle or its tendon and a bone or the exterior of a joint, or between two muscles or tendons, and frequently communicate with the cavities of joints ; the latter lie immediately under the skin, interposed between it and some firm prominence underneath.2 From their location and function, they are peculiarly liable to injury, hence to inflammation. Inflammation of the deep-seated bursae appears as local painful swellings, which are often mistaken for common phlegmons. The in- flammation may resolve with more or less consolidation, or terminate in suppuration, or assume a chronic form with an accumulation of fluid, — dropsy. The early treatment should be rest and cold ; if pus form, they must be opened cautiously with antiseptics, and healed as quickly as possible; if they become dropsical, use blisters, tincture iodine, and pressure, and open them for radical treatment only when obsti- nate, and then with antiseptics. The bursae, which occasionally en- large, are numerous in the region of large joints, as the hip, the knee, the shoulder, and elbow ; the following are examples : — (a.) The deltoid bursa • at times communicates with the joint through the bicipital groove; when inflamed there is swelling around the shoulder joint, pain and crepitation on movement, simulating mischief in the joint; it may become distended with simple fluid, or loose bodies; the treatment should be absolute rest of the arm and blisters; it should be opened only after grave con- sideration, and when obstinate, and there is bulging in front of the deltoid. If antiseptics are used there is much less danger. (b.) The quadriceps extensor eubiti bursa3 often inflames and the swell- ing is distinguished from that of the knee by being limited to the upper border- of the patella, especially noticeable when the patient stands, and fluctuation is above and not through the joint. The treatment is rest, tr. iodine, blisters, and when very obstinate, tapping; if it suppurate it must be freely opened, but with antiseptics. 1 T. Billroth. 2 Quain's Anatomy. 3 x. Bryant. DISEASES OF THE MUSCULAR SYSTEM. 199 (c.) The ligamentum patella bursa, distended by fluid, presents itself conspicuously on both sides of the ligamentum, extending from the tubercle to the top of the tibia; it is painful after exercise, swollen, and tender; the treat- ment is rest, blisters, and tr. iodine; as it often communicates with the joint, operations, as incision, puncture, the insertion of a seton, are very dangerous. Other bursas which are liable to inflame, and which must be treated on the same principles, are located as follows: Under the tendon of the subscapularis; in the sheath of the long head of the biceps; between the tendon of the latissimus dorsi and the inferior angle of the scapula; under the insertions of the tendon of the biceps into the radius; under the tendon of the triceps; several at the hip, the largest beneath the conjoined tendon of the psoas and iliacus internus; several in the popliteal space; under the insertion of the tendo-Achillis; about the ankle and tarsal articulations. Of the superficial bursa? those on the patella and olecranon are types; if the inflammation is acute the fluid collects rapidly, the skin is red, the swelling painful, preventing walking; the fluid may wholly or partially be absorbed, or the sac may suppurate, or rup- ture subcutaneously, or through the skin. The treatment of the acute stage is rest, with cold; and in the chronic stage rest, with tr. iodine, compression, blisters, mercurial ointment, or plasters. Compression J by means of a well-padded splint in the ham, and bandaged as firmly as possible with a flannel roller, often effects a cure. But chronic dropsy of this, as of other bursae, is not always curable by these rem- edies; more radical measures are required, as injection of iodine, free incision, or extirpation; injections are not dangerous if the pa- tient remains quiet; use equal parts of strong tr. iodine and water; first draw off a portion of the fluid, then inject the preparation, re- tain it for several minutes, and withdraw whatever will reenter the syringe. If the sac is very thick, it is justifiable to extirpate it en- tirely, which must be done with great care to avoid injuring the cap- sule of the joint.2 After the walls are reached, if the edge of the knife is directed towards the tumor, it may be dissected from the ex- panded tendon of the quadriceps, and from the patella, without injury to either; remove any redundancy of integument; bring the edges of the flap exactly together; fix the limb upon a well-fitting posterior splint, and secure it by a few turns of a roller inclosing the front of the knee and portions of the limb above and below.8 Still greater safety is secured by operating and dressing with antiseptics and confining the limb in a fenestrated gypsum bandage. III. CONTRACTION. Although contraction can only take place in muscles, yet a wider meaning is generally given to the term, and tendons and fascia may 1 R. Volkman. 2 T. Billroth. 3 F. H. Hamilton. 200 OPERATIVE SURGERY. become contracted, being shortened and shrunken, and without their normal elasticity.1 1. A muscle contracts when inflamed, and where there is inflam- matory new formation in muscle, cicatricial connective tissue may take the place of the muscle; this process causes the drawing together by atrophy and induces contraction. Contractions may also result from continued direct irritation of certain nerves, or they may have a reflex origin, or follow as a result of long-continued paralysis of antagonizing muscles. Finally, shortening may occur as a result of continued approximation of the points of insertion, as in curvatures of the spine, and clubfoot; this form of contraction, contractured muscle,2 is an adaptation of the muscle to the new relations of the points of origin and insertion, and is attended with diminished func- tion, and consequently size, adaptive atrophy.3 The treatment de- pends upon the cause; during inflammation extension should be maintained to avoid contraction, but if contraction finally occurs, deformity must be relieved by division of the muscle;4 in paralysis of antagonizing muscles, as in infantile paralysis, contraction must be prevented by well-adjusted appliances; if contraction exist and has so long continued that the muscle has become adapted to its new position,3 it must be divided before the deformity can be overcome. 2. A tendon undergoes contraction, both as a result of inflamma- tion and from long continued position, and not only causes deformities, but ag- gravates and renders permanent exist- ing deformities. The treatment is the same as in contraction of muscles. 3. The fasciae may shrink from the displacement of a part by which the fas- cia is relaxed, as occurs in the fascia lata during hip-joint disease, or the con- traction may occur as a result of a low grade of inflammation, especially in the palmar fascia. This contraction, though sometimes occun-ing in persons suffering from rheumatism, seems to be due to frequently repeated and protracted pres- sure of hard substances, as in handling tools. The integument and subjacent fascia inflame, induration succeeds, and adhesion with contraction follows, with flexion of the finger to which the fascia is attached (Fig. 160), at first slight, but progressively in- creasing until in some cases the ends of the fingers are almost in 1 T. Billroth. 2 A. Delpech. 8 Sir J. Paget. 4 E. lirown-Sequard. DISEASES OF THE MUSCULAR SYSTEM. 201 contact with the palm of the hand. This morbid condition may oc- cur in one or in both hands; the fingers are not usually all contracted to the same degree; the ring finger is generally more flexed than the others, and the little finger more than the index or middle finger. There is little or no pain, except an effort is made to extend the finder, when great resistance is offered and severe pain is induced; indurated and knotty cords can be seen and felt, extending from the palm to the fingers, the firmness of which is greatly increased by efforts at extension; these cords are formed by contracted bands of the palmar fascia together with the closely adherent integument; the skin of the palm is drawn into folds in the form of arcs of cir- cles whose concavities are downwards towards the fingers; in some cases the sheath of the flexor tendon is involved in the vicinity of a single articulation, generally that of the first with the second pha- lanx. It is distinguished from paralysis of extensors by complete extension of fingers; from cicatrices by the absence of scar; from rheumatism by the healthy state of the joints; from contraction of flexor muscles and tendons by the absence of tension when there is extreme flexion of wrist. The case always progresses unfavorably when untreated, but recovery is probable if the contracted bands are thoroughly divided, and the affected fingers are extended and maintained in that position by proper splints, and passive motion is vigorously and persistently applied. As the treatment is tedious and painful, and must be protracted through several months, the patient should be fully informed of these facts. Secure full anaesthesia; make subcutaneous section as far as practicable at every point where there is tension; if the skin is very adherent divide it, but as slightly as possible; close the wounds with adhesive plaster and place the fingers in an extended position ; apply to the back of the forearm, hand, and affected fingers, a metallic splint adapted to the surface, with an intervening layer of lint or cotton wool; secure the fingers to the corresponding portions of the splint by narrow strips of ad- hesive plaster, and the arm, by a bandage; renew the dressings at intervals of two or three days, and apply passive motion persistently until recovery is completed.1 The fascia lata is liable to undergo permanent contraction by long continued spasmodic action of the tensor vagina? femoris, as in hip- joint disease. Division of the muscle will not always be followed by sufficient relaxation of the fascia; wherever contractions still exist, section must be made with the long tenotome carried under the bands. 1 W. G. Elliott; A. C. Post; C Post. 202 OPERATIVE SURGERY. CHAPTER XX. GENERAL OPERATIONS ON THE MUSCULAR SYSTEM. I. MYOTOMY; TENOTOMY; FASCIATOMY. These several general operations on the muscular system, namely, myotomy, section of muscle; tenotomy, section of tendon; and fas- ciatomv, section of fascia, are generally classed under the more com- mon term, tenotomy. They are undertaken for the relief of deformi- ties or displacement of parts, caused or maintained by the contraction of muscle, tendon, or fascia, or of all combined. The muscle and its tendon are more frequently alone at fault, but occasionally the fascia is also involved in the contraction. The true value of tenotomy does not consist simply in division of the contracted structures, but rather in substituting for the unyielding tissue a cicatrix capable of being extended, and which will enable the part to perform again its proper function. It follows that to render the operation successful, great discrimination is required in the selection of the muscle to be divided and the point of division, and in the after treatment. In general the operator may select between division of the muscle and tendon, and then preference should always be given to the tendon, owing to the marked difference in the methods of repair of these two tissues, namely, in section of muscle repair is always by fibrous tissue, while tendon and fascia are regenerated. If the tendon has a synovial sheath avoid it if practicable,1 or if divided, precautions should be taken to preveirt inflammation by the use of a tenotome rendered aseptic by immersion in a carbolized solution. 1. The indications favorable to tenotomy depend upon the follow- ing conditions: (1) The contracted tissues must have undergone such adaptive changes as to render extension by mechanical means im- possible or unadvisable; (2) the antagonizing muscles should not be so paralyzed that they are not capable of restoration of function, at least in some degree. To determine these questions the following general rules are useful, and should be fully applied in every case: — (a.) The force of the contraction may be tested as follows: - If the displaced limb can be brought nearly into position by the force of the hands, the contraction is not so great and permanent that mechani- cal appliances will not overcome the distortion; but if manual efforts do not greatly improve the abnormal position of the part, a condition exists which renders extension excessively tedious, or quite impossi- ble, (b.) The permanency of the contraction is proved thus:8 Place 1 T. Billroth. - \V. Adams. 3 L. A. Savre. OPERATIONS ON THE MUSCULAR SYSTEM. 203 the part contracted as nearly as possible in its normal position by means of manual tension gradually applied, and then carefully re- tain it in that position; while the parts are thus placed upon the stretch, make additional point pressure with the end of the finger or thumb upon the parts thus rendered tense, and if such additional pressure produces reflex contractions, that tendon, fascia, or muscle, must be divided, and the point at which the reflex spasm is excited is the point where the operation should be performed; but if the ad- ditional point pressure does not produce reflex contractions, the de- formity can be permanently overcome by means of constant elastic extension, (c.) The paralysis of antagonizing muscles is proved by their atrophy; the loss of voluntary power over them; their insensi- bility to the electric current; and finally, by the congenital, rather than non-congenital, nature of the distortion, the former being gen- erally due to spasmodic contraction of the muscles involved, and the latter to paralysis of the antagonizing muscles.1 2. The instruments2 (Fig. 161) are tenotomes of different con- struction. The handles should be so marked that the direc- tion of the blade may be known when it is buried in the tissues; the shank should be one to one and three fourths inches long; strong, and firmly inserted into the handle; the blade should be three quarters of an inch to one inch in length, very thick at the heel, very narrow in the cutting portion, and always blunt pointed, the point being some- what rounded and sharpened from side to side, like a wedge or chisel, so that it will split rather than puncture the tis- sues; the blades are of various shapes, being straight or curved, having the cutting edge on the convex or concave border; the steel should be properly tempered to prevent ^ lfi. breaking in cutting condensed structures. For the division of fascia a longer blade is required, but a probe point is preferable to a sharp point. (Fig. 162.) 3. The operation is as follows2: Anaesthetics are necessary in severe operations ; the tendon being made tense, introduce the ________________________ tenotome flatwise, giv- ^ ~) ing it a slight rotary Fig. 162. motion, until the ten- don, muscle, or fascia is reached; carry the blade flatwise under the structure to its oppo- site side, then turn the cutting edge towards the tissue to be divided, the mark on the handle indicating the direction of the edge; press the tendon or muscle down upon the blade, at the same time giving the instrument a slightly sawing motion until the part gives way, 1 W. Adams. 2 l. A. Sayre. 204 OPERATIVE SURGERY. which can be recognized by the finger, and often by a snap; the di- vision being made complete, turn the instrument flatwise and with- draw it, the finger or thumb following and forcing out any blood in the track of the knife and preventing the en- trance of air; the wound must be hermetically sealed by applying two strips of adhesive plaster which cross over the cut, but do not surround the limb, and secure them by a roller bandage. (Fig. 163.) 4. The treatment of the divided tissue should aim to secure reunion of the structure of such length and power as to maintain the proper balance of the forces acting on the part previously displaced. In order to effect this object the deformed part must be restored by such degrees as will not prevent the union of the several tissues; for if restoration is complete immediately after section, the smaller tendons may be so far separated that union will not take place, or the cut ends may unite to their sheaths. If the tendon is large, as the tendo-Achillis, the deformed part may be at once restored,1 but if the tendon is small, as the posterior tibial, extension should be gradual.2 The ob- ject of gradual extension is not so much to elongate or stretch the new material, as to regulate its length, and the rate at which this is to be accomplished must depend upon the activity of reparation pro- cess, and the required length of the new tendons.2 The period must therefore vary from two weeks in a healthy child, to three or four weeks in the adult, and to five or six weeks in atrophied paralytic limbs. TENOTOMY IX THE UPPER LIMBS. The contractions of the muscular system which give rise to distor- tions of the upper limbs are very numerous, and tend to seriously impair function. Distortions of the fingers are peculiarly disabling, and require judicious treatment. Tenotomy, as a remedial meas- ure, must be applied with great care, especially in the region of the hand, owing to the extended synovial sheaths. 1. The flexors profundus and sublimis digitorum are inserted into the phalanges by long tendons running in fibrous sheaths lined by synovial membrane. The deep flexors are inserted into the base of the third row of phalanges, and the superficial flexors into those 1 J. Syme; L. A. Sayre. 2 yy. Adams. OPERATIONS ON THE MUSCULAR SYSTEM. 205 of the second row; contraction of the long flexors consequently flexes the third phalanges, and contraction of the superficial flexors, the second row; section of these tendons is dangerous, owing to the liability to inflammation of the sheaths,1 and should, therefore, be made with such precautions as will prevent the exposure of the sy- novial surface to injury or septic matter. The division should be made on the first or second phalanx. The knife blade, having been wet with carbolic solution, enters the point on the side of the second phalanx, near the anterior surface, and having reached the tendon, cut to the bone; withdraw the knife, keeping the thumb of the left hand firmly applied to the wound which forces out any blood; the wound should instantly be hermetically sealed, and several days be allowed to elapse before the finger is fully extended. Section of the tendons in the palm is still more dangerous, owing to the proximity of arteries and nerves, as well as the large synovial sheaths. If the attempt is made to operate in the palm, make the tendon tense, and puncture anterior to the transverse fold of the skin to avoid the arterial arches, on a line with the middle of the metacarpal bones, and cut directly upon the bone; close the wound as in the former case. 2. The extensor communis digitorum is inserted into the bases of the third row of phalanges; they have no important surgical relations at points where they are most accessible, namely, the dor- sum of the metacarpus. Pinch up the skin over the tendon, and avoiding the veins and articulations, pass the tenotome down to the tendon, and cut towards the bone; if several tendons are retracted, it is better to divide each separately, rather than by a single puncture, as is sometimes advised. 3. The extensors primi and secundi internodii and ossis metacarpi pollicis, may fix the thumb in a state of extension; the radial artery passes beneath them where they cross the carpus. Sec- tion may be made by bringing the tendons out prominently; flex the extended thumb and abduct, which will make the extensors ossis metacarpi and secundi internodii pollicis prominent below the sty- loid process of the radius, at a point where the radial artery passes to the dorsum; if the blunt tenotome is inserted through an incision while the tendons are made tense, and kept well applied to it, divis- ion may be made without danger. . The extensor primi internodii pollicis, lying more external, is now prominent, and may be divided safely where the artery passes under it, over the second phalanx. 4. The flexor carpi radialis runs along the radial side, and is inserted into the base of the second metacarpal, and has the radial vessels on its radial border. It may be divided above the wrist, the 1 T. Billroth. 206 OPERATIVE SURGERY. tenotome entering on the radial border of the tendon, made tense, but inside of the radial artery, and passed beneath it; or, if neces- sary, the palmaris longus may be divided at the same time; first cut the palmaris longus, and then the flexor carpi radialis. 5. The flexor carpi ulnaris runs along the ulnar border, and is inserted into the pisiform bone, and has the ulnar vessels on its radial border. It can be safely divided by making it tense, and puncturing on the radial side, and keeping the blunt tenotome closely applied to the tendon. 6. The palmaris longus runs down the middle of the wrist, is inserted into the annular ligament and palmar fascia, and has the median nerve on its ulnar and posterior surface. Section is effected while the tendon in made prominent by passing the tenotome on its ulnar side carefully under it above the wrist or near its insertion, avoiding the median nerve, and cutting towards the skin. 7. The biceps flexor eubiti is inserted into the tubercle of the radius; it lies in front of the brachial artery and median nerve; it firmly flexes the forearm when permanently contracted; there is a marked prominence of the body of the muscle, and an elevated cord or band at the bend of the elbow when attempts are made to straighten the limb. Section is to be made above the aponeurotic expansion of the tendon, the contraction of which must be relieved, and from before backwards. Make firm extension of the forearm, and when the tendon is rigid, insert the tenotome at the external border, avoiding the median veins; depress the handle as the blade glides under the skin to the opposite border, turn the edge to the tendon and with a sawing motion divide it; the brachial artery is half an inch behind the tendon, and is not in danger unless the incision is made too freely. 8. The triceps extensor eubiti is inserted into the olecranon and has no other important feature than its relation to the joint on its under surface. Extension of the forearm is caused by contraction of the triceps; it may also prevent reduction of a backward disloca- tion. Section should be made by puncture, at least an inch above the joint, and on the inner border, to avoid the ulnar nerve; flexion should not be made for several days, and then gradually. 9. The pectoralis major is inserted into the anterior bicipital ridge of the humerus, and tends by its contraction to fix the arm on the front of the chest; it forms the anterior wall of the axillary cav- ity. In section the tenotome may be passed along its anterior or pos- terior surface, and if the point is kept in contact with the muscle, division is easily effected without complication. 10. The deltoid is inserted into the middle of the outer sur- face of the shaft of the humerus; its origin is so extensive as to give OPERATIONS ON THE MUSCULAR SYSTEM. 207 it the functions of several muscles. Section may be made of differ- ent parts of its insertion according as it may be necessary to relieve contraction; the anterior portion by inserting the tenotome near the insertion from before backwards along its internal surface and cut- ting to the skin, and the posterior margin by a reverse movement. 11. The latissimus dorsi and teres major are inserted into the posterior margin of the bicipital ridge, and form the posterior wall of the axilla; they depress the arm and draw it backwards. Section may be made of the combined muscles by passing the tenotome along either surface, turning its edge to the muscles and dividing with a sawing motion. TENOTOMY IN THE LOWER LIMBS. The distortions of the lower limb, due to contractions of the mus- cular system, form an important part of orthopedy. The differ- ent forms of club-foot and hand are due largely to this cause, and are remedied by restoring the balance of muscular forces. 1. The flexor longus digitorum affects the toes so as to require division, only when its contraction aids in causing or maintaining other distortions; it lies in such immediate relations with the tibialis posticus behind the malleolus, that if the knife is pushed a little deeper when behind the latter tendon, it will include the tendon of the former muscle, and both may be divided at the same operation; the point of the knife should be moved about as little as possible to avoid wounding the posterior tibial artery. 2. The flexor longus pollicis may require section to liberate this part of the foot, so important in every act of walking. It may be divided on the first phalanx,1 or near the inner edge of the foot, where it can be made to project by strong extension of the toe. The point of division should depend upon the prominence of the tendon; by carefully passing the tenotome along the tendon, the plantar ar- teries will escape injury. 3. The extensor longus digitorum may fix the toes in a state of extension, or, by contraction, may elevate the anterior part of the foot. In the former case, section of separate tendons should be made on the dorsum of the metatarsus where there are neither important arteries nor nerves; the extensor of the great toe often requires sec- tion also; the skin may be pinched up and the tenotome passed be- tween it and the tendon, and division made towards the bone. In the latter case section should be made where the tendons pass over the ankle; enter the tenotome close to the inner border of the tendon made tense, pass it outwards, and when the point is at the extremest border turn the edge upwards. 1 J. Syme. 208 OPERATIVE SURGERY. 4. The extensor proprius pollicis has upon its internal bor- der below, the anterior tibial vessels and nerves and dorsalis pedis artery. Section may be made through the same puncture as that used for section of the long flexor of the toes, the point of the knife beinc turned inwards, and carried no farther than the internal bor- der of the tendon to avoid the vessels and nerve. Or, being made tense, the knife may be inserted on its inner margin and passed out- wardly. 5. The tibialis anticus passes from the annular ligament of the ankle over the internal surface of the tarsus, and is inserted into the inner and under surface of the internal cuneiform bone and base of the metatarsal of the great toe. In talipes varus it is placed very much to the inner side, and passes obliquely downwards across the inner malleolus, inclined backwards towards the internal cunei- form bone, which occupies a lateral position, owing to the altered position of the scaphoid bone. The tendon can generally be easily felt, except in fat infants; it should be divided a little above its in- sertion as it crosses the ankle joint. G. The tibialis posticus passes through a groove behind the in- ner malleolus with the tendon of the flexor longus digitorum, but in a" separate sheath, then through another sheath over the internal lateral ligament, beneath the calcaneo-scaphoid articulation, and is inserted into the tuberosity of the scaphoid and internal cuneiform bone.1 The posterior tibial artery lies behind it. In talipes varus the tendon at the point of division, just above the inner malleolus, is relatively more forward than in the healthy foot, and in the sec- ond part of its course, between the malleolus and its insertion into the scaphoid, the tendon does not pass beneath the inner malleolus, and then obliquely downwards and forwards to its insertion; but on the contrary, passes directly downwards to the scaphoid bone.2 If the tendon is normal, divide it half an inch above the inner ankle; the posterior tibial artery lies posteriorly; make a puncture between the artery and tendon, turn the foot outwards, and cut towards the skin; the artery may often be pressed one side by the finger, — by the nail of the left index finger. If the tendon is displaced, as in varus, the following is important: If neither the tendon nor the inner edge of the tibia can be felt, as is commonly the case in fat infants, a puncture made in the inner aspect of the leg exactly midway be- tween the anterior and posterior borders, is a true guide to the posi- tion of the tendon at the point of section. Thrust the tenotome or a sharp-pointed knife straight down to the tendon, and open the sheath by a movement of its point; now insert a blunt-pointed knife beneath the tendon, which will at once be so fixed that it cannot be 1 H. Gray. 2 \y. Adams. OPERATIONS ON THE MUSCULAR SYSTEM. 209 moved from side to side if it is between the tendon and bone; make a complete section of it. 7. The peroneus tertius is a part of the long extensor, and branches off to be inserted into the base of the fifth metatarsal. Section is readily made when the long extensor is tense by inserting the tenotome on its external margin and passing it inwards; or it may be divided at the same time with the long extensor. 8. The peroneus longus and brevis pass through the same groove behind the external malleolus, and are invested by a common fibrous and synovial sheath; the long peroneus then passes across the outer side of the os calcis, in a separate sheath, over the margin of the cuboid, across the foot to the base of the first metatarsal; the short peroneus passes on the outer side of the os calcis to the base of the fifth metatarsal bone. Section of these tendons may be made: (1.) An inch above the base of the external malleolus, the tenotome entering from before backwards between the fibula and the tendons; or, (2.) half an inch in front of the apex of the malleolus, where they may be made prominent and divided by a single puncture; or, (3.) the long tendon could be divided at a point midway between the end of the malleolus and the tubercle of the cuboid, and the short tendon at the external border of the extensor brevis digitorum. 9. The tendo-Achillis is about six inches long, commencing about the middle of the leg, and is inserted into the lower part of the tuberosity of the os calcis; it is separated from the deep vessels by a considerable interval; the external saphenous vein runs along its outer side; section is made as follows: Place the patient on his stomach with the foot hanging over the table or bed; an assistant should put the tendon on the stretch by attempting to flex the foot; introduce the tenotomy knife obliquely downward with its flat surface parallel with the tendon, close to its inner or outer edge, as most convenient, when the tendon is prominent; but when the tendon is deep, enter the knife on the fibular side to avoid the possi- bility of puncturing the posterior tibial artery; carry the knife to the opposite side, depressing the handle to a horizontal direction; now turn the cutting edge towards the tendon and divide it trans- versely from the internal to its external surface; close the wound with a compress fixed by adhesive strip and bandage. If the foot is immediately restored, it must be retained in position by a proper shoe or by adhesive strips passed around the anterior part of the foot, and fastened to the upper part of the leg. If reduction is to be gradual, these appliances should not be resorted to in three or four days. 10. The biceps flexor cruris is inserted into the head of the fibula, and forms the external hamstring; the external popliteal 14 210 OPERATIVE SURGERY. nerve lies close to its internal border. Place the patient in a prone position, extend the leg firmly, and recognize the tendon; enter the tenotome an inch above the head of the fibula, on its inner bonier, inclining it at first outwards, until its point passes under the tendon; then depress the handle to the horizontal, and when its point is felt on the opposite side, turn the edge upwards towards the tendon and divide. 11. The semi-tendinosus, semi-membranosus, gracilis, and sartorius, form the inner hamstring, and are inserted upon the inner and anterior surface of the tibia; the nerves and vessels of this re- gion lie quite external. The patient being in a prone position, enter the probe-pointed knife close to the outer side of the tense hamstring to avoid the vessels and nerves of the ham, incline it inwards towards the median line of the body as it passes under the mus- cles, and until its point is felt on the inner side; now depress the han- dle and divide the structures towards the skin; the section may be limited to the semi-tendinosus and membranosus, or by deeper pene- tration all the tendons and muscles forming this group may be safely divided. 12. The quadriceps extensor cruris is composed of the rectus, vastus externus and internus, and crureus; the tendon is inserted into the tubercle of the tibia through the medium of the patella and the ligamentum patella ; a large bursa lies under the conjoined ten- dons above the patella. Section above the patella is made as fol- lows: pinch up a fold of skin parallel with the ligament; pass the tenotome through to the tendon, but do not penetrate too deeply; carry the blade along the anterior surface under the skin; turn it towards the tendon, and with a sawing motion cut until all resist- ance ceases; effectually close the wound, and do not attempt flexion until the repair has begun. 13. The pectineus is situated at the anterior part of the upper and inner aspect of the thigh, extending from the ilio-pectineal line of the pelvis to the rough line below the trochanter minor; it is an adductor of the thigh and may be divided as follows:1 While one assistant fixes the pelvis, and a second straightens the contracted thigh, recognize the tense and elevated tendon of the muscle and pass a long blunt tenotome blade under it from the external side, an inch and a half below its origin; with a few passes of the blade the entire muscle is divided towards the skin, or the section may be made from the skin. 14. The adductor longus lies on the same plane as the pectineus; it arises by a flat narrow tendon from the angle of junction of the crest with the symphisis, where it may be readily severed. Abduct 1 F. Stromever. OPERATIONS ON THE MUSCULAR SYSTEM. 211 the thigh and make the muscle prominent near its insertion. Pass the tenotome from without downward and inward, until the muscle is passed; then cut with a sawing motion towards the skin until the contracted tissue is divided. 15. The tensor vaginae femoris is a short, flat muscle arising from the anterior part of the outer lip of the crest of the ilium, and 'from the outer surface of the anterior superior spinous process, and terminates in the fascia lata of the thigh, one fourth down the ex- ternal aspect of the thigh. It is easily divided by making it tense and passing a tenotome on either border about an inch from its origin, and cutting towards the skin. 16. The sartorius arises by tendinous fibres from the anterior su- perior spinous process of the ilium, and the upper half of the notch below it. Make a section of its tendon thus: An assistant strongly abducts the thigh, which makes the muscle prominent; pass the long blunt tenotome under the muscle on its external border two and a half inches from its origin and cut towards the skin. TENOTOMY IN THE TRUNK. Many of the muscles in the region of the back have been divided to relieve curvature of the spine.1 The first effect of division of con- tracted muscles, as the latissimus and longissimus dorsi in lateral cur- vature, was in some cases instantly, apparently, very beneficial.2 But in no instance has the operation itself produced a cure, its effect being simply to take off, either in part or whole, the power of muscles engaged in maintaining the curvature, and thus placing the spine in a condition to be more easily influenced by mechanical and physiological causes.3 1. The multifidus spinae consist of a number of fleshy and ten- dinous fasciculi which fill up the groove on either side of the spinous processes from the sacrum to the axis. The tension of the deep- seated layer of muscles of the back is weakened by dividing the thickest part of this muscle, as it lies comparatively superficial upon the dorsum of the sacrum opposite the posterior superior spine of the ilium ; 3 pinch up the skin so that the fold is parallel with the spine; pass the tenotome upon the surface of the muscle, and cut towards the spine. 2. The longissimus dorsi and sacro lumbalis are portions of the erector spinae; the former is the inner and larger portion, and is inserted into the tips of the transverse processes of the dorsal ver- tebrae, and into seven to eleven ribs; the latter is the external and smaller portion, and is inserted into the angles of the six lower ribs. The tension of the middle layer of spinal muscles is relieved by di- 1 Gue>in. 2 Report of Committee on Guenn's Practice. 3 R. Hunter. 212 OPERATIVE SURGERY. viding these muscles in the lumbar region near their origin;1 operate as above. 3. The latissimus dorsi covers the lumbar and lower half of the dorsal regions, and is inserted into the bicipital groove of the hume- rus. The muscle is made tense by elevating the shoulder forcibly, and may be divided as follows:2 Select a long, strong tenotome; pass the point under the anterior edge of the muscle, nearly opposite' the angle of the scapula, and along the under surface; now turn the edge towards the muscle and cut with a short sawing motion, the thumb being pressed upon the tightly drawn band ; turn the knife upon its side and withdraw it, closing the wound with the thumb; dress the wound with adhesive plaster and firmly adjusted roller.2 4. The trapezius has one origin from the superior curved line and protuberance of the occipital bone. In lateral deviations of the head this muscle may become permanently contracted and require division at its cranial origin. The muscle being made tense by car- rying the head to the opposite side, enter the tenotome below the occipital protuberance, pass its blade along the external surface of the muscle, then turn its edge to the muscle and divide the contracted tissue. The sterno-cleido-mastoid muscle has its origin from the upper part of the sternum by a flat tendon, and from the sternal third of the clavicle by fleshy fibres; behind it are the carotid and subclavian arteries, and internal jugular vein. Division of this part of the muscle is necessary in distortion of the head, wryneck or torticollis, when it depends upon unyielding contraction of the sterno-mastoid without caries of the spine. In some cases only the clavicular portion needs to be divided. The operation is perfectly free from danger, if carefully performed, since the muscle stands out well from the vessels below it, which are again separ- ated by a strong membrane.3 A separ- ate puncture should be made for each portion of the muscle. An assistant should put the head on the stretch so as to render the muscle prominent (Fig. 164), pass a long tenotome closely along the surface of the clavicular fibres about half an inch above the clavicle, turn its edge towards the muscle and divide completely; enter the teno- tome in the same manner and divide the"sternal origin. 1 R. Hunter. 2 l. A. Sayre. 3 T. Holmes. IV. THE CIRCULATORY SYSTEM. THE HEART; THE ARTERIES; THE CAPILLARIES; THE VEINS; THE LYMPHATICS. CHAPTER XXI. THE INJURIES OF THE CIRCULATORY SYSTEM AND SPECIAL OPERATIONS. I. THE HEART. Wounds may involve only the pericardium, or they may pene- trate to the walls of the heart, or even reach its cavities. The in- struments with which they are inflicted are projectiles and pointed bodies, as needles, pins, knives. The symptoms are, haemorrhage from the wound, more or less free; sudden convulsive movement; pal- lor; faintness; sighing respiration; cold extremities; small, unequal, and intermitting pulse, and acute pain in the sternal region. Death may be immediate, caused by the sudden arrest of the heart's ac- tion, either from shock or the accumulation of blood in the peri- cardium, or life may be prolonged for days, or complete recovery may follow. The treatmentl should aim (1) to favor the formation of a coagulum in the wound; close it with antiseptic dressings at once, and do not reopen unless the collection of blood in the peri- cardium becomes so great as to cause intense dyspnoea and interfere materially with the action of the heart; place the patient in a re- cumbent position, and enforce the strictest quiet and silence; freely expose the chest to the air, and if there is a tendency to haemor- rhage, apply cold, as ice; remove any foreign body when it can be effected without difficulty, but use no violence in attempting to with- draw it lest fatal haemorrhage ensue; (2.) prevent the separation of the clot; persistent rest of the body in the recumbent position, and 1 J. F. West. 214 OPERATIVE SURGERY. removal of all sources of irritation, local or general, must be enforced for a considerable period; venesection is not required, but digitalis to moderate the force of the heart's action, acetate of lead to favor coagulation of the blood, and hypodermic injections of morphia to allay excitement, will be required; interfere with the wound as little as possible; (3) to control inflammation; leeches, perfect rest, low diet, with calomel and opium, are most useful; in all cases a broad flannel bandage applied around the thorax gives the greatest com- fort. If the praecordial dullness becomes very extensive from serous effusion into the pericardium, or if still later, there is evidence of a collection of pus, it will be expedient to draw off the fluid with a trocar or aspirator, the cicatrix being the guide to the point of punc- ture. When a foreign body remains and the diagnosis has been sat- isfactorily established, extraction by incision has been undertaken with success, as follows :1 Chloroform being given, a spot was selected at which each impulse of the heart gave the feeling of something firmer than the surrounding tissue; the skin and subcutaneous struc- tures were divided, when the extremity of the needle was brought into view on a level with the surface of the intercostal muscle movin» with each impulse of the heart, and describing a curve; the needle was now seized and removed. II. ARTERIES. The deep situation of arteries, and their unexposed position at joints, protect them from the more common injuries. 1. Contusion may be so slight as to cause but temporary dis- turbance of the circulation, or so severe as to lead to closure of its calibre, or destruction of its coats. Closure is due to the formation of a thrombus,2 and is liable to be followed by gangrene of the parts supplied by the artery. If a lesion of the coats finally occurs, a pulsating tumor, traumatic aneurism, forms. The treatment of con- tusion depends upon its secondary effects; if gangrene follows, am- putation will be required when the disease has become limited; if an aneurism appears it must be treated according to the rules estab- lished. 2. Rupture of the coats of an artery occurs when the limb is sub- jected to a violent strain. The lesion may involve the internal coat only, or the external coats without lesion of the internal coat, or all of the coats may be torn through. The symptoms depend upon the nature of the lesion; if the internal coat alone is ruptured, there is sudden pain in the part, and the circulation ceases. The artery is finally closed, as in ligature at the point of injury. Lesion of the external coats is followed by pain, and a pulsating tumor, an aneu- 1 G. W. Callender. 2 r. Moxon. INJURIES OF THE CIRCULATORY SYSTEM. 215 rism. If all the coats are ruptured, extravasation to a variable extent takes place into the surrounding tissues, with diffused swelling. If the blood is effused in large quantities from a ruptured artery of an extremity, as from the popliteal, which is most frequently injured, gangrene will soon follow. If the extravasation takes place slowly, or to a limited extent, the conditions of an aneurism are gradually developed. The treatment must depend upon the degree of injury to the artery; if blood is c-ffused in small quantities, rest, position, and cold, with pressure upon the distal portion of the trunk, may effect a cure; if there is large effusion, without coldness of the limb below, apply a tourniquet, or the elastic bandage above, cut down upon the ruptured artery, turn out the clot, find the rent, and tie above and below; if the extravasation is excessive, followed by cold- ness and numbness of the extremity, amputate at once above the seat of injury. 3. Penetrating wounds by a small instrument, as a needle, will heal without haemorrhage or other symptom. If the instrument is large, haemorrhage may be immediate, or the elasticity of the coats may close the wound temporarily, but it is liable to reopen and bleed. If the wound is incised it maybe transverse, oblique, or longitudinal to the axis of the vessel; it may partially or wholly divide the artery; in complete division there is less liability to haemorrhage than in partial division, owing to the contraction and retraction in the for- mer case; longitudinal incised wounds tend to unite without dress- ing. The treatment should be as follows: (1.) Remove any foreign body from the wound which might interfere with the closure of the artery; (2.) arrest the haemorrhage according to the following gen- eral rules: — («.) If the wounded artery is in an extremity, the hemorrhage may be tem- porarily controlled, either by strongly flexing, or by very forcibly extending the limb (in the former case the artery is compressed at the bend of the limb, and in the latter compression is made in its course by the muscles and the fasciae); (b.) in all cases of punctured wounds, when pressure can be effectually made, and especially against a bone, it should be tried by graduated compression over the part injured (Fig. 165) and, if necessary, on yi :^>m^ /,, the artery above and below the wound; if it is •—^—~^^fe^~ """"TZZTSr^— in an extremity, bandage the whole limb, the mo- ^^3H^^^^^===-^3^V~^~— tions of which should be effectually prevented, v^^^^3fegg3^r^> -^T and absolute rest must be enjoined, especially ■*-----— ^^^ "^ if the artery is large; continue this treatment Fig. 105. for two, three, or more weeks, according to the nature of' the injury; (c.) if the artery is small, like the temporal, divide the vessel, when it will be enabled to retract and contract; and the bleeding will in general permanently cease under pressure, especially when it can be applied against the bone. If the artery is of a larger class, and continues to bleed, it should be sufficiently exposed by enlarging the wound; a ligature should be applied above and below the opening 216 OPERATIVE SURGERY. in the vessel, which may or may not be divided between them. If it is deter- mined to apply a ligature, it is a rule that no operation is to be done for a wounded artery in the first instance but at the spot injured, unless such operation not only appears to be, but is impracticable. No operation should be performed if bleed- ing has ceased, unless its repetition would endanger life.1 Wounds of certain arteries require special treatment, as follows: — 1. In the neck. (1) When the internal carotid is wounded through the mouth, place a ligature above and below the opening made into it;2 the rule which generally obtains among surgeons is to apply a ligature to the common carotid; (2) when any one of the branches of the external carotid has been wounded, tie both ends at the part wounded; if this is impracticable, and the haemorrhage demands it, the trunk of the external carotid should be ligated, not the common carotid; (3) the internal carotid artery, when wounded near the bifurcation of the common carotid, is to be secured by two ligatures; (4) a ligature may be placed on the internal or external carotid, close to the bifurca- tion, with safety; but if the wound of either vessel should encroach on the bi- furcation, one ligature should be applied on the common trunk, and another above the part wounded; but as neither of these would control the collateral circulation through the uninjured vessel, whichever of the two it might be, a third ligature should be placed on it above the bifurcation; (5) a wound known or suspected to be of the vertebral artery should be treated either by direct pressure or by ligature of the vessel in the wound'3; (6) never place a ligature on the subclavian artery above the clavicle for a wound of the axillary below it. 1. In the upper limb. (1) In punctured wounds of the arteries of the arm and forearm apply pressure to the part injured, and a bandage to the limb gen- erally; but when the bleeding cannot be restrained in this manner, a ligature should be applied above and below at the part injured whether the artery be radial, ulnar, or interosseal; (2) when the ulnar artery is wounded in the hand, which is comparativeh' a superficial vessel, pressure may first be tried; but failing, apply ligatures upon each extremity; (3) when the radial artery is wounded in the hand, in which situation it is deep seated, and the bleeding end or ends of the artery can be seen, place a ligature on each; if this cannot be done, search by incisions through the fascia, as extensively as the situation of the tendons and nerves in the hand will permit, that the bleeding point may be fully exposed, remove all coagula, lay a piece of lint, rolled tight and hard, of a size only sufficient to cover the bleeding point, upon it; place a second and larger hard piece over it, and so on, until the compresses rise so much above the level of the wound as to allow the pressure to be continued and retained on the proper spot, without including the neighboring parts; apply a piece of linen, constantly wet and cold, over the sides of the wound, which should not be closed, to allow of the free escape of blood. It is desirable to ligate the brachial artery rather than the radial and ulnar in secondary haemor- rhage of hand.1 3. In the lower limb. (1) The anterior tibial artery is to be tied at that part of its course at which it may be wounded; if the wound is very near its origin, or just behind the interosseous space and ligament, and the bleeding free, make an incision on the fore part of the leg, and if the bleeding point is so deep between the bones as not to admit of two ligatures being placed on the artery above and below it, make an incision through the calf of the leg, when the ar- tery can be secured without difficulty; (2) the posterior tibial, or the peroneal 1 C. F. Maunder. 2 C. J. Guthrie. 3 T. Holmes. INJURIES OF THE CIRCULATORY SYSTEM. 217 artery, or both, if wounded at the same time, are to be tied through a free in- cision in the calf; (3) the popliteal artery should be secured by ligature, only when bleeding; (4) when a wound of the femoral artery or its branches occurs, and the bleeding cannot be restrained by a moderate but regulated compression on the trunk of the vessel, and perhaps on the injured part, recourse should be had to an operation, by which both ends of the wounded artery may be secured by ligature; and the impracticability of doing this should be ascertained only by the failure of the attempt; if the lower end of the artery cannot be found at the time, the upper only having bled, a gentle compression maintained upon the track of the lower may prevent mischief; but if dark-colored blood should flow from the wound, which may be expected to come from the lower end of the artery, and compression does not suffice to suppress the haemorrhage, the bleed- ing end of the vessel must be exposed, and secured near to its extremity; (5.) wounds of the branches of the internal iliac require that a ligature should be applied to both cut extremities, and not to the arteries at their origin. III. THE VEINS. The veins are liable to traumatic lesions, but owing to the quiet flow of the blood-current, and the compression of surrounding tis- sues, the effusion is rarely serious. When, however, injuries of deep-seated veins, especially those communicating with cavities, oc- cur, the haemorrhage may be dangerous. 1. Contusion 1 causes the rupture of a greater or less number of superficial veins, followed by the extravasation of blood into the sur- rounding tissues, or into cavities. The more vascular and yielding a part, and the more severely contused, the greater the extravasation; if the blood escapes slowly it forms a passage-way between the con- nective-tissue bundles, especially subcutaneous connective-tissue and muscles, the wounds being rough and ragged, obstacles are pre- sented to the free escape of blood, and fibrinous clots form, extend- ing into the calibre of the vessel, causing mechanical closure by thromboses. The escaped blood undergoes various changes, namely: the fibrine coagulates, the serum enters the connective tissue and is re-absorbed, the coloring matter leaves the blood-corpuscles and is distributed in solution among the tissues, passing through various metamorphoses, with change of color till it is transformed into hema- toidin; the fibrine and blood corpuscles for the most part undergo disorganization and are re-absorbed. The effused blood assumes different conditions : (1.) Suggillation is a diffuse, subcutaneous haemorrhage, of a dark blue color, which changes into a green, and then into a brighty ellow, which remains for a long period. Re-ab- sorption usually takes place, owing to the diffusion of the blood, and the good condition of the vessels; apply cold to prevent further ex- travasation, and spirit or stimulating lotions to promote absorption. (2.) Ecchymosis is the accumulation of blood into a circumscribed 1 T. Billroth. 218 OPERATIVE SURGERY. space of connective tissues, and may be superficial with a dark blue color, or deep without discoloration ; fluctuation is often very dis- tinct. The blood will have the same fate as the contused tissues; if they return to their normal state, re-absorption will follow; but if they are broken down and pass into disintegration or decomposition, the blood collection will undergo the same change. Immediately after the accident apply compression as accurately as possible to the rup- tured vessel to prevent further effusion; apply ice, or cold lotions, to prevent inflammation; employ uniform compression, with moist dressings to promote absorption; if there is no marked change in two weeks, to compression add painting with tr. iodine daily; if it become hot, red, and painful, apply warm, moist dressings, as poul- tices, and wait for thinning of the skin over the forming abscess before opening it; if the tension and swelling rapidly increase, with chills and fever, the blood and pus are decomposing, and the contents must be evacuated by free incision, and the cavity cleansed and dressed with carbolic solution. 2. Wounds of veins are of frequent occurrence, and generally of slight importance. They are recognized by the flow of dark blood without jet or impulse. They heal readily, owing to the easy ap- proximation of the cut surfaces, and the prompt formation of the blood clot in the wound and vessel. The danger is three-fold, namely, haemorrhage; the entrance of air; inflammation in the con- nective tissue with the formation of thrombus. Ligate the vein, if exposed and accessible, or use torsion or acupressure; elevate the limb or part, and remove all constriction above the wound; apply firm compression over the wound; prevent inflammation by the use of cold. V. THE LYMPHATICS. Wounds 1 of the lymphatic vessels occur in every considerable wound of the soft tissues, but their injury is concealed by the flow of blood, and the lesions of other vessels. It is only by the subse- quent inflammation that their lesions become important. From the margins of the wound fine red striae run longitudinally towards the glands, which swell and become very sensitive, accompanied by fever, loss of appetite, and general depression. The inflammation may terminate in resolution, or the limb may become red and oedem- atous, with high fever, and even chills, and fluctuation soon after an- nounces the formation of pus in the glands or cellular tissue. The early treatment should be cleansing and disinfection of the wound to prevent the further absorption of septic fluids; rest; active purga- tion; local applications of lead and opium lotions, or inunctions of mercurial ointment; wrapping the limb in cotton, the limb mean- 1 C.H.Moore; T. Billroth. INJURIES OF THE CIRCULATORY SYSTEM. 219 time being elevated and wrapped so as to maintain an even tem- perature. If pus forms it must be evacuated early; if it is in a gland, and healing does not progress satisfactorily, use hot, moist applications, lest the poison againextend from the gland. VI. ARTERY AND VEIN. Wounds may penetrate an artery and adjacent vein, or the lesion of the two vessels may occur spontaneously, and lead to an admix- ture of the two currents, creating a form of aneurism. Arterio-venous aneurism is described as of two kinds: (1) An- eurismal varix, when the two vessels are s united at the seat of lesion that the arterial -EE current passes directly into the vein without the Fig. 1(>6. intervention of a sac (Fig. 166); (2) varicose aneurism, when there is a sac interposed between the artery and vein (Fig. 167). The symptoms are well defined; the vein pulsates, enlarges, becomes tortuous, and has a fusiform shape; there is often a Fig. 167. harsh rasping sound on the proximal side; the mass is soft and com- pressible. The tendency of the tumor is to an arrest of growth. At an early period it may often be cured by pressure simultaneously made on the main artery and on the orifice of communication by two persons, one pressing lightly on the point at which the arterial stream enters the tumor, with sufficient force to suspend the coo- ing murmur, the other compressing the artery at some convenient spot above the tumor.1 If the tumor enlarges and radical treat- ment is necessary, the ligature should be applied to the vessels at the seat of lesion.2 An anaesthetic being given, apply the elastic bandage to the limb; make a long and free incision over the tumor; lay open the sac to its full extent, and remove the blood; pass a probe through the orifice into the sac and lay it open; now find the opening into the artery, and apply a ligature to that vessel above and below the lesion ; 3 the artery may be tied outside of the sac in small tumors; if necessary, the vein may also be ligated.8 Both the artery and vein have been successfully tied above and below the tumor.4 1 T. Holmes. - W. H. Van Buren. 3 F. H. Hamilton. * x. Annandale. 220 OPERATIVE SURGERY. CHAPTER XXII. DISEASES OF THE CIRCULATORY SYSTEM AND SPECIAL OPERATIONS. I. THE HEART. 1. Inflammation of the serous pericardium, if of traumatic origin, may result in the formation of pus in its cavity, or, if idiopathic, may terminate in an accumulation of serum. Whatever may be the nature of the distending fluid, if it leads to great embarrassment of the heart's action and the respiration, and all the usual remedies have failed to give relief, removal by the aspirator or trocar and canula may with proper precautions be undertaken. II. THE ARTERIES. 1. Arterial thrombosis is the formation of blood-clot, or throm- bus, in an artery, and is caused by retardation of the blood-current, or irregularities on the inner wall of the vessel, which increase the friction between it and the passing blood; they are laminated when formed by an intermittent, gradual, and long-continued coagulation, as in aneurism, and non-laminated when they originate in sudden coagulation of an isolated mass of blood, as after ligature of an ar- tery. The clot may organize and become a member of the series of vascular connective tissues, or it may soften, giving rise to abscess or embolism.1 2. Cirsoid aneurism is the dilatation and lengthening of an ar- tery, giving it the appearance of varicosity; it may appear over the occiput, vertex, temples, or in the extremities; it usually lies just under the skin, and is readily recognized by the tortuous pulsating artery or arteries.2 The treatment should be directed to the prevention of the further enlargement of the artery by elevating the part as much as possible, douches of cold water followed by supporting appliances, as elastic bandages, laced stockings when the lower extremity is af- fected. When the tumor is inconvenient, or from other causes it is necessary to undertake a radical cure, the ligature of the trunk ar- tery leading to it, though an exceedingly uncertain measure, is per- haps the best, the dilated vessel itself being too much altered in structure to bear the ligature with safety.8 3. Aneurism by anastomosis differs from the preceding only in 1 E. Rindfleisch. 2 T. Billroth. 3 x. Holmes. DISEASES OF THE CIRCULATORY SYSTEM. 221 the larger number of arteries involved and the final implication of capillaries and veins. They are large, irregular, tabulated, pulsating masses, in which a considerable bruit can often be heard, and nu- merous large vessels can be traced into them on all sides; the capil- laries share in the enlargement, and the veins thus receive the pulsa- tion; as the arteries enlarge, their coats become thin, so that it is impossible to distinguish between the arteries and veins around the tumor; their favorite seats are the scalp near the ear and the lip.1 Excise the mass, if small and favorably situated, as on the lip, cut- ting wide of the growth;2 apply the ligature subcutaneously, as in naevus, when the tissues admit; apply a ligature to the trunk of the main artery when the growth is favorably located, as to the external carotid when the disease is in the temporal artery, to the common carotid when the orbit is the seat of the disease; electro:puncture should be employed in severe cases, especially when deeply situated; 3 coagulating agents, as perchloride of iron, may be injected, care being taken to prevent the escape of coagula by accurate pressure around the growth; amputate when the disease affects seriously the bones of the extremity. 4. Atheroma 4 consists in a chronic inflammation of the inner coat of the artery; the predisposing causes are advanced age, alcoholic stimulants, gouty diathesis, and the localizing cause, mechanical irri- tation of the impact of the blood on points of curvature and bifurca- tion of the artery; the change consists in a thickening of the mem- brane itself, a proliferation in and from the connective tissue of the intima, causing an increase of its bulk, and culminating in an in- flammatory overgrowth. Retrograde tissue-metamorphosis now be- gins, which may terminate in fatty degenerations of the cells, com- bined with solution of the intercellular substance, and the formation of an atheromatous abscess; or the intercellular substance may be- come impregnated with earthy salts, a calcification, and form plates of variable size and form. The result of these changes is diminu- tion of the calibre of the vessel, which leads to diminished force of the circulation beyond the lesion, and increased force on the proxi- mal side. Two effects may follow: (1) lessened nutrition, and even gangrene of the extremity supplied by the obstructed artery; or, (2) yielding of the vessel, causing aneurism. The treatment is lim- ited to the effects of the disease. If gangrene occur, amputation must be performed only when the line of demarcation is well estab- lished; if the operation is undertaken too early, reamputation may be required, owing to the extension of the disease. Aneurism re- quires special treatment. 5. Aneurism occurs when the coats of an artery, weakened by 1 T. Holmes. 2 Heine. 3 J. Spence. 4 E. Rindfleisch; R. Moxon. ■>•)•> OPERA IT VE S UR GER Y. atheroma or calcification, yield at the point of greatest pressure of the blood-current, and give rise to a tumor. The shap^ and size which it assumes depend upon the number of coats involved, the location of the lesion, and the surrounding tissues. It may be in- vested by all of the coats of the artery, by one or more coats, or the coats may have all ruptured, and the investing capsule may be the connective tissue; or, finally, the blood may be extravasated among the tissues, due to the rupture of the coats from atheroma, or overstrain, and generally at arterial curves or subdivisions. The diagnostic signs are: (1) A tumor in the course of an artery; (2) ex- pansive pulsation, synchronous with the heart; (3) a bruit; (4) ces- sation of pulsation and diminution of tumor on compressing the artery on the proximal side. There are many sources of error in these signs, and hence they must be carefully studied as a group; if doubt remains, puncture with a hypodermic syringe, or the needle of an aspirator, and examine the contents. The various methods of treatment aim at the consolidation of the blood in the tumor, and obliteration by absorption or organization of its contents. This may be effected by operations upon the tumor and upon the arteries. The operations upon the tumor are designed to diminish the force of the circulation, or interrupt it altogether, in order to effect coagulation of its fluid contents. 1. Manipulation 1 is practiced to displace a clot which, escaping from the cavity into the artery, is carried to a lower point where it lodges, and plugs the artery, and leads to a set-back and interruption of the current through the aneurism. It has been successfully employed in popliteal, femoral, carotid, and subclavian aneurism, and is, undoubtedly, a justifiable measure in tumors which cannot be operated on without very great danger, and are not near to bursting, and in which there is evidence of blood-clot.2 Fatal results have fol- lowed this operation when practiced on aneurisms of the neck from embolism of the brain.3 Place the flat end of the thumb on the prominence of the tumor, and press until the fluid contents escape, and the upper surface of the aneurism is pressed against the lower; now give a rubbing motion to the thumb so as to cause a friction of surfaces within the flattened mass. 2. Injection of coagulation agents has proved successful; but as this method is always liable to cause dangerous inflammation, gangrene, embolism, it is not justifiable where compression can be used.4 The agent preferred is a neutral solution of perchloride of iron, twenty minims strength.5 Compress the artery above and below the tumor so as to completely arrest the circulation; introduce the needle of the hypodermic syringe perpendicularly to the tumor until the extremity is within the cavity of the aneurism, as will appear by the escape of arterial blood; the canula, containing fifteen to twenty drops of the fluid, is screwed on to the needle; now inject drop by drop, occasionally changing the position of the extremity of the needle to form new centres of coagulation; when the tumor has become sufficiently firm, draw the piston to suck up any 1 Sir W. Fergusson. 2 T. Holmes. 3 F. Esmarch. 4 Marsacci. 5 Valletta. DISEASES OF THE CIRCULATORY SYSTEM. 223 free acid-which would irritate the soft tissues, and carefully withdraw the instru- ment ; continue compression on the cardiac side for an hour or more. 3. The elastic bandage has been successfully employed, the object being to completely control the circulation of the limb and tumor for a time. Apply the elastic bandage from the extremity upward above the tumor, but lightly over the aneurism; apply the elastic tubing around the limb over the highest turn of the bandage, and remove the bandage; the limb is now pallid and the tumor pulseless; after fifty minutes, apply compression to the main trunk, and remove the tubing; continue pressure, if necessary, in an intermittent manner for a day or two, when the cure will be found complete.1 4. Flexion2 has been successful in aneurism at the bend of the elbow, knee, and hip, and is indicated in small aneurisms, so situated that the pulsa- tion and bruit are suspended by bending the joint: it need not be extreme nor painful, nor need the limb be bandaged or confined in any way in many cases, as voluntary flexion, the patient being allowed to change the position of the limb slightly, will sometimes succeed when forced flexion would not be tolerated; as flexion acts by retarding the blood-stream and displacing clot, pressure may be combined in the treatment; forced flexion may cause rupture of the sac3 Bandage the limb from the extremity nearly to the joint, then flex the limb firmly and turn the roller around the part above, thus fixing the forearm or leg in a flexed position. 5. Foreign bodies have been introduced into the cavity of the aneurism for the purpose of inducing coagulation by whipping the blood; the cases selected were most unfavorable, and all were fatal, but not from the effect of the opera- tion. Iron wire,4 horse hair,5 carbolized catgut,6 are the agents which have been used; they were introduced through a tine canula. 6. Electrolysis is designed to secure a gradual deposit of the layers of fibrin, and has proved successful in forty-eight out of ninety cases,7 for the most part of the extremities ; abdominal and thoracic aneurisms have rarely been benefited; in the latter case, if the disease tends certainly to death and other methods have failed, electro-puncture would be justified.8 Give an anaesthetic; begin with one or two cells; introduce into the aneurism two or three needles connected with the negative pole, while a sponge electrode connected with the positive pole is applied to the adjacent surface; the length of the application may be five to forty-five minutes: from one to four or five operations are usually sufficient.9 Operations upon the arteries are performed for the purpose of ar- resting the flow of blood into the aneurism, and thus promoting co- agulation. 1. Ligation of the arterial trunk has long been the approved method of ob- structing the circulation in an aneurism. The ligature has generally been some irritating, indestructible material, as silk, which, in its application, ruptured the internal coats, and then by slow degrees divided the external coat, and was cast off from the wound. The cure of the divided artery was effected by the organ- ization of a clot, and the final repair of the cut ends; but this process is al- ways liable to be interrupted; the clot may not organize and the cut ends of the artery may not repair, owing to the inflammation which the ligature creates. This result is followed by haemorrhage from the wound, alwaj's a dangerous 1 W. Reid. 2 E. Hart. 3 T. Holmes. 4 C. H. Moore. 5 R. J. Levis. G Murray. " A. M. Hamilton. 3 H. I. Bowditch. » Beard & Rockwell. 224 OPERATIVE SURGERY. complication. These dangers are very materially diminished by the use of an unirritating ligature, as silver or iron wire, which may remain long in the wound without causing inflammation. But the most perfect results are ob- tained when an unirritating and absorbable ligature is used, as carbolized cat- gut. The ligature need not be so tightly applied as to sever the coats of the artery, and the wound may at once be permanently closed. The course of re- pair consists in the union of the external wound without suppuration, the union of the opposed surfaces of the internal coat of the artery, the replacement of the old ligature by a new ligature of living tissue which strengthens the artery at the point of ligation. It follows that such a ligature may be applied where silk would ordinarily prove fatal, as in the vicinity of large trunks, and where a resulting inflammation would dangerously complicate the operation, as in prox- imity with serous cavities. The only defect in the method of applying absorb- able ligatures is the liability of their absorption before the cure is completed; but this has been remedied by preparing the catgut so that it will remain firmly applied for a sufficiently long time and then undergo absorption without irrita- tion. The rule, therefore, should be to select a ligature which is unirritating, and will be absorbed, and to apply it with antiseptic dressings. But if such a ligature is not at hand, the silk should be carbolized, and applied antiseptically. The several points of ligation are as follows: (1) On the cardiac side, near the tumor,1 or near the first collateral branch, above the aneurism;2 the latter point is always to be preferred when the artery is readily accessible, as the femoral, for popliteal aneurism; (2) on the distal side3 when the artery cannot safely be reached on the cardiac side, as the subclavian or common carotid in innomi- nate aneurism; (3) At its entrance into, and exit from, the aneurism, the old operation,4 as in carotid aneurism at the base of the neck, or traumatic aneu- risms. 2. Compression consists in the application of pressure to the artery, on the cardiac side, with a view to cause stagnation of a mass of blood in the aneu- rism until it coagulates. This method is capable of curing the majority of surgical aneurisms, and when it fails, in no marked manner militates against the adoption of other measures.5 Pressure may be digital or instrumental; the former, when successful, is more rapid and less painful, and should be preferred if all the conditions are favorable. To be successful, pressure must be regular, efficient, and equable.6 Commence the treatment by preparing the patient with several days of rest and low diet to reduce the circulation: select three or four reliable assistants, who must be employed for four or five hours consecutively, each in rotation applying pressure for ten minutes at a time; the pressure must be steady and equal by the finger or thumb placed directly over the vessel, with just suf- ficient force to arrest the flow of 'blood and no more;5 if the patient becomes restive, give anodynes; or it may be necessary to intermit to give the patient rest. The pressure of the fingers majr be reinforced by placing a weight, as a bag of shot, upon the ends. The cure may be very rapid, even occurring in one and a half, two and a half, and three hours,7 or it may be prolonged; pressure should not be given up unless after several days no impression is made, or the surface ulcerates. Instrumental compression may be made in a variety of ways, but in all cases the point used for pressure should, as far as possible, be small, like the linger ends, in order to make accurate pressure on the artery and avoid compression of the vein. A simple appliance is a bag 1 Anel. 2 j. Hunter. 3 Brasdor. 4 J. Syme. 5 x. Bryant. 6 T. Holmes. • J. Knight. DISEASES OF THE CIRCULATORY SYSTEM. 225 sac of sand or small shot, made tapering at one end, and suspended by an elastic band; tourniquet pads may be adapted to various forms of apparatus so as to make pressure at a single point (Fig. 1C8), or at several points allowing intermittent pressure. 3. Acupressure can be practiced with safety upon arteries which are so much dis- eased that they are too brittle and friable to bear the strain of a ligature; in cases of aneu- rism where the artery is diseased for some dis- tance above the sack, the vessel may be closed by an acupressure-needle at a point where it would be inexpedient to apply a ligature; Fig. 168. thus, an aneurism of the lower femoral may be treated by acupressure at the upper portion of the femoral, whereas, if treated by deligation, the ligature would have to be placed upon the external iliac artery, a much more serious operation.1 Pass the needle under the artery and make a figure of 8 with the thread. 4. Constriction2 is made by the artery constrictor (Fig. 169); expose the artery at the point for constriction, and apply the constrictor (Fig. 170) as di- Fig. 169. I Fig. 170. rected (p. 25); the internal coats being ruptured, remove the instrument and accurately close the wound; a clot forms, the current of blood is permanently interrupted, and the consolidation of the aneurism takes place. III. THE VEINS. 1. Venous thrombosis is due to the same conditions which cause thrombus of an artery, namely, retardation of the circulation, or irregularities in the coats of the vessels. More frequently they are caused by acute inflammation of cellular tissues, especially under fascia, tense skin, or bone.8 The thrombus forming at one point often extends by the deposition of fibrin to other branches until a large number, or a plexus of veins, is filled. The clot may be re- absorbed, or organized into connective tissue, or suppurate, forming an abscess, or undergo disintegration, giving rise to embolism.3 The treatment is absolute rest, with applications of ice ; friction with mercurial ointment to prevent embolism; early evacuation of purulent collections.3 2. Varices are veins in a state of permanent dilatation. Veins in certain localities, as in the plexuses of the true pelvis and its outlet, 1 J. C. Hutchison. 2 S. F. Spier. 3 T. Billroth. 15 226 OPERATIVE SURGERY. and in the superficies of the leg, undergo permanent dilatation, causing varix, phlebectasy. This change is the result of a local rise in the blood-pressure; the disorder is never restricted to a sin- gle and very marked dilatation of a vein, but always involves the moderate dilatation of an entire plexus, or of all of the branches of a single trunk; the distention begins just above the valves, which, havino- to support a greater weight than usual, become incompetent, and the vein is stretched longitudinally; the fixed condition of both ends of the vein compels the elongated vessel to bend, forming zig- zags, or become spirally twisted.1 The tendency to varices is indi- vidual, or inherited; hence the ordinary causes act upon existing predispositions.2 Dilatation may affect alike both the superficial and deep veins;3 in the former case the disease is apparent, in the latter it is recognized by the enlargement of parts, the unusual weight, achino-, and sense of weariness. In general, varices are merely causes of discomfort and inconvenience; but they may create disa- bilities so serious as to necessitate operations designed for their radical cure. The general plan of treatment is as follows : Remove the causes of local blood-pressure; support the distended veins and restore their tonicity; operate only upon such varices as cause serious inconvenience or permanently disable the patient. The special treatment must vary with the particular class of veins affected, their condition, and the causes which created and maintain the varicose state. The veins which more frequently become varicose and require radical treatment by operations are as follows: — 1. The internal saphena vein, varicose, forms soft nodular masses, or tortuous elevations of the skin on the anterior and inner aspect of the leg; the disease may involve a few branches or the entire plexus and the trunk above the knee. It occurs more often in persons who stand much; in women who have borne many chil- dren; and in those who have undue pressure upon some part of the main trunk. Palliative treatment, in the form of the elastic stock- ing, can be most satisfactorily employed. Operations are very rarely required; those most approved are as follows: (1) Acupressure; raise the vein so as not to puncture it, pass two pins under it an inch apart, and twist a figure-of-8 silk ligature around the pins, or use India-rubber, or wire; now pass a tenotome under the included vein and divide it subcutaneously; support the limb with a bandage; re- move the pins in three to five days; excision should be delayed several days;4 (2) injections of coagulating fluids; use persulphate of iron with hypodermic syringe thus : apply a compress and roller on the vein above, the patient first standing until the vein is well dis- 1 E. Rindfleisch. 2 T. Billroth. 3 Verneuil. • 4 H. Lee. DISEASES OF THE CIRCULATORY SYSTEM. 227 tended; fill the syringe and then force out a drop or two to expel the air, pointing upwards; select several of the most prominent nod- ules and inject into each three or four drops; apply adhesive plaster over the punctures; retain the compress over the vein two or three days and enjoin perfect rest. 2. The haemorrhoidal veins, varicose, constitute haemorrhoids; they have their origin in congestion of the venous radicals in the lax submucous tissue of the rectum close to the anus; mucous ca- tarrh and overgrowth of the mucous follicles follow; at a later stage the phlebectasy proceeds to the development of large plexuses of varicose veins which push the mucous membrane before them and form a ring of transverse rugae round the anal aperture; the dilata- tion finally concentrates at one or more points of these rugae, which develop into rounded protuberances, and ultimately into fungoid tu- mors of considerable size ; the chief part of the texture of a haemor- rhoid is spongy, being atrophied connective tissue, caused by the pressure of the distended veins kept up by the persistently increased tension in their interior; inflammation often occurs about these venous plexuses, resulting in induration or suppuration, and blood may co- agulate in their interior.1 Veins may rupture into the connective tissue around the anus, and by subsequent inflammation and con- densation of connective tissue give rise to tumors of various size, color, and density, external piles. In general, patients complain of fullness and weight in the rectum, pain in the loins and thighs, bleeding after defecation. Every case should be thoroughly exam- ined before the plan of treatment is settled. Place the patient on the side, on the edge of a sofa, with the knees drawn up; separate the nates gently; external piles will appear as tabs, or bluish more or less inflamed masses covered by skin ; internal piles may protrude from the anus as large grape-like tumors, often very sensitive, or, if not protruding, the finger well-oiled, introduced into the rectum, will detect the growths. In early stages haemorrhoids may be cured by the removal of those conditions which cause congestion of the veins of the rectum, and the free use of cold water to the anus when the bowels move. If the piles are inflamed, direct rest in the recumbent position; hot or cold applications, as maybe most agreeable; mild cathartics, as the following: mag. sulphate, mag. carb., sulphuris precipitati, sacch. lactis, aa ^ss. ; pulv. anisi, 3ih; M.; take one or two teaspoonfuls at bed-time.2 If external piles suppurate, apply anodyne poultices; when the inflammation subsides use astringents, as lead water, oint. nut-galls. If internal piles become prolapsed and painful, with fin- gers well oiled, or with a cloth wet with cold water, reduce them by 1 E. Rindfleisch. 2 G. T. Elliot. 228 OPERA TIVE SUR +i u> H, the centre being the foramen; the object is to fully ex- pose the foramen, and the margin of the orbit; the canal may be entered by the trephine applied to the antrum,2 or by raising the tissues covering the floor of the orbit, and entering the posterior part where the canal is covered by fibrous structures. The trephine is required when the nerve is removed at 4 (Fig. 239), the foramen ro- tundum;3 the crown should be small and be so placed as to open the antrum at the canal; the lower wall of the canal is broken with the chisel to the spheno-maxillary fossa; the dissection may now be car- ried on, and the nerve divided at the foramen rotundum with scis- sors curved on the flat. The canal may be opened by raising the soft parts from the floor of the orbit an inch or more from the orb- ital edge, and with a hook set at right angles with its shaft, the nerve may be raised and excised an inch.4 The latter method is to be preferred when the resection is confined to the portion of nerve in the canal. 4. The lingual, or gustatory, nerve,/(Fig. 239), one of the spe- cial nerves of the taste, supplies the mucous membrane of the mouth, the gums, the sublingual gland, and the papillae and mucous mem- brane of the tongue; it is one of the posterior branches of the inferior maxillary branch of the fifth nerve; it is deeply placed, lying first be- neath the external pterygoid muscle to the inner side of the inferior 1 J. F. Malgaigne. 2 j. M. Carnochan. 3 j. r. Wood. 4 T. G. Morton. 296 OPERATIVE SURGERY. dental, then between the internal pterygoid and the inner side of the ramus of the jaw, and crosses to the side of the tongue beneath the stylo-glossus muscle. Resection is made where the nerve lies upon the ramus, 6 (Fig. 239), thus: the mouth opened widely, recognize the pterygo-maxillary ligament below the attachments of which the nerve may be felt on the inner side of the jaw; make an incision backward from the molar tooth over the nerve, an inch in length; the nerve will appear in the wound, and may be picked up and resected; or, draw out the tongue to the opposite side, and make an incision over the sub- lingual gland, e (Fig. 239), continue the dissection through the upper edge of the gland, when the nerve will be exposed and may be excised.1 5. The inferior dental nerve, d (Fig. 239), is a branch of the inferior maxillary ; it accompanies the inferior dental artery beneath the external pterygoid between the internal lateral ligament and the ramus of the jaw, to the dental foramen, along the dental canal in the maxillary bone, beneath the teeth, to the mental foramen. Resection may be intrabuccal, or by external incision. The intra- buccal operation is as follows : 2 the corner of the mouth being held wide open, make an incision about one inch long, obliquely from within outwards, along the anterior border of the ramus of the jaw through the anterior fibres of the internal pterygoid muscle; tear through the connective tissue between the pterygoid and the peri- osteum with the finger, when the nerve is easily reached at its en- trance into the dental canal. Resection by external incision may be made at any point of the course of the nerve. If the trunk is to be removed before the nerve enters the canal, 5 (Fig. 239), make an in- cision from the sigmoid notch down to the edge of the jaw, raise and turn back the parotid gland, dissect up the lower portion of the mas- seter muscle, and remove a section of bone with the trephine; half an inch of the nerve is exposed for resection; the dental artery is liable to be cut, but may be ligated.3 Resection of any portion of the nerve in the canal may be effected by raising a flap, exposing the bone, and applying the trephine once, twice, or more, and re- moving the external wall of the canal.4 Or, the trephine may be applied at two different points, the nerve trunk cut in them, and that portion then be extracted.5 The terminal portion of the in- ferior dental, as it emerges from the mental foramen, 7 (Fig. 239), is distributed to the integument of the chin and lower lip. Resection is made at the foramen thus: Evert the lower lip, and make an in- cision down to the bone where the lip and gum unite along the groove which separates the alveoli of the canine and first molar teeth; the ends of the divided nerve appear in the wound; seize the proximal end with forceps and draw out of the canal as much as possible. 1 J. Hilton. 2 Paravicini. 3 j. M. Warren. * S. D. Gross. 5 c. Sedillot. OPERATIONS ON THE NERVOUS SYSTEM. 297 6. The facial nerve, s (Fig. 239) emerges from the cranium at the stylo-mastoid foramen, and passing through the parotid aland divides into the temporo-facial and cervico-facial branches. Section of the nerve trunk may be made at the stylo-mastoid foramen as fol- lows: Make an incision vertically two inches in length alona the an- terior border of the process, and of the sterno-mastoid muscle ; draw the parotid gland strongly forwards and dissect with the handle of the scalpel to a depth varying from a half to three fourths of an inch, when the nerve will be found crossing the wound; the internal jugular vein is within a quarter of an inch of the foramen, and in the direction of the Avound. The temporal branch may be divided where it crosses the condyle, by an incision slightly oblique from before backwards, starting from the zygomatic arch and terminating above the posterior border of the angle of the jaw; the dissecbion should be continued through the connective tissue, the parotid aland being drawn down when exposed; the nerve will be found close to the bone and separated from it by connective tissue. NKRVES OF THE UPPER LIMB. The nerves of the upper limb requiring section are branches of the brachial plexus, which is composed of the four lower cervical and first dorsal nerves. 1. The brachial plexus may require resection when the neuralo-ic condition involves a large num- ber of branches. The part most favorably situated for re- section is the first combination of nerves in the two cords. These nerves lie above and to the outer side of the subclavian artery, and external to the sca- lenus anticus muscle. Operate as follows:1 Elevate the shoul- ders, drop the head backwards with the face strongly inclined to the sound side; this renders the tissues of the affected side tense, and makes prominent the sterno-cleido-mastoid, the landmark for the first incision; I an assistant makes the external ' jugular prominent by compres- sing it with a finger applied over the upper margin of the clavicle at its middle, or on a line drawn from the angle of the jaw to the middle 1 II. B. Sands; F. F. Maury. Fig. 240. 298 OPERATIVE SURGERY. of the clavicle; make an incision downwards along the external bor- der of the sterno cleido-mastoid beginning three inches above the clavicle ; from this point make a second incision along the course of the clavicle, giving an L form to the incisions of the integument; the length of both incisions must be regulated by the size of the neck of the patient; the next important guide is the tendon of the omo-hyoid muscle, which must be searched for with the finger and handle of the scalpel, the external jugular vein being drawn aside; the posterior belly of the omo-hyoid being recognized is held aside by the finger or ligature ; the two cords of the plexus now appear; place a liga- ture loosely around the upper cord by means of the aneurism needle, or hold it aside with a blunt hook (Fig. 240); pass the index finger of the left hand into the wound and ascertain the exact position of the subclavian artery, which is to be held out of the way and carefully protected; now divide the cord as near the finger of the left hand as possible, with blunt-pointed scissors, and make a second division above the point of section, as far up as practicable, care being taken not to interfere with the scalenus anticus muscle across which passes the phrenic nerve; four fifths of an inch of the cord may be removed, and the cut ends by retraction separated two and a quarter inches. The outer cord is next resected to the requisite extent. The outer cord may be cut first, and then the inner, by carefully protecting the subclavian artery, as it lies in im- mediate proximity with the latter cord. 2. The external, or musculo- cutaneous nerve, 1 (Fig. 241) rises from the outer cord of the brachial plexus, passes obliquely between the biceps and brachialis anticus to the outer side of arm, then becomes cutaneous, and is distributed to the integument of the radial border of the arm. Recognizing the space above the elbow, between the biceps and the anterior border of the supinator radii longus, make an incision two inches in length, oblique from above downwards, and from be- hind forwards; divide the skin, fascia, and aponeurosis, and the nerve will be exposed, and may be resected to the required extent. 3. The internal cutaneous nerve, 2 (Fig. 241) is a branch of / Fig. 241. Fig. 242. OPERATIONS ON THE NERVOUS SYSTEM. 299 the internal cord, and is distributed to the internal portions of the forearm. Make an incision obliquely from the lower part of the biceps downward and inward to a point an inch below the internal condyle ; cut only through the skin, then open the connective tissue, in which the nerve will be found. 4. The musculo-spiral nerve, 1 (Fig. 242), is the largest branch of the brachial plexus, and is distributed to the muscles and skin of the posterior surface of the arm, forearm, and hand; it winds around the arm in a groove, with the superior profunda artery, passing from the inner to the outer side of the bone, beneath the triceps muscle; it descends between the brachialis anticus and supinator longus to the front of the external condyle, where it divides into the radial and posterior interosseous.1 Resection is made above the external condyle as follows : Make an incision three inches in length alona the external border of the triceps muscle, and between it°and the brachialis anticus. Commencing three inches above the external condyle, and in line with it, dissect the connective tissue with the handle of the scalpel; the nerve is readily exposed close to the bone, and may be resected to any necessary extent. Or the nerve may be exposed above and internal to the external condyle, by recognizing the space between the supinator longus and the brachialis anticus, and making an incision two and a half inches long. o The median nerve, 3 (Fig. 241), has been excised for neural- gia in the lower part of the forearm below the origins of the mus- cular and anterior interosseous branches, and above the origin of the palmar cutaneous branch.2 Ascertain precisely the margins of . the flexor carpi radialis and palmaris longus muscles by extendina the hand upon the forearm; make an oblique incision two and a half inches long from over the border of the first to that of the last-named muscle, the lower end of the incision terminating two inches above the line of the wrist joint; divide the superficial fascia and muscular aponeurosis on a director; seek the nerve in the intermuscular space, and expose it at the lower end of the cut, where it emerges from be- neath the oblique fleshy fibres of the flexor sublimis digitorum; raise this muscle and the nerve will be exposed the length of the cut. 6. The radial and ulnar nerves may be resected by the same operative procedures as are taken in ligature of the respective ar- teries which they accompany, 4, 5 (Fig. 241). 7. The digital nerves3 may be excised by an incision on the inner or outer aspect of the first phalanx of the finger; in severe cases of neuralgia, resection should be performed on both sides of the finger; subcutaneous section of these nerves may be made by passing a nar- I'ow-bladed knife on both sides. 1 H. Gray. 2 j. h. Brinton. 3 j. m. Warren. 300 OPERATIVE SURGERY. NERVES OF THE LOWER LIMB. The nerves of the lower limb requiring section are branches of the lumbar and sacral plexus. 1. The great sciatic, 5 (Fig. 243), the largest nerve of the sacral plexus, supplies largely the integument of the leg. Place the patient on the abdomen; rec- ognize the gluteal fold, and the point of junction of the flexor muscles of the thigh, make an incision three inches long through the skin, fascia, and con- nective tissue; with the finger and handle of the scalpel expose the nerve, and resect to the required extent.1 2. The popliteal nerve, 3 (Fig. 243), the con- tinuation of the great sciatic, may be resected at the interval between the flexor muscles above the pop- liteal space; the incision being made through the skin and fascia, the nerve should be uncovered by dissection with the finger and handle of the scalpel, and an inch and a half removed. 3. The perineal nerve is the larger branch of the pudic; it is distributed to the organs of genera- tion. It has been divided for severe vaginal neu- ralgia successfully,2 as follows: With the finger in- troduced deeply into the vagina, recognize the nerve, which feels as a hard "cord and is very sen- sitive on pressure ; make a deep vertical incision, which will bring the nerve into view; remove it to the extent of an inch. 4. The small sciatic nerve, 4 (Fig. 243), has been excised8 for multiple neuroma successfully, as nearly as possible to its origin, by an oblique incision almost in the direction of the gluteal fold; the portion of nerve was removed from under the edge of the gluteus maximus. 5. The peroneal or external popliteal nerve is, 2 (Fig. 243) given off from the popliteal nerve and passes along the inner margin of the tendon of the biceps, or external hamstring muscle. It is excised as follows : Make an incision two to three inches long, on the inner border of the biceps tendon, through the integument and superficial fascia; the nerve will be found close to the tendon and may be easily excised to the extent of an inch or more. 6. The anterior and posterior tibial nerves, 2 (Fig. 244), 6 (Fig. 243) accompany their respective arteries in such proximity that the incisions for the ligature of these arteries may be adopted for the resection of the nerves. 1 T. Billroth. 2 T. G. Morton. 8 Kosinski. OPERATIONS ON THE NERVOUS SYSTEM. 301 7. The internal saphenous nerve, 1 (Fig. 244), is a branch of the anterior crural and is distributed to the in- tegument on the inner side of the leg; it lies super- ficially in immediate relations with the internal sa- phenous vein. Make an incision' along the track of the vein made prominent by pressure above; the nerve lies immediately behind the vein; if necessary, the vein may also be divided and tied. It (3, Fig. 244) may also be resected where it emerges from be- neath the sartorius muscle at the inside of the knee. Recognize the sartorius and gracilis muscles at the inside of the knee, and the trunk of the internal sa- phenous vein by compressing it above; make an incision two inches long in the course of the vein through the skin and fascia, draw the vein aside, and the nerve will be found as it escapes from the deep aponeurosis and may be resected to the desired extent. 8. The external saphenous nerve, 1 (Fig. 243), a branch of the lumbar plexus, descends along the fibular side of the posterior surface of the leg in con- nection with the vein of the same name. Make an incision along the vein, distended by pressure above, behind the malleolus, or external to the tendo- Achillis; carefully turn the vein aside and the nerve will be exposed. 9. The internal plantar nerve has been successfully resected1 for tetanus caused by injury of the digital branches. The nerve is the larger division of the posterior tibial and accompanies the internal plantar artery; from the point of division of the posterior tibial nerve between the internal malleolus and heel, it is directed forwards under cover of the abductor of the great toe, passing between that muscle and the short flexor of the toes. Make an in- cision along the internal margin of the foot, commencing at the an- terior border of the heel about one fourth of the distance from the inner to the outer margin, forwards two inches ; this incision will be along the external margin of the abductor pollicis; carefully open the space between this abductor and the short flexor and the artery will be recognized with the nerve accompanying it, which may be resected an inch or more. 1 G. E. Foster. Fig. 244. VI. THE TEGUMENTARY SYSTEM. THE SKIN; THE HAIR AND GLANDS; THE NAILS. CHAPTER XXVII. INJURIES OF THE TEGUMENTARY SYSTEM AND SPECIAL OPERATIONS. I. THE SKIN. Though the skin consists of several separate tissues, as the epi- derms and papillary body, the coriuin and subcutaneous areolar tis- sue, and glands,1 they are all so implicated in injuries, and the various results which follow, that they cannot practically be isolated. 1. Contusion2 without external wound is the common bruise of skin and subcutaneous tissue, and may be of various degrees of se- verity; when slight, the textures suffer only shaking or jarring, fol- lowed by rupture of blood vessels and effusion of fluid; in severe contusions the damaged structures are broken, and there may be visi- ble ruptures of soft parts, especially splittings of the subcutaneous. tissue, and separations of it from the fasciae; in extreme cases the parts are thoroughly crushed. Swelling generally quickly follows the violence ; first, there is some depression or indentation, with soft- ening of the injured tissues; swelling succeeds, due partly to extrava- sation, but much more to the rapid afflux of blood and exudation from the vessels. The most frequent subcutaneous haemorrhages are from the veins; if the extravasation is into the cutis it has a dark blue color, passing into brown; if it escape more deeply and slowly, the blood forms a passage-way between the connective tissue and muscles, mfiltratina the tissues and causina swelling, suggillation; if much blood escape suddenly and create a distinct cavity, it forms a blood-tumor, ecchymosis, or haematoma. 1 E. Rindfleisch. 2 Sir J. Paget. INJURIES OF THE TEGUMENTARY SYSTEM. 303 The colors of ordinary recent contusions are various shades of purple tending either to black or blue, or to crimson, or pink; and with these are mingled shades of yellow, pale brown, and green, dependent, apparently, on the quan- tity of effused serum and its mingling with fluids of other colors; after a vari- able time the darker colors fade out, and give place to gradually lightening shades of brownish olive, green, and yellow, the changes commencing at the border. In the treatment, when the effusion is going on, ice may be applied, the limb or part being suitably elevated. Simple contusions, left to themselves in the quietude necessary to avoid pain, recover, but the process may be hastened by stimulant applications, the best of which, except for persons of irritable skins, seems to be tr. arnica, with equal parts of water; if there is much breaking and crushing of tissues the parts should be kept warm to prevent sloughing, with wrappings of cotton-wool soaked in oil, or linseed poultices; extreme cases should be treated as for traumatic gangrene; if the blood remain in large quantities, friction and kneading may promote absorption by diffusing it in the tissues; if it still remain, evacuate it with anti- septic precautions, and treat the cavity as an open abscess. 2. Incised wounds l are made with sharp instruments, as knives, sabres; the edges are smooth-cut, regular, the tissue unchanged. Pain follows the injury at once, varying with the nerve supply of the part and the sensitiveness of the patient; the feeling is that of a peculiar burning or smarting; haemorrhage is the second immediate symptom, its extent depending upon the number, size, and variety of the vessels divided; if the capillaries alone bleed, the haemorrhaae quickly ceases ; if an artery is cut, the bright red blood flows in a stream, often pulsatile; haemorrhage from the veins is characterized by the steady flow of dark blood. A rapid, excessive loss of blood induces perceptible changes in the whole body; the face, especially the lips, becomes pale — the latter bluish, the pulse is smaller, and at first less frequent; the bodily temperature sinks, and most perceptibly in the extremities; the patient faints on rising, has dizziness, nau- sea, or vomiting, noises in the ear, and everything whirls around; he becomes unconscious, and falls, owing to rapid anaemia of the brain. In the horizontal posture, these effects usually soon pass off; but if the bleeding continue the countenance grows paler and waxy, the lips pale blue, the eves dull, the bodily temperature lower; the pulse is small, thready, and very frequent; respiration is incomplete; the patient faints repeatedly, constantly grows more feeble and anxious; at last he becomes unconscious; there is twitching of the arms and legs, renewed by the slightest irritation; this state may pass into death. The treatment of an incised wound demands, first, the arrest of haemorrhage; second, perfect quiet of the injured part, in a position to diminish the flow of blood to and through the part. If the bleed- ing is capillary, it will usually cease on exposure of the wound to the 1 T. Billroth. 304 OPERATIVE SURGERY. air, or the application of cold, as ice water, or, for more permanent effect, in ice-bags; other simple remedies are alum solution, vinegar, dry lint; more powerful haemostatics are liq. ferri persulphate, tur- pentine, creosote, hot iron. In the use of these remedies it should be remembered that in proportion as an incised wound is disturbed, and its sensitive surfaces exposed to irritation, the possibility of prompt union is diminished; as a rule, therefore, where compres- sion or ligation will answer, avoid styptics, and resort to them only when it makes no difference whether the wound suppurates or not. Compression may be required for immediate or permanent effect. For immediate compression, use the fingers, thumb, or a key, ac- cording to the situation and depth of the artery. The arteries more often requiring compression, and the points at which pres- sure is to be made, are, the carotid against the vertebrae, with the fingers of the right hand applied along the anterior border of the sterno-mastoid muscle, about the middle of the neck; the subclavian against the first rib, with the right thumb behind the outer border of the relaxed sterno-cleido-mastoid muscle; the brachial against the humerus, with the fingers placed along the inner side of the belly of the biceps about the middle of the arm; the femoral against the pubic bone just below Poupart's ligament, with the thumb. For more permanent compression use the tourniquet, where it can be applied without harm, as to the femoral. The best form of tourniquet for this purpose compresses the limb at but two points (Fig. 108), namely, over the artery, and at an opposite point; this tourni- quet can be used for compression of the femoral or abdominal artery. Compression as a permanent haemostatic, as in venous haemor- rhage, bleeding from numerous small vessels, and especially when parenchymatous, must be made with the nicely adjusted compresses, and bandages, applied from the toes or fingers above the wound. Ligation is practiced when the bleeding vessel is an artery; in an ordinary wound the ligature should be carbolized catgut, which admits of the immediate and complete closure of the wound; silk is best if the wound is to heal by granulation. If the artery has retracted and cannot be isolated, take up with the forceps, or with a curved, threaded neeedle, the con- nective tissue into which the artery has with- Fig. 245. drawn, and inclose the whole in the ligature. Cut the ends of the catgut ligature close, but let one end of the silk ligature depend from the wound. Torsion may be practiced when the arteries are small. Seal hermetically with collodion, if there is no gaping of edges. Employ common adhesive plaster, or, better, adhesive rubber plaster, if gaping is slight; add sutures, if it gape INJURIES OF THE TEGUMENTARY SYSTEM. 305 widely, tie with the surgeon's knot, but do not draw them so firmly as to cause strangulation of the integument (Fig. 245):1 apply such additional dressing as will secure perfect rest; change the dressing only for cleanliness; remove sutures when they irritate, or no longer support the wound. 3. Contused and lacerated •wounds 2 may be simple solutions of continuity, or be attended with loss of substance. The borders are generally uneven tags, and not unfrequently large flaps of the soft parts hang in the wound, having a bluish-red color ; the skin for some distance is often detached from the fascia, especially if the contusing force was combined with tearing and twisting; tendons are torn or pulled out; the skin-wound usually gives no means of judging of the extent and depth of the contusion. The pain is not great, es- pecially if parts have been crushed; the bleeding is slight, and not in a stream; even if large arteries and veins are involved, the blood will ooze from the wound. This is due to the plugging of the arteries by the in-rolling of their coats, and feeble action of the heart from shock. AVhen reaction occurs, haemorrhage may take place from vessels which have not previously bled, and now require the ligature. The treatment depends upon the extent of injury; if slight, the parts may be trimmed with the knife, and the edges be converted into an in- cised wound. The severe forms must heal by secondary union, and only after the dead tissues have been separated by granulation. The first applications to an ordinary contused and lacerated wound should be cold, to diminish the tendency to excessive suppuration. This is best effected by immersion in cold carbolized water, kept cool by ice; if immersion is impracticable, the part may be sur- rounded by ice-bladders, or ice-compresses; irrigation with cold water may be employed, but is less reliable, the temperature of the water varying from 54° to 90° F., as the patient may prefer. This treatment should be continued eight to twelve days, when the part may be removed from the water and dressed with cloths wet with carbolized water, covered with oiled silk. In many cases, the hot water treatment may well be substituted at an early period, or adopted from the first to hasten the separating process. The water bath does not favor the escape of pus, but rather prevents it; and hence where there is suppuration from a cavity the water bath is of no use, but is even injurious; it should be discontinued when deep, progressive inflammation extends beyond the wound. It must be remembered that the water bath greatly retards the healing process, and hence the necessity for discontinuing it as early as practicable, and substituting simple dressings. 4. Gunshot wounds3 vary in extent and severity according to 1 T. Bryant. - T. Billroth. 3 x. Longinore. 20 306 OPERATIVE SURGERY. the nature of the missiles and the conditions under which they ex- pend their force. When a cannon-ball at full speed strikes in direct line a part of the body it carries away all before it; in case the force of the cannon-shot is partly expended, the extremity or portion of the trunk may be equally carried .away, but the laceration of the re- maining parts of the body will be greater, and the surface of the wound will be less even; if the speed be diminished so that the pro- jectile becomes spent, there will not be removal of the part of the body struck, but the external appearance will be limited usually to ecchymosis and tumefaction, without division of surface, or even these may be wanting, notwithstanding the existence of serious in- ternal disorganization; should a cannon-ball strike in a slanting direc- tion, the external appearance of the wonnd will be similar to those just described, according to its velocity, modified only in extent by the degree of obliquity with which the shot is carried into contact with the trunk or extremity wounded; large fragments of heavy shells generally produce immense laceration and separation of the parts against which they strike, but do not carry away or grind, as round shot; small projectiles, with force enough to penetrate the body, leave one or more openings, the external appearances of which also vary according to their form and velocity; when the musket- ball strikes at a distance from the weapon by which it was propelled, but still preserves great velocity, an opening is observed, irregularly circular, with edges generally a little torn, the whole wound is slightly inverted, and there may be darkening of the margin, of a livid purple tinge, from the effects of contusion, or it may be simply dead-like and pale; should the ball have passed out, the wound of exit will be probably larger, more torn, with slight eversion of its edges, and protrusion of the subcutaneous fat, which is thus ren- dered visible; these appearances are the more easily recognized the earlier the wound is examined, and are more obvious if a round musket-ball has caused the injury than when it has been inflicted by a cylindro-conoidal bullet. A musket-ball ordinarity causes either one wound, as when after entering it lodges, or, as sometimes happens, from its escaping again by the wound of en- trance; or two wounds, from making its exit at some point remote from the spot where it entered; but occasionally leads to a greater number of openings; this last result may happen from the ball splitting into two or more portions within the body, and causing so many wounds of exit; the number of wounds made by one ball may be increased by its traversing two adjoining extremities of the same person, or even distant parts of the bod}-, from accidental relative position at the time of the injury. The two openings made by one ball may hold such a relative situation as to lead to the mistake of their being supposed to be caused by two distinct balls. Length of traverse, and consequent distance between the two openings, parts of the body brought into unusual relations from peculiarities of posture, and peculiar deflections of the ball, may all be INJURIES OF THE TEGUMENTARY SYSTEM. 307 sources of this error. The appearances of wounds resulting from penetrating missiles of irregular forms, as small pieces of shells, musket-balls flattened against stones, and others, differ from those caused by ordinary bullets in being- accompanied with more laceration, according to their length and form; being usually projected with considerably less force than direct missiles, such projec- tiles ordinarily lead to only one aperture, that of entrance. A wound by musket-shot is attended with an amount of pain which varies very much in degree according to the kind of wound, and con- dition of mind, and state of constitution ; sometimes it is described as a sudden, smart stroke of a cane; in other instances as the shock of a heavy, intense blow; occasionally the pain will be referred to a part not involved in the track of the wound; when a ball does not penetrate, but simply inflicts a contusion, the pain is described as more severe than where an opening has been made by it. Asa gen- eral rule, the graver the injury, the greater and more persistent is the amount of shock. In the examination of these wounds it is important to place the patient, as nearly as can be ascertained, in a position similar to that in which he was, in relation to the missile, at the time of being struck. When only one opening has been made by a ball, it is to be presumed that it is lodged somewhere in the wound, and search must be made for it accordingly. But even where two openings exist, and evidence is afforded that these are the apertures of entrance and exit of one projectile, examination should still be made to detect the presence of foreign bodies. Portions of clothing, and other harder substances, are not unfrequently carried into a wound by a ball; and, though it itself may pass out, these may remain behind, either from being di- verted from the straight line of the wound, or from being caught and impacted in the fibrous tissue through which the ball has passed. The inspection of the garments worn over the part wounded may often serve as a guide in determin- ing whether foreign bodies have entered or not, and, if so, their kind. Of all instruments for conducting an examination of a gunshot wound, the finger is the most appropriate. By its means the direc- tion of the wound can be ascertained with least disturbance of the several structures through which it takes its course. The index fin- ger naturally occurs as the most convenient for this employment; but the opening through the skin is sometimes too contracted to admit its entrance, and in this case the substitution of the little fin- ger will usually answer all the purposes intended. When the finger fails to reach sufficiently far, owing to the depth of the wound, the examination is often facilitated by pressing the soft parts from an opposite direction towards the finger-end. Where the finger is not sufficiently long to reach the bottom of the wound, even when the soft parts have been approximated by pressure from an opposite di- rection, and when the lodgment of a projectile is suspected, a probe is the best substitute. It may be single, n (Fig. 246), or jointed, 308 OPERATIVE SURGERY. I, m, n. w burr, h, j (Fig. Q It must be employed with great nicety and care, for it may inflict injury on vessels or other structures which have escaped from direct contact with the ball, but have returned, by their elasticity, to the situations from which they had been pushed or drawn aside during its passage. But frequently it is difficult to determine whether any solid body felt with the probe is lead, and for this purpose the end of the probe may be of porcelain, which is marked only by lead,1 a (Fig. 247), or which has a 246), which will chip off fragments of lead when rotated on the ball. An electrical probe has been devised2 which is very delicate in its action. It consists of two pointed steel wires, pro- jecting about four inches from an ivory handle (Fig. 248); they are surrounded 'Lvv/,/M, near their points by a tube of vulcanite ^ inclosed in a slotted tube of German silver, and may be moved slightly forward so as to project beyond this by means of a but- ton to which they are connected, sliding in the slot; the other ends of the wire are forming an open circuit; the Fig. 246. =© Fig. 247. Fig. 248. connected with the terminals of a galvanic batter battery is formed of a zinc and carbon element, inclosed in a case of hardened India-rubber hermet- ically sealed, the exciting liquid being bisulphide of mercury; for use, the probe is pushed into the wound until a resistance is encountered which in the judgment of the operator may be the bullet. The points are then protruded and the instrument turned about, if necessary, until both points touch the object, when, if it be the bullet sought, the circuit is completed by metallic contact, actuating the armature of an electromagnet and causing it to ring a bell. A small pocket instrument has also been invented.3 As soon as the presence of a ball or other foreign body is ascer- tained it should be removed; if it be lying within reach from the the wound of entrance it should be extracted through this opening by means of some of the various instruments devised for the pur- pose (i, Fig. 246, e,f, Fig. 247). 1 E. Nelaton. 2 m. Trouve\ » T. Longmore. INJURIES OF THE TEGUMENTARY SYSTEM. 309 The way to the removal of a bullet may often be smoothed by judiciously clearing away the fibres, among which it is lodged, during the examination by the finger; and sometimes, by means of the finger in the wound, and external pressure of the surrounding parts, the projectile may be brought near to the aperture of entrance, so that its extraction is still further facilitated. Such foreign substances as pieces of cloth can usually be brought out by the finger alone, or by pressing them between the finger and a silver probe inserted for the purpose. Sometimes a long pair of dressing-forceps, guided by the finger, is found necessary for effecting this object. Caution must be used in employing forceps, where the foreign substance is out of sight and of such a quality that the soft tissues may be mistaken for it. It does not often happen that it is nec- essary to enlarge the openings of wounds to remove balls, although a certain amount of constriction of the skin may be expected from the addition of the instrument employed in the extraction; but if much resistance is offered to their passage out, it is better to divide the edges of the fascia and skin to the amount of enlargement required than to use force. In removing fragments of shells or detached pieces of bone, the fascia and skin have almost invariably to be divided to a considerable extent. In instances where the foreign body has not completely penetrated, but is found lying beneath the skin away from the wound of en- trance, an incision must be made for its extraction; before using the knife, the substance to be removed should be fixed in situ, by pres- sure on the surrounding parts; in the instance, of a round ball, the incision should be carried beyond the length of its diameter; an ad- dition of half a diameter is usually sufficient to admit of the easy ex- traction of the ball. In removing conical balls, slugs, fragments of shells, stones, and other irregularly-shaped bodies, the surgeon can- not be too guarded in arranging so that the fragment will present its long axis in line with the track of the wound. To effect this object, it is necessary to seize the missile in such manner as to bring its long axis to correspond with that of the track of the wound. (Fig. 249.) When there is reason for concluding that a ball or other foreign body has lodged, but after manuaI,examination, and obseryation as well by varied posture of the part of the body supposed to be implicated as by indications derived from the patient's sensations, effects of pressure, or injury to nerves, and all other circumstances which may lead to information, the site of lodgment cannot be ascertained, the search should not be persevered in to the distress of the patient. Neither, although the site of lodgment be ascertained, if extensive incisions are required, or if there is danger of wounding important organs, should the at- tempts at extraction be continued. Either during the process of suppuration, by some accidental muscular contraction, or by gradual approach towards the surface, its escape may be eventually effected; or, if of a favorable form, and if not in contact with nerve, bone, or other important organ, it may become encysted, and remain without causing pain or mischief. 310 OPERATIVE SURGERY. All foreign matters being removed, the wound must be syringed with carbolic solution to its deepest recesses, suitable drainage pro- vided, and a position of perfect rest secured. It may be closed with adhesive strip, and ice-bladders applied, but carbolized spray and solutions should be used at each change of the dressings, if possible. When much local inflammation has set in, and when there is much constitutional fever, even without unusual local irritation, the non- evaporating or warm applications will be found to be the most ad- vantageous. When suppurative action has been fully established, care must be taken to prevent the accumulation of pus, lest it bur- row, and sinuses become established, not an unfrequent result of want of sufficient caution in this regard; if much tumefaction of mus- cular tissues beneath fasciae occurs, or abscesses form in them, free incisions should be at once made for their relief. 5. Poisoned wounds are wounds inoculated with a poison ca- pable of producing either (1) fever and its complications; or (2) symptoms of specific general poisoning; or (3) definite diseases.1 (1.) The first variety of poison is developed in decomposition of animal matters, and appears in butchers, cooks, and those engaged in dissections. Ordinary dissection wounds are generally harmless, unless the person is very susceptible; it is in the bodies of those dead of pyiumial diseases, as puerperal peritonitis, that the poison is especially virulent; in these cases it may enter the system even through the unbroken skin.'- The effects of the poison may appear in various degrees of sever- ity; (a) there may be a slight induration of the part, with moderate pain, followed by a dry scale which recurs as often as it is removed; the epidermis thickens over it and forms a painful, wart-like nodule — the anatomical tubercle ;8 (b) there may be an inflammation of the lymphatic vessels and axillary glands terminating in abscesses; (c) the poison may develop an acute septicaemia and rapidly prove fatal;4 (arts, and applica- tions which relieve the local distress; the latter must be selected by the experience of each patient. Those generally useful, where the skin is unbroken, are stimulating liniments, as, camphorated oil; equal parts turpentine and copaiba; tr. iodine; tr. cantharides 1 part, and soap liniment, 3 parts; solutions of nitrate of silver; to relieve itching, cold water, or hot mustard water are most effective; if there are vesicles, collodion is very serviceable ; for ulcers, bals. Peru is necessary. 8. Burns and scalds may be of different degrees of severity, but the risk to life is to be measured by the extent of surface involved; they are most serious to the young and the old, but at all ages ex- tensive burns are to be feared; first, from their immediate depressing effects; second, from inflammatory complications; and, third, from suppuration ; when the injury is over the thoracic region, chest com- plications are liable to follow ; if over the abdomen, dangerous in- testinal affections may appear.3 The several grades of burns are as follows: (1.) They may be so slight as to cause simple redness of the skin, due to a dilatation of the capillaries, and slight exudation of serum in the tissue of the cutis ; there is a mild grade of inflamma- tion, followed in many cases with detachment of the epidermis; the pain is severe for a few hours. The treatment depends upon the ex- tent of surface involved. If it is limited, apply soothing remedies, as, cold water, lead water, scraped potatoes, or such one of the do- mestic articles recommended as may be convenient.4 (2.) The burn may be deeper, followed by the formation of vesicles, due to the rapid escape of fluid from the capillaries between the mucous and horny layer.1 If this burn is quite limited, recovery is rapid and satisfactory; but if spread over a large surface, the shock and col- lapse may be severe, and recovery uncertain. The treatment should be directed first to the shock and depression, which may be mitigated by external warmth with hot drinks, stimulants, and opium to relieve pain; next, remove the clothes, with care to avoid tearing off the ves- icles, and puncture the blisters at the most depending part to allow the escape of the fluid without the removal of the pellicle, which is the best protection of the injured surface. The local applications should 1 T. Billroth. 2 T. Smith. 3 T. Bryant. •* S. D. Gross. DISEASES OF THE TEGUMENTARY SYSTEM. 313 soothe the irritated parts and protect them from the air; for this purpose the following remedies may be used, according as they are at hand: equal parts of linseed oil and lime-water on lint, and covered with cotton-wool; carbolized oil; a complete covering with flour; white lead in the form of paint;x zinc ointment on lint. (3.) In this form the destruction is deeper and the eschars, or sloughs, result with varying degrees of suppuration. If the surface involved is considerable, reaction will probably not occur, and death will soon follow. If limited in extent, the early treatment must be directed to relief from the shock, and then to the immediate dressing of the surface. The second dressings must be applied with reference to the separation of sloughs, and the most important is the carbolic acid dressing, as follows: carbolic acid, one ounce to a pint of olive or linseed oil, or an ointment made of carbolic acid 3iv., lard %iv., and castor oil 51-! 2 to fne other surfaces involved, apply the oil and lime-water, or zinc, or creosote ointment gtts. x. to lard an ounce; or a lotion of tr. iodine 3i- to water one pint. When the sloughs separate, ulcers are left, which heal very slowly by granulation. The slow process of healing is attended with contractions of the cicatricial tissues, which tend powerfully to cause distortions and result in disfigurement and impairment of the functions of the parts involved. The most efficient preventive measure is elastic exten- sion by rubber straps, so applied as to maintain gentle, but firm, re- sistance to the contraction, without pain or inconvenience. CHAPTER XXVIII. DISEASES OF THE TEGUMENTARY SYSTEM AND SPECIAL OPERATIONS. I. THE SKIN. The epidermis and papillary body form the more superficial por- tion of the integument, the former being an insensible covering of flattened cells, while the latter is richly supplied with vessels and nerves, and reacts to stimulants by hyperaemia and inflammation; the two constitute a vegetative whole, the latter being the matrix of the former, through the constant supply of young cells; a morbid sub-activity of this process results in various hypertrophies of these tissues.3 1. The callosity is a circumscribed thickening of the horny layer of the epidermis, and consists of many strata of epidermic scales superimposed on one another, the deeper resting on the rete muco- i S. D. Gross. 2 J. Lister. 3 E. Rindfleisch; F. Hebra. 314 OPERATIVE SURGERY. sum; it increases gradually by the continual addition of new epider- mic tissue from below, and finally develops into a plate which stead- ily becomes more elevated; its consistence depends upon its moisture, and varies from the elastic and flexible to the horny and brittle; it appears on parts of the skin exposed to a frequently recurring but not continuous pressure, and which rests on bone, as the heads of the metacarpal and tarsal bones; they sometimes form as large and painful plates on the sole or palm.1 The treatment consists in re- moval of the growth and prevention of its recurrence; after pro- longed soaking in hot water, apply glacial acetic acid, or nitrate of silver, and detach the plates which form; 2 protect the part from pressure of the substance which caused the original thickening. 2. The corn (Fig. 250) is a callosity so modified by the yielding of the deeper parts to the external pres- sure that the deep layers assume the form of a nail (Clavus) with its point pene- trating the cutis (Fig. 250); the external elevation is small, but the swelling from the under surface of the thickened horny layer forms a truncated cone with the axis at right angles to the surface of the skin into which it has penetrated for some distance ; like the callosity, it varies in consistence with the degree of moisture, on exposed surfaces being hard, but between the toes soft; a bursa may form when the corn penetrates the skin.3 The treatment is the same as for a callosity. 3. Warts, Verruca, are overgrowth of the epidermis, in which the papillary body shares more or less; the common hard wart consists of a circular group of elongated papillae, with their free extremities slightly enlarged and bulbous, their vessels dilated and extending close up to the epidermic covering.3 The treatment should be, (1) an effort to turn the wart out by pressure with the finger-nail, which frequently succeeds with dry warts on the face, and moist warts on the genitals ;l (2) excision with knife or curved scissors, and cauterization of the base with chloride of zinc ; (3) de- struction by caustics, as chloride of zinc, nitric acid ; (4) dessica- tion by applications of tr. iodine or acetic acid. 4. The cutaneous horn results from hypertrophy of a group of papillae; in its growth it may involve hair sacs and contain seba- ceous cysts.8 The treatment is extirpation. 5. Erysipelatous inflammation is located chiefly in the papil- lary layer and in the rete Mahjighii ; any part may be attacked, but it is most frequent in the head and face; the local symptoms are 1 F. Hebra. 2 Ormsby. 3 E. Rindfleisch. Fig. 250. DISEASES OF THE TEGUMENTARY SYSTEM. 315 great redness and oedematous swelling of the. skin, pain on being touched, and high fever; it lasts from one day to three or four weeks. The treatment, is laxatives to improve the digestive organs; then give tonics, as quinine and iron; good diet; locally, light scari- fications are often useful, followed by lead and opium lotions; if pus form it must be evacuated. 6. The furuncle, boil,1 seems to have its origin in the death of a small portion of skin, or perhaps of a cutaneous gland, which becomes the centre of an inflammation; by infiltration with plastic matter the tissue of the cutis partly turns to pus and partly becomes gangrenous; the peculiarity of this form of inflammation is, that it shows no tendency^ to spread, but remains circumscribed, and ter- minates in the detachment of the central dead tissue; regions where the secretions of the cutaneous glands are particularly strong are predisposed to furuncles, as the axilla, perineum; they occur more often in the emaciated and feeble, but may appear in the robust and well-fed. There are also constitutional conditions and diseases which dispose to the formation of boils, creating a diathesis, furunculosis, which may prove very exhausting, especially to children and old persons. The disease appears first as a red and rather sensitive nodule in the skin, size of a pea or bean; soon a small white point forms on its apex; the swelling spreads around this centre, and usually attains the size of a dollar; towards the fifth day the central white point becomes loosened, and is evacuated as a plug with pus mixed with blood and shreds of tissue; suppuration ceases in three or four days, and the cavity cicatrizes. The abortive treatment with ice is not advisable; warm, moist appli- cations should be made, as poultices, to hasten suppura- tion, and an early opening be made to relieve tension and evacuate the contents. Select a lancet having a fine point and a broad, sharply-cutting shoulder; plunge the point nearly vertically to the sur- face (Fig. 251) so deeply as to reach the pus, and then cut outwards. To the debilitated, give quinine, iron, wine, nutritious foods. 7. Carbunculous inflammation, anthrax,1 anatomically resem- bles several furuncles lying close together, but the process is more intense and inclined to spread; their chief seat is the hard skin of i T. Billroth. 316 OPERATIVE SURGERY. the back, especially in old people; they first appear like the furuncle; but soon a number of white points form near each other, the swelling, redness, and pain increases, and the carbuncle may attain the size of a soup-dish, while plugs and gangrenous shreds are detached, until the skin appears perforated like a sieve; the process is almost always limited to the skin and subcutaneous cellular tissue, fasciae, muscles and arteries rarely being destroyed; after the separation of the cel- lular tissue and arrest of the process, luxuriant granulations appear and healing progresses favorably. Carbuncle of the back is tedious and painful, but rarely causes death. The disease may, however, attack other parts, as the lips, or cheeks, or head, and prove rap- idly fatal; in many cases of malignant carbuncle the inflammation extends to the cranial cavity; but in other, and the more quickly fatal, cases, the brain is not affected, and the probability is that there is a rapidly-occurring decomposition of the blood of which the car- buncle may be the cause or the result. This decomposition may have its origin in infection conveyed by an insect which has previously been on carrion; the high fever and fatal blood infection are mostly results of the local disease. The ordinary carbuncle of the back is easily recognized by its broad inflamed base with perforations of the skin; on the lip, face, or head, it may be mistaken for erysipelas, but is readily distinguished by its hardness, purplish color, severe pain, high fever. The treat- ment of all forms of carbuncle must be very energetic to prevent the spread of the disease; numerous incisions should be made early to permit the escape of the decomposed putrid tissues and fluids; they should be crucial in form, through the whole thickness of the cutis, and extending to the healthy skin; the applications to the exposed surfaces should be strongly disinfectant, as strong carbolic acid solu- tions, creosote, chlorine water, or turpentine; hot poultices may be added to hasten suppuration unless they aggravate the pain or the head symptoms. The general treatment should be actively support- ing ; wine or whiskey as stimulants ; quinine and iron ; opium both to relieve pain and promote capillary circulation,1 and easily digested nutritious food. 8. Phlegmonous inflammation, cellulitis,2 may occur in any part of the body, but is most frequent in the hand, forearm, knee, foot, and leg; the cause is often obscure, but it may arise from inju- ries, infection, cold; the spontaneous form'is more frequent in the extremities, above than below the fasciae, and is especially prone to affect the fingers and hand, about the nails, panaritium. The disease is a serous exudation from the vessels, and infiltration of the conr nective tissues with quantities of young, round cells; it begins with 1 F. C. Skey. 2 T. Billroth. DISEASES OF THE TEGUMENTARY SYSTEM. 317 pain, swelling, and redness of the skin, and usually with high fever; the tissues become tense, there is stagnation in the vessels at various points, especially in the capillaries and veins, and in some parts the circulation ceases entirely, resulting in extensive gangrene of tissues; as the inflammation spreads the entire inflamed part is changed to fluid matters, consisting of cells, with some serous fluid mixed with shreds of dead tissue; the process, finally, involves the skin, perfo- rates it at some point, and the pus and debris escape externally. The inflammation now ceases to extend, the walls of the cavity unite, and the plastic infiltration of the part is finally absorbed, and the tissues return to their normal state. Or, the ease may terminate fa- tally, owing to the absorption of the putrid products of suppuration, as in deep collections about the neck of old people. The treatment aims to arrest the development of the disease by securing the earliest possible absorption of the serous and plastic infiltration; for this pur- pose light scarifications may be made, or ice may first be used, or mercurial ointment well rubbed in, followed by enveloping the part with warm, moist cloths or large poultices ; if these fail, suppuration must be hastened by hot poultices; the pus should be evacuated as soon as detected, and from several punctures if it is diffused. If the pus lie deeply in vascular parts, as the neck, the opening should be made, not by plunging a bistoury into the swelling, but by careful dissection, or after the skin and fascia are incised, by working a blunt instrument, as a director, cautiously through the structures, and when pus appears, introduce the blades of forceps and expand them.1 9. An ulcer 2 is a wounded surface which shows no tendency to heal; it mostly starts from chronic inflammation, and is always pre- ceded by cellular infiltration of tissue; two opposite processes are combined, namely, new formation and destruction, the latter result- ing from liquefaction of tissues through suppuration or molecular dis- integration or both; two classes of ulcers result from this antagon- ism: (1) those in which the new formation predominates, proliferating ulcers, and (2) those in which suppuration and disintegration are most prominent, atonic or torpid ulcers. For the purposes of description the following forms are recognized: (1) The erethitic or irritable ul- cer, which constantly has red and sensitive borders, bleeds readily, and the granulations are painful to the touch; the proper treatment is the destruction of this surface with nitrate of silver or the hot iron, and the subsequent compression with adhesive plaster; the hot iron is but slightly painful; if this treatment is not practicable, zinc ointment or lead lotions may be used, or other mild salves; (2) fungous ulcers exist when the granulations project above the level of the skin and are proliferating; the treatment requires that the surface of the i J. Hilton. 2 T. Billroth. 318 OPERATIVE SURGERY. granulations shall be destroyed by caustics, as the solid nitrate of silver or the hot iron; milder remedies are, compression with adhesive strips, and astringents, as oak bark, alum, Peruvian bark; (3) callous ulcers have thickened and hardened margins, owing to the long dura- tion of chronic inflammation; the ulcer is torpid, lies deeply below the surface, with sharply rounded edges, and the surface is glazed. In treating the more tractable cases the indications to be met are, to soften the hardened borders and base, and to induce a proper amount of vascularity in these parts ; the former is most thoroughly effected by the hot iron, or by strapping with adhesive plaster cut into long strips and applied partially around the limb and very firmly over the ulcers, drawing its edges down and towards each other; the second is best accomplished by moist warmth, as poultices or the con- tinued warm bath. It is not always possible to obtain healing of a callous ulcer of the leg, espe- cially when it is situated on the anterior face and extends to the periosteum of the tibia, or when it surrounds the leg like a ring. 10. Lupus1 commences with small nodules in the superficial lay- ers of the skin, more often on the face, especially on the nose, cheeks, and lips. They may enlarge and run together so as to form large nodules and tuberculous thickenings of the skin, L. hypertro- phicus; or there may be a free exfoliation of epidermis on their sur- face, L. exfoliatus ; or the surface may ulcerate, L. exulcerans; with strongly proliferating granulations, L. fungosus; or with rapid de- struction of tissues, L. exedens. The process commences essentially in the connective elements of the cutis, with very abundant new formation of vessels; the cutis at first becomes con- verted into separate, entirely circumscribed nests ; then more diffusely into a layer of small cells which does not differ essentially from a common granular tissue; the cells have the form and size of the white elements of the blood, and often form under the mucous layer as sharply defined, large, round, or oval masses. The disease must be classified with new growths, consisting of granular tissue, characterized by such a copious aggregation of small exuberant cells that the elements of the cutis, and not infrequently of the still deeper-seated layers of cellular tissue, are completely dis- placed and destroyed by them ; this infiltration soon results in com- plete substitution, and if the exuberant cells disappear, there is per- manent loss of substance which may appear as a special defect, or a contraction of parts, or sometimes as a scar; the disfigurements of lupus may, therefore, occur without as well as with open ulcers, for as the infiltrated parts recover they shrink to less than their former volume, as does ordinary cicatricial tissue, the skin appearing to be 1 R. Yolk man. DISEASES OF THE TEGUMENTARY SYSTEM. 319 interwoven, with irregular, cicatricial lines, which may even acquire an irregularly filled surface. The treatment is exclusively local, and aims to remove every nodule: (1) by destroying affected tissues, and (2) by effecting in parts still firm and comparatively healthy the absorption of the lu- poid cellular infiltration. The most effective method is as follows: for the removal of parts entirely converted into lupoid tissue, use sharp scoops; give an anaesthetic, and with the scoop scrape off or out all soft structures until the part is entirely free from the diseased structures; the necessary force may be employed for the scoop will only remove diseased tissues; touch the surface lightly with the solid nitrate of silver, and cover it with small pieces of lint which should be allowed to dry, or cold applications may be made. For the re- moval of diffuse lupoid infiltrations with preservation of the layers of the skin resort to multiple punctiform scarification, as follows: the patient being under an anaesthetic, with a narrow-bladed, sharp- pointed knife, make hundreds or even thousands of punctures two or more lines in depth, close to each other; in many cases the skin after the completion of the puncturing appears of a lead color, or even suspiciously white, and resembles chapped flesh; but gangrene never has ensued; cover the part with lint, press it on firmly to stop bleed- ing, and leave it until it falls spontaneously; repeat the operation three, five, or even eight times if necessary, at intervals of two to four weeks; the skin gradually becomes firmer and loses its abnormal swelling and redness, while no cicatrices are formed. If this treat- ment is rejected, caustics must be used; of these, the caustic potash, or nitrate of silver in the stick, may be selected. The attached crusts must first be removed by applying cod-liver oil one or two days; then bore the caustic stick into the soft lupoid granulations, retaining the potash in contact with the tissue much less time than the silver; wipe off the syrupy, tar-like mass with pads of wadding until a sound, firm surface appears; now cease to apply the caustics, for if the application is continued the erosions will be too deep, and disfiguring scars will result; apply simple dress- ings. 11. Elephantiasis arabum is an hypertrophy of the corium and subcutaneous connective tissue, beginning with an inflammatory stage, during which the lymphatic glands become swollen, and the lymph- paths through them permanently blocked, and resulting in stasis of the lymph, and hypertrophy. The treatment is rest, with the use of the elastic bandage for a long period; or ligature of the main artery to the limb;1 the chief "nerve of the limb has been divided with good results.2 1 J. M. Carnochan. 2 t. G. Morton. 320 OPERATIVE SURGERY. 12. Soft fibrous or connective tissue tumorsr are composed of a very tough, somewhat uedematous, white tissue, and are usually covered with the thin papillary layer of the cutis; on the surface there are almost always pointed papillae. Even when the tumor is developed in a part of the skin which normally has no papillae, they usually hang loosely and are often, distinctly pedunculated; the growth is slow, free from pain, and may develop into enormous tu- mors, and maybe multiple; they occur towards the end of middle life, and are often found in women on the labia majora. The treat- ment is extirpation. 13. Sarcomata x of the skin are generally spindle-celled, and may be alveolar or melanotic; they usually ulcerate early, without, how- ever, extensive destruction; they develop with peculiar frequency after precedent local irritations, especially after injuries ; cicatrices are not unfrequently the seat of these tumors; black sarcomata may come from irritated moles. The diagnosis is often difficult, owing to the variable characters which they assume; they are generally of slow growth, free from pain, occur in middle life, and their location is at irritated points. The treatment is extirpation. 14. Epithelioma, squamous, of the skin,2 begins as a flattened and indurated elevation of the surface, and extends progressively both in depth and superficial area; when it reaches a certain maxi- mum of development at its place of origin it breaks open at this point; the somewhat tuberculated surface grows rough, erosions, fissures, and holes appear in great numbers, and exude a white, inodorous, pulpy fluid mixed with pus; it next falls in at its centre, and a hol- low is produced which is henceforth marked, either by the dried secretions, or, when these are removed, by the sloughy shreds of the original tissue; it now has a hard base, and hard, raised edges; at the periphery the infiltration advances into the neighboring parts, while in its centre there is disintegration, and the phenomena of re- pair.1 The most frequent seat is the face, especially the cheeks, brow, nose, and eyelids; the genitals, as the penis, the clitoris, the neck of the uterus. The treatment is extirpation by free incision, for this variety does not belong to the most malignant group of mor- bid growths ; within a year the cicatrix usually becomes the seat of a new analogous growth, but cases occasionally occur in which the disease has not returned after radical extirpation. II. THE HAIR AND GLANDS. 1. Overgrowth of hair2 can only be said to exist in hairy moles; these brown, hemispherical or flattened elevations seem to offer peculiar facilities for the most luxuriant growth of hair ; 1 T. Billroth. 2 E. Rindfleisch. DISEASES OF THE TEGUMENTARY SYSTEM. 321 not only are the individual hairs very stout, but they are shed and renewed much oftener than those of the head and beard. A vertical section shows at least one fourth of the hair-follicles very thickly set and furnished with a little accessary sac occu- pied by a new hair in a more or less ad- vanced stage of development. When the growth is a serious deformity, excision may be practiced, or it may be removed by caustics,1 as follows: The surface being shaved, apply the disk-shaped cautery at a red heat on the surface until a dark, brownish eschar is produced; then immedi- ately apply compresses wet in ice-water, and renew them frequently; by this means the patient suffers but little pain on coming out of the anaesthesia, the eschar separates in due time, and the granulation growth is kept level with the neighboring skin by the application of nitrate of sil- ver. Or, the solid caustic potassa may be rubbed into the surface till the skin becomes a disorganized pulpy paste, its action being checked by diluted vinegar. 2. Retention of secretions of the hair-follicles and seba- ceous glands,2 gives rise to a variety of affections commonly known as wens. The cause of retention is often a closure of the hair-fol- licle by over-secretion of epidermis and tumefaction of the sub- epidermic connective tissue about the mouth of the hair-sac. The retained secretion may often be squeezed out when it assumes the form of a worm, comedones; in other cases it has the appearance of honey, creating another variety, meliceris. The treatment, when they become large and troublesome, is extirpation; the dissection need not be carefully made, as it is not necessary to preserve the sac en- tire; when the capsule is reached it may be bi- sected and each half removed separately by evulsion ; seize the edge with strong forceps and forcibly detach each portion. 3. Acne rosacea3 consists of retention of secreted matter on one hand and a perifollicular inflammation on the other; the sac of connec- tive tissue appears to be converted into pus, while hyperaemia, plastic infiltration, and sup- puration follow one another in an area extending from half a line to two lines from the follicle. The growths have as- sumed such size (Fig. 253) by hypertrophy of the connective tissue 1 G. Buck. 2 •£. Rindfleisch. 3 0. Wagner. 21 Fig. 253. 322 OPERATIVE SURGERY. as to require excision.1 In the operation for the removal of the tumors, divide the pedunculated ones close to the cartilage ; from the sessile growths remove slices by elliptical incisions, and dissect out from under the skin the hypertrophied tissue, care being taken to leave sufficient flap to cover the cartilage; close the wounds with fine silk suture. (Fig. 254.) II. THE NAIL. The nail consists of the flattened cells of the papillae of the posterior part of the matrix, and of the mucous layer of the beds of the matrix; the former are pushed forwards along the beds in ridges, and the latter are added to the under surface of the nail.2 1. Inflammation, acute, may follow injuries, as blows, the pene- tration of sharp bodies ; the chronic is caused by syphilis, eczema, psoriasis; the result may be irregular growth of the nail, or its destruction by suppuration and ulceration; in unhealthy children the inflammation may be followed by the ulceration of the matrix. The treatment should be to relieve the inflammation by the removal of the cause, and such general and local remedies as the special conditions demand. 2. Atrophy and hypertrophy8 depend upon the same condi- tions, namely, general diseases, as syphilis; local skin affections, as eczema, psoriasis; injuries, as pressure, blows, penetration of splin- ters, needles; trades, as hatters, gilders; fungi, as favus. In atrophy the function of the matrix is diminished, and the nail may become thin, small, narrow, soft, or be wholly lost. In hypertrophy, the functions of the matrix are increased, and as a consequence the nail may be of unusual length and width, appearing as if too small for its place ; or the substance bf the nail may be thickened throughout, but most considerably in front, having the shape of a chisel, with its thick base forward; or the thickening may chiefly affect the middle portion, so that it is elevated in the form of a cone or wedge raised in a shapeless hump, often continued in a long, straight or curved, tap-shaped excrescence. The treatment of these affec- tions is the same so far as they depend upon the same conditions. All sources of local irritation should first be removed; syphilis re- quires the ordinary general treatment, and the local application of mercurial plaster wound round the ungual segment of the finger or toe, so that it compresses the fold of the nail. Non-syphilitic affec- tions require the same treatment as in other parts, but special effort must be made to secure the effect of the remedies upon the matrix 1 C. Wagner. 2 Virchow. 3 T. Annandale. DISEASES OF THE TEGUMENTARY SYSTEM. 323 and bed of the nail. In hypertrophy, India-rubber worn upon the part soon macerates the epidermis and diminishes hyperaemia of the papillary layer.1 The local treatment should aim to remove such excrescences as are deformities and annoyances, by means of scis- sors, the knife, bone-nippers, or a fine saw, care being taken not to extract the nail from its bed. 3. Ingrowing is a curving downward of the margin of the nail, and in general is found on the external border of the nail of the great toe; it is due to the pressure of tight boots or shoes, and espe- cially when the nail is hypertrophied; the fold of the nail becomes in- flamed, the skin ulcerates, red, spongy granulations appear, and the part becomes exquisitely tender; the ulcerative process may extend backward, and finally the matrix and the whole end of the toe may be involved in the inflammation. The treatment at first should con- sist in attempts to heal the ulcerated point where the nail penetrates the skin. Of the various "methods proposed, select the following: Cut dossils of charpie, having parallel threads, of the length of the lateral fold of the nail, or rather larger ; lay it on the nail parallel with the fold; by means of a flat probe push the mass down, thread by thread, between the swollen inflamed fold and the border of the nail, so as to completely separate the skin and the nail; pad around the furrow of the nail with charpie; apply long strips of adhesive plaster one and a half lines wide around the toe, from above downwards as regards the inflamed fold ; repeat this dressing daily, if necessary.2 When the inflammation involves the whole fold and extremity of the toe, extirpate the portion of the nail involved, as follows: with sharp pointed scissors, slit up the nail, (Fig. 250) then seize the offending portion, and with a slight twist remove it from the matrix3 (Fig. 251). When the inflammation extends completely around the nail, the entire nail should be removed and the matrix excised. 4. Onychia4 is an inflammation of the matrix of the nail, causing ulceration, and gradually involving the soft textures around ; it is sometimes the effect of injury, but more frequently occurs as a result of some unhealthy state of the constitution; the sim- pler forms begin with the usual signs of in- flammation in the soft textures around the nail, which become, red, painful, and swol- len ; the nail itself becomes affected, and its margins roughened and displaced; suppuration and ulceration follow, and a sore is formed which is often kept in a state of irritation by the uneven margin of 1 Hebra. 2 Kaposi. 3 Dupuytren. 4 T. Annandale. Fig. 250. Fig. 2oL 324 OPERA TIVE SUR GER Y. Fig. 2." the nail pressing against it; the nail is loosened, its edges and root roughened and raised up. In its most severe form, onychia maligna, it occurs in children, generally after slight injuries; the whole soft textures around the nail and at the extremity of the fingers become red and swollen, giving it a bulbous appearance (Fig. 257) ; the dis- charge is thin and fetid, the nail is loosened, and the bone may be ex- panded. In the mild form use ni- trate of silver to arrest the ulcera- tion, and remove the nail if it keeps up the irritation. In the severe forms, remove the nail at once, and freely cauterize with caustic potassa, nitric acid, or ni- trate of silver. The nail is best removed as follows : The patient being under an anaesthetic, thrust the sharp point of strong scissors under the nail and through the matrix (Fig. 255) ; now seize one sec- tion of the nail with strong forceps (Fig. 256), and by sudden ever- sion tear it from its position. 5. The claw-like nail, onychogryphosis, depends upon a hyper-plastic state of the entire matrix of the nail (Fig. 258); the long, horizontal papillae furnish nearly all the substance of the nail, which is no thick- er at the finger-tip than at the edge of the lunula; this gives the nail its ridged appearance, each ridge corresponding to a papilla.1 The only reliable rem- edy is complete removal of the nail and its matrix,2 with such general treatment as the case requires. 6. Horny growths (Fig. 259), resembling exos- toses, sometimes appear at the margin of the great toe, and create much suffering. The only treatment is excision.2 7. Psoriasis3 appears as a thickened, rough, scabrous, and un- usually convex condition of the central portion of the nail ; the free edge is often split, and the cuticular fringe at the bottom of the nail is ragged and retracted; the whole nail resembles the concave shell of an oyster. If it is caused by syphilis, give mercury in small doses for a long period ; if not specific, give arsenic with a tonic. The appearance of the nail is improved by smoothing with glass or sand-paper; or by friction, with dilute acetic acid. 1 E. Rindfleisch. 2 T. Bryant. 3 t. Smith. Fig. 259. OPERATIONS ON THE TEGUMENTARY SYSTEM. 325 CHAPTER XXIX. GENERAL OPERATIONS ON THE TEGUMENTARY SYSTEM. THE SKIN. Thermometryx is generally practiced upon the skin to determine with exactness the state and variations of bodily temperature, and is an important mechanical aid in diagnosis.2 Two kinds of instruments are now employed, one, b, c, to be used in enclosed cavities, and the other, a, upon the surface of the in- tegument. Many varieties of the former in- strument are now in use, but the straight, self-registering, clinical thermometer (Fig. 261) is recommended for general use.2 Thermometers are also made with spiral tubes and a constriction in the stem a short distance from the bulb, to prevent the index from passing into the bulb when Fig. 260. jerking the instrument to bring the index below the normal. An indispensable condition for accurate investigation is that the instrument itself be accurate; to determine this question, the thermometer should be tested by placing it in a water-bath with a standard thermometer and the variation noted; as the glass changes by use it is found that clinical thermometers change, and hence it is desirable to repeat the test occasionally. The same ther- mometer should be used continuously on the same patient. Before making an observation of the temperature of the body, the thermometer should first be examined to ascertain the position of its index or the detached portion of the col- umn of mercury in the tube separated by a very minute por- tion of air; if the bulb is warmed the ascending column of mercury will be seen to push the index before it. but not to touch it; upon cooling the bulb, the column withdraws and leaves the index at the maximum temperature attained ; f^T^I. the index being a portion of the column of mercury, that end of it most distant from the bulb indicates the temperature; if the index is found to be above ninety-eight degrees Fahrenheit, it i (J. A. Wunderlich. 2 A. L. Loomis. 326 OPERATIVE SURGERY. should be shaken down until it is at least two or three degrees below that point, say ninety-five degrees. The shaking of the index from a higher to a lower point in the scale of the instrument is often a matter of some difficulty; there are three ways of accom- plishing it.1 The index of mercury is prevented from sliding backwards and forwards in the tube of the instrument, as each end of it is raised or depressed, by the law of capillary attraction; to overcome this it is necessary to give to the index an impetus capable of counteracting the attraction of the sides of the enclosing tube; this may be done by holding the instrument between the thumb and index finger, about the upper fourth of its length in a line continuous with the arm, then raise the forearm until the thermometer is as high as the shoulder, and bring it down with a rapid swing or jerk in a line with the body; this mo- tion, if vigorously executed, will have the effect of propelling the index toward the bulb at the rate of two or more degrees for each movement; this should be repeated until the index points below ninety-eight degrees. Another method is to seize the tube about the middle, between the thumb and finger, with the bulb downwards, and to strike the wrist or edge of the palm of the hand upon the other hand; this, if sharply done, will have the desired effect. There are, however, disadvantages to this method. When in cold weather the mercury has retreated into the bulb, and the thermometer is jerked in this way, the mercury is liable to be forced up the tube and there form one or more indices ; but a more serious objection is, that the tube may be split, for when the mer- cury is so suddenly forced into the small, empty conical chamber above the bulb, in a quantity and at a speed that the tube cannot relieve it quickly enough, it acts like a wedge and produces a minute fissure, usually in a line with the enamel. If this fissure exist, the tube should be held at different angles, when it will be seen as a segment of Newton's rings extending to near the edge of the tube. A third method is to hold the thermometer as at first by the upper fourth of its length, between the thumb and finger, but horizontally and at right angles to the forearm, then bring it down with a quick rotation of the wrist, somewhat accelerating the motion by the downward action of the arm at the same moment. The introduction of this instrument into the well-closed axilla ap- pears to be the most convenient method in the great majority of cases ; its use in this situation is attended by scarcely any difficulties, and no objection can be made on the score of decency. The application of the instrument in the inside of the mouth apparently af- fords uncertain indications, because the cool air inspired may easily lower the temperature; but the mouth must be employed when other parts are inaccessi- ble; taking the temperature in the rectum and vagina is repulsive, and can sel- dom be repeated often enough, and is to be resorted to only in infants, in the emaciated, during collapse, and other special circumstances. Use it as follows: If the axilla is wet with perspiration wipe it dry; press the arm against the side to close the cavity for a few min- utes, all clothing being removed from it; warm the whole instru- ment in the hand to 85° F. or 90° F.; now place the bulb deep in the axilla behind the anterior fold, the stem inclining upwards, and i T. H. Hawksley. OPERATIONS ON THE TEGUMENTARY SYSTEM. 327 close the axilla by pressing the arm firmly against the chest; the arm should be firmly held in position, the stem being lightly covered with the clothing. The instrument should be accurately retained in the closed axilla at least five minutes; on removing it note the point of elevation or depression of the upper end of the column. The circumstances of the case and the objects sought to be attained must decide the question of time and frequency of the observations; it is desirable to repeat the observation at a similar time each day; usually it is sufficient to make the observation twice daily, which is best done between seven and nine a. m., the period of probable low- est daily temperature, and in the evening, between four and six o'clock, the period of probable highest daily temperature. The surface thermometer must have its broad extremity placed upon the part to be examined, and be held in position about five minutes. The variations of temperature and rate of radiation of any part of the surface may be accurately determined by the thermoscope (Fig- 262).1 It consists of 1 a glass tube seven inches long with a minute bore, open at one end, and terminating at the other in a bulb; an adjustable scale is at- tached to the outside of the tube. Prepare it for use as follows: im- merse the bulb in hot water to raref}' the air inside; then plunge the open end into cold water and quickly withdraw it, when a drop or two will be found to have entered the tube, and will form a water index which should become stationary within an inch or two of the bulb; adjust the scale, bringing its lowest figure on a level with the top of the column of water in the tube. It may be applied to any surface, and registers the volume of heat escaping by radiation and the ve- locity of loss. 2. Rubefacients produce intense irritation, redness, and congestion; their effect is temporary, and in proportion to the extent of surface covered; they are preferable to blisters to arouse the system.2 Mustard is used in the leaf with vinegar, as essential oil, as a flour sprinkled on a wet cloth, or laid on paper sinapisms, or as common „ ~ 9 paste, made by adding water of the temperature of 90° to 160° F. Linseed or Indian meal may be added to diminish its action; one part of mus- tard to sixteen of meal will make a slightly irritating poultice, which children with acute diseases of the lungs will wear continuously with great benefit; re- move the mustard before the skin is broken, wipe the surface with a wet cloth, and dress the part with cotton-wool or well-oiled cloth. Make the application directly to the skin when prompt action is required, but interpose a thin cloth when more permanent effects are sought. An artificial essential oil of mustard may be used, namely, sulphocyanide of allyl in solution in alcohol, one to fifty. Capsicum may be used in a poultice, or on cloths wet with a strong watery solu- tion. Turpentine is a highly stimulating application, and may be used as a liniment, i E. (J. Seguin. 2 H. C. Wood. • 328 OPERATIVE SURGERY. or sprinkled on a wet cloth; it reddens the skin very promptly, and the sur- face requires no other attention. Dry-cupping draws the blood to the skin, where it remains many hours, relieving deep-seated congestion; apply the cup with an exhaust pump, or use the common cupping-glass, or a small tumbler, or other accessible cup; moisten the internal surface with pure alcohol; ignite with a burning wisp of paper, and invert the cup on the part. Croton oil causes a fine pustular eruption, and is applied by rubbing briskly one part of oil to three parts of olive oil, and repeating carefully, limiting it to the part. Potassio-tar- trate of antimony, tartar emetic, causes a large pustular eruption, and is applied as an ointment, well rubbed into the skin; the surfaces are to be dressed as after the application of mustard. The strong tincture of iodine repeated sev- eral times, and nitrate of silver, in concentrated solution, or mixed with lard, produce desquamation. 3. Vesicants are more permanent in their effects than rubefa- cients ; their local action consists in first diminishing and then de- stroying the vitality of parts with which they are brought in contact; this local action is depletory, as by increasing the amount of blood in the tissues immediately under the blistered surface, the deeper subjacent structures are rendered very anaemic; they also affect the heart through the nervous system, the weak applications strengthen- ing, and the powerful depressing its action.1 There are man}' agents which may be made to act as vesicants, as canthari- des, ammonia, hot fluids. Cantharides acts most promptly on the young, and on parts where the integument is thin. It may be used in the form of blistering liquid, cantharidal collodion, applied with a brush, or of tissue, or of the offi- cinal emplast cantharis. The surface to which it is to be applied should be cleansed, and if there is liability to strangury, dusted with camphor, or covered with oiled tissue-paper. Fresh cantharides will vesicate within three to five hours; if not fresh, vinegar applied to the skin or plaster will often hasten its action. The redness of the surface and small blisters, are evidence of the ac- tion of the vesicant; the application of cloths wrung out of hot water, or a poultice, causes immediate effusion of serum; open the blister with a needle at the most depending part; allow the cuticle to fall upon the surface underneath; dress the surface with oil or simple cerate. To make the effects of the blister more permanent, remove the cuticle and apply stimulating substances, as the leaf of the cabbage, beet, ivy, or savin ointment. To vesicate quickly, apply chloroform on cotton covered by a watch-glass or saucer; or liquid ammonia on a swab, or hot water. A heated iron, thermal hammer, dipped in water of 120° F. and applied to the skin two or three seconds, is a rubefacient, and con- tinued fiye to ten seconds is a vesicant. If excessive inflammation, or erysipelas, follow the blister, apply poultices of bread and water or flax-seed. 4. The endermic application 2 of remedies is frequently prefer- able to administration by the stomach or hypodermically. The method consists in introducing the substance into the skin by rub- bing, inunction, or occasionally it will be useful to remove or to irri- tate the cuticle, and to apply the remedy to the denuded or reddened spot. Morphine and quinine may be thus applied: but they must be 1 A. W. Hollis. 2 W. Bernatzik. • OPERATIONS ON THE TEGUMENTARY SYSTEM. 329 used in quantities about one third larger than when applied hypo- dermically. Mercurials are generally applied to the unbroken skin, for instance, the ung. hydr., or ung. hydr. nitrat., or the oleate of mercury. Solutions of alkaloids in oleic acid, such as the oleates of morphia, aconitia, veratria, atropia, and quinia, are very readily absorbed. The quantities usually employed for a single application are the following: morphia, one sixth to one half grain; veratria, one twelfth to one third grain; strychnia, one twentieth to one twelfth grain; atropia and hyoscyamia, one sixtieth to one twentieth grain.1 5. Acupuncture is a method of counter-irritation effected by passing slender needles tT%=-_______________________________ into the part, and al- ^ __________________ lowing; them to remain, Fig. 203. from a few minutes to several hours. The needle should be of steel, from two to four inches in length, polished, very sharp-pointed, flexible, and soft, having a metallic head. (Fig. 263.) They are inserted by making the skin tense with the left hand, and with the right introducing the needle, with a rotatory motion, to the required depth, avoiding joints and viscera. They may safely penetrate several inches, and have even been introduced into viscera without ill effects. They are liable to become oxidized, and on removing them pressure should be made upon the adjoining surface, while the needle is rotated slightly. An instrument has been devised to introduce a vesicatory liquid beneath the epidermis.2 The piston containing the needles is ad- justable in its cylinder, which holds the medicinal preparation; the needles project through the diaphragm to the required extent, and the epispastic liquid insinuates itself along with the needles into the punctures. Another form of acupuncturator s (Fig. 264) lias a regulating nut, g, to adjust the depth of penetration of the needles which project through the diaphragm to conduct the liquid from the cylinder A and introduce it through the skin; the needles b, e, are stacked in the piston B, whose stem d is sleeved in the stem screw c,f. 6. The issue is a suppurating wound of the deeper structures of the skin. It may be made with a seton, incision, caustic, or moxa, and must be so limited as not to extend its action beyond the subcu- taneous areolar tissue. Apply them at points as free as possible from local irritation, and remote from large vessels and nerves, as the nape of the neck, the insertion of the deltoid on the arm, the external part of the thigh and internal part of the leg. The seton may consist of a few threads, a piece of linen, or of lamp-wicking, or, what is now more frequently used, on account of cleanliness, a 1 C. Rice. 2 Fiermenich. 3 Klee. Fig. 264. • 330 OPERATIVE SURGERY. strip of India-rubber cloth. The instruments required for its intro- duction are either the seton needle (Fig. 265) or a straight bistoury, and a probe having an eye. Pinch up a fold of the skin corresponding with the direction of the muscles of ijNf the part, or vertical with the body, pass the needle, armed I | V ' 1 Fig. 265. Fig. 266. Fig. 267. with the seton, deeply through the parts, but without involving ten- dons or muscles; draw the seton through and tie loosely. If the bis- toury and eyed-probe are used, pinch up the integuments and trans- fix with the bistoury (Fig. 266); pass the probe having the seton through the eye, or attached by a thread (Fig. 267), through the wound, and tie. The subsequent dressings consist of greased lint, and a bandage around the part to be exchanged for a poultice when suppuration commences. The seton must be drawn through daily, and the part saturated with pus cut off. When an issue is made with the knife, the incision must penetrate into the subcutaneous cellular tissue, and a foreign body, as a pea, or a small bead, is introduced and retained by adhesive straps until suppuration is es- tablished. The caustic may be the actual cautery, or Vienna paste, or other powerful escharotics. In shape, the iron cautery should have a more or less flattened surface, when it is required to produce a superficial slough, or conical when it is re- Yl I quired to penetrate more deeply (Fig. 268). If | J it is applied at a white heat, and firmly pressed gy fl uPon tne Par* until an eschar is formed, although ^ not severely painful, local anaesthetics should be Fig. 268. used; cold-water dressings should be applied for several hours, followed by moist warm applications, as a poultice, until the slough separates. Vienna paste is prepared by triturat- ing equal parts of quicklime and caustic potassa; it is applied to the part, of the required size, and allowed to remain ten or fifteen min- utes; when removed, wash the surface with diluted vinegar, to coun- teract its action. Caustic potassa may be used in a similar manner, OPERATIONS ON THE TEGUMENTARY SYSTEM. 331 the parts being circumscribed by a piece of adhesive plaster, through an opening in which the application is made. Strong sulphuric acid also makes an issue of the proper depth, its effect being controlled by an alkali. The subsequent dressings are poultices. The moxa is a combustible substance, burned upon the surface; it may be com- posed of lint, carded cotton, hemp, agaric, etc., or the lint may be saturated with the nitrate of potassa. The substance selected should be firmly rolled into a pyramidal form, and held together by threads, or a solution of gum arabic, an inch or an inch and a half long, and of a diameter at the base corresponding with the size of the proposed eschar. Local anaesthesia being produced, the moxa is held in posi- tion with forceps or wire, and is ignited at the top; as it burns down, any desired degree of irritation can be obtained, from a sim- ple redness to a deep eschar, according to the time it is maintained in contact with the skin. 7. Hypodermic injection is a method of inserting remedies into the subcutaneous areolar tissue. Its advantages are, rapidity of ac- tion; intensity of effects; economy of material; certainty of action; facility of introduction in certain cases; with some drugs the avoid- ance of unpleasant symptoms.1 The apparatus required is a hypo- dermic syringe, needles, and solutions. The syringe consists of a barrel and rod, and a canula of silver or steel, which has a point for pene- n tration and an opening for injection of the liq- uid (Fig. 269); a, b, c, is a form with a glass tube, a graduated rod, and detachable points of two shapes; d, e, is a form of hypodermic syringe to be carried in a pocket-case; the point, inclosing the wire-cleaner, fits into a hollow graduated piston; the barrel is Ti^^SBBi Fig. 269. an ordinary silver tube, the size of No. 10 catheter, and is six inches long. There are numerous cases, varying in size to suit the convenience of practitioners. To meet the increasing necessities of this form of medication the case 2 should contain a double fenestrated hypodermic syringe; three needles of different sizes, the smallest being the most delicate manufactured, the second larger, and the third of the ordi- nary size ; extra leather washers and wires for keeping the tube open and clean; a small hone of the finest quality for sharpening the 1 Com. on Hypodermic Method. 2 YV. A. Greene. 332 OPERATIVE SURGERY. points; a twenty-four minim glass measure perfectly exact; five two- drachm vials filled as follows: (1) sol. sulph. morphia, 16 grs. to the ounce, or \ gr. to 15 in.; (2) sol. sulph. morphia, 8 grs. to the ounce, for children, or delicate females; (3) sol. atropine, 1 gr. to the ounce; (4) strong alcohol for cleaning the points; (5) fluid ext. ergot. The case may contain other solutions, a thermometer, and thumb lancet. It is not necessary to confine the injection to the painful part, and thus a tendency to abscess from repeated injection may be avoided.1 As a rule, the least pain and irritation is caused when the injection is made at or near the insertion of the deltoid, or in front, between the ribs and hip bone, or from near the spine to the median line. Operate thus: On the first trial always use a minimum quantity of the drug;2 draw the required amount into the syringe; elevate the point of the needle and force V out a drop to ex- Fig. 270. pel the a]r. pinch up the skin at the point selected and thrust the needle into the sub- cutaneous connective tissue, avoiding any veins apparent; now gently force the fluid out drop by drop, watching its effects; if no effect is produced when the last drop is injected, withdraw the needle in- stantly and press the finger on the puncture for a moment; if faint- ness or other unusual symptom appear, withdraw the needle and ap- ply such restoratives as may be required. (Fig. 270.) The needle3 may be little larger than the proboscis of a fly, so delicate in fact that fluids as thin as water barely pass through it, and that quite slowly; it will penetrate the skin and reach the cellular tissue without pain, the little child and delicate female not being aware of its introduction in the cervical and lumbar spinal regions, or about the insertion of the deltoid. The needle should not screw on, but slide in, and thus avoid the wearing of the screw and the destruction of the thread. To keep the leather washer of the piston always damp, draw a few drops of water into the barrel after using it, and let it remain;'when about to use the syringe, draw this water out, and the piston will work well. Prepare the solution of morphia sulph. by putting four grains in the vial and filling it with hot water; no acid is required to make and keep this a perfect solution; it is general!}'required in an emergency, and should always be in the case; it keeps indefinitely. To clean points draw the alcohol up and force it out of the tube several times; then detach the point and blow through the tube; finally, pass the wire through, wiping it every time it is withdrawn, after which leave the wire in the point. 8. Vaccination destroys or diminishes susceptibility to variola; every practitioner is under imperative obligation to exercise reason- 1 C. Hunter. 2 y. e. Anstie. 3 YV. a. Greene. OPERATIONS ON THE TEGUMENTARY SYSTEM. 333 able care and diligence in the protection by this means of all persons subject to his professional advice and care.1 It may safely be per- formed at any period of life, and no age should exempt a person from vaccination who has been exposed to small-pox; the most suit- able period is six weeks from birth, and it should not be delayed be- yond the third month, unless conditions unfavorable are unavoidably present, as acute febrile diseases or vesicular eruptions.1 The practitioner is responsible for the purity of the lymph which he uses, for pure virus can cause no other disease than variola; diseases are invaccinated only when the lymph is contaminated with blood, pus, or other carriers of con- tagia.2 Lymph is of two kinds, human or bovine, accordingly as it is taken from man or animal. Humanized virus must be selected from children of healthy parentage, and free from all hereditary taint, and cutaneous or other discoverable affections. In the collection of lymph, the following rules should be observed3 : — The vesicles should be perfect, having passed through all the stages without complications. Lymph must be taken from the vesicle before the areola has formed, the most favorable period being the eighth day, or day week after vac- cination. Several fine punctures should be made in the top of the vesicle, when the lymph will exude from the cells and may be taken for immediate use, or for preservation. The vesicle should never be squeezed to obtain more lymph, but the surface may be gently wiped with a wet cloth to remove any obstruction of the puncture. If any blood appear it must be allowed to coagulate, and then be removed, before lymph is again taken. The virus may be taken on points, pieces of ivory, or quill scraped smoothly, two coats being applied; or in capillary glass tubes into which the lymph is drawn by capillary attraction, and which are then sealed at both ends by the flame of a candle, to the exclusion of the air. The lymph is frequently preserved in the scab, or crust, which is the dried ves- icle. This falls between the twentieth and twenty-fifth days, is of a mahogany or amber color, and semi-transparent. If there is pus or blood in the scab, that portion, or the whole, should be rejected. The virus, in whatever form, must be preserved from the air, and in a cool place. Vaccination may be successfully performed on any part of the body; but for convenience and freedom from irritation, the arm near the insertion of the deltoid muscle is ordinarily selected. The left arm is preferred to the right, in first vaccination, as it is not so much used. Though the operation is extremely simple, it requires great care and delicacy in its performance. A variety of instruments have been used, but a common lancet, slightly dull, answers every indica- tion. It should be kept in a state of perfect cleanliness, as rust or filth are liable to poison the wound. After each vaccination it should be cleaned with a wet cloth. The operator should grasp the arm so as to make the skin tense at the point of insertion of the virus, and either make several punctures with the point of the lan- i E. ('. Seaton. 2 J. Simon. 3 j. B. Taylor. 334 0 PERA TIVE S UR GER1'. cet, thus iV>, or several incisions (Fig. 271), thus |||||, or abrasions, thus ggfc. The lancet should penetrate sufficiently to cause the appearance of blood. If the virus is taken from another arm, the point of the lancet should be charged by uncapping cautiously one of the cells of the vesicle. If the quill is used, first wet the charged extremity with a drop of water. If the scab is used, dissolve a small portion in a drop of water or glycerine on a piece of glass, and charge the point of the lancet. Whatever form of virus is used, be careful to rub the lymph well into the abrasions: the flow of blood, though considerable, does not interfere with the success of the operation. The following facts1 in regard to the progress of successful vaccination, and the complications which may arise, are important: After the inoculation, a period of inaction, comprising three or four days, is followed by a papule-like elevation of the skin, due to swelling of the cells of the deep layers of the epi- dermis, accompanied by hyperemia; these cells continue to enlarge, and, by the fifth or sixth day, the pock is found augmented in size, and, from increased distention of the cells, presents the appearance of a vesicle, with a central de- pression, and is multilocular in structure. The contained fluid (vaccine lymph) is a colorless, adhesive liquid, containing leucocytes and minute granules, in which latter resides its virulent property. The papillary layer of the derma is now invaded by the morbid process; the free ends of the papillae become stran- gulated by cell-impaction, and, melting down, mingle with the fluid contents of the pock. Occasionally, the disease extends completely through the derma, and involves the subjacent, cellular tissue, which then shares the fate of the destroyed papillae. On the eighth day (inclusive) the pock has, if it have been produced by long-humanized virus, acquired its greatest size; if it have been produced by bovine virus, or by humanized virus of early removes, it continues to increase in size for several days longer. On the ninth day the pock has in- creased in plumpness, its central depression is more marked, a brown incrusta- tion has begun at the centre, the fluid contents are more decidedly purulent, and the whole is surrounded by a sharply-defined, bright redness of the skin, extending over a disk of from one to two inches in radius, and technically called the areola. In the human subject the areola is usually accompanied by febrile reaction; but in the calf there is no areola, and but little, if any, constitu- tional reaction. The further progress of the disease consists in the gradual fading of the areola, with the transformation of the entire pock into a hard, dry, translucent brown crust, which separates'some time between the fifteenth and the thirty-second days, leaving a more or less depressed cicatrix, which is usually permanent, and which shows numerous lesser depressions, which give it the ap- pearance termed foveolation. If the individual have previously had the disease, it usually runs a more rapid and less regular course, although the inflammation is apt to be more marked. Vaccinia usually runs its course without complica- tions, and does not call for treatment. Excessive erythema is best treated by the application of a liniment composed of 5ij of ung. stramonii, 3j of liq. plumb, subacetat., and 3 viij of linseed-oil. True erysipelas is very rarely caused by vaccination, and does not require a modified treatment. Axillary 1 F. R. Foster. JF8 OPERATIONS ON THE TEGUMENTARY SYSTEM. 335 adenitis is common, and should be treated on general principles. The same is true of cellulitis. Ulceration of the pock (generally caused by violence) may be treated by sprinkling with equal parts of powdered starch and oxide of zinc, and the same may be used to check an immoderate flow of lymph, after open- ing the pock for the purpose of obtaining virus. The conveyance of syphilis in vaccination may be certainly prevented by complying with all of the following rules: (1) Use only bovine virus, or humanized virus which is known to be free from syphilitic virus; (2) after once applying the lancet, or other instrument, to the vaccinee, it should on no account be again applied to the vaccinifer, or any other person, until it has been thoroughly cleansed; (3) after once using a quill-slip, throw it away. Vaccination generally confers complete and lasting protection against small-pox; any person may, however, constitute an excep- tion. Hence, every individual should be revaccinated as often as once in five years, and whenever small-pox is present as an epidemic, or upon setting out on a voyage, or when about to undertake military duty. As a rule, revaccina- tion succeeds. It should be carefully done, and repeated if unsuccessful. 9. Transplantation of skin is frequently required to repair de- fects either congenital or due to injuries and diseases which cause destruction of integument. These operations are chiefly confined to the face and joints, and have for their special and ultimate object the relief of the disfigurements, and the restoration of function of the parts involved, as of the mouth, or nose, or eye. Innumerable spe- cial operations have been planned and executed to meet the ever- varying indications which these deformities present; but there are certain underlying principles which should always govern the pro- cedure, whatever method may be adopted. The objectl in all cases is to obtain union by first intention, and -to effect this purpose, (1) the flap must be of such ample size that subsequent shrinking will not interfere with the perfection of the cure; (2) there must be no effusion of blood forming a clot under the flap; (3) the margins of the flap must be held accurately together with the smallest amount of irritation. The more important features of the operation are as follows:2 (1) in the choice of skin, select that which is normal and in healthy condition; dispose the patch of skin to be transferred so that its long axis corresponds to the direction in which the arterial vessels are distributed, and the free extremity of the patch towards their destination; (2) to secure precision in adapting a patch of skin to a new locality to which it is to be transferred, first prepare the space to be fiUed by paring its edges and dissecting them up suffi- ciently from their underlying connections to allow of their eversion; cut from oiled silk an exact pattern of the space and apply it to the surface which is to supply the new material; insert small pins at in- tervals around the pattern, at a distance of one line from the margin, as an allowance for shrinkage, but a larger allowance must be made for the length, so as to permit the patch to be brought around edge- i T. Holmes. 2 G. Buck. 336 OPERATIVE SURGERY. wise without strain. The methods of transfer of the skin are as fol- lows: (1) By approximation ; when the skin is supple and movable on both sides of the space, pare the opposite edges, dissect up the adjacent skin to a sufficient distance to permit their meeting and beino- secured by sutures; if there is too much strain, make incisions through the skin parallel with the wound; (2) by sliding; if upon one side only the skin is sound, prepare the space, and dissect up a patch of the required size in the healthy skin; glide this patch edgewise over the space, and attach its edges by sutures; (3) by Fig. 272.1 Fig. 273.1 transfer to a distance; this is done either by transferring the patch edgewise, but making its pedicle describe a part or the whole of a semicircle; or by jumping over intervening tissue, and severing the pedicle when union has taken place. The raw surface left after transfer of a patch should first be covered with scraped lint, and then with lint saturated with collodion; a crust forms which only separates to leave a healthy granulating surface. The suture used may be (1) the interrupted thread; the needle should be trocar- pointed; the glove-makers' thread answers as well as wire; insert the needle obliquely from the edge backward so that the suture will have a tendency to evert the edges of the wound; insert sutures enough to secure exact coaptation, for multiplicity is not objectionable; (2) the common figure-of-eight; (3) the beaded wire clamp as an auxil- iary for the support of other sutures.2 In many instances these several sutures may be required in differ- ent parts of the same flap or flaps, depending upon the degree of tension of the parts. The beaded wire clamp, however, when the tissues are in suitable condition, is more available than the others, being easily applied, and very powerful in retaining the flaps in exact apposition. This consists of silver wire with a glass bead on the extremity, held in place by a disk of leather; the wire being drawn through the two sides at the desired point, another bead is slipped down and pressed firmly against the wound, while the wire is fastened by twisting the end round a piece of wood; this i M. Serre. 2 G. Buck> OPERATIONS ON THE TEGUMENTARY SYSTEM. 337 Fig. 274. suture may remain for six to ten daj-s, and if immediate union fail, they still retain the parts in good position for union by granulation. Losses of integument from the forehead may be supplied by the neighboring skin, as follows (Figs. 272, 273): The margin and the space itself being well freshened, dissect up on either side flaps which may be glided to such an extent as to meet the flaps on tbe-oppo- site side without tension. The form of these flaps must depend upon the shape of the surface to be covered, and can be governed by no fixed rules. Restoration of the lower eye-lid is effected by the removal of a V-shaped flap and the formation of a quadrangular patch from the cheek (Fig. 274). Illustrations of the methods of restoration of other parts, as the lips, nose, penis, will be found in connection with those subjects. 10. Cicatricial contractions 1 follow all wounds with extensive loss of skin, and as this is generally greatest after burns, cicatrices from this cause usually contract most; it results from the disposition of the inflammatory new formation in the wound to give off water as the original gelatinous tissue by degrees atrophies to dry connective tissue. Operations should not be undertaken for the relief of cicatri- cial contractions until every proper effort has been made to overcome them; for in the course of months or years the vessels are obliterated, and the structure becomes more like that of subcutaneous tissue, being less rigid, more distensible, tougher, more elastic; hence mo- bility increases with time. This atrophy of the cicatrix may be aided by compression and distention, long and per- sistently applied. When these measures have ac- complished all that can be reasonably expected, some one of the many methods practiced may be adopted. In general, the entire cicatrix should, if possible, be removed, and its place supplied with new skin. This may be effected when the cicatrix is narrow and linear (Fig. 275), as follows : 2 Dis- sect out the cicatricial tissue cleanly; now make incisions on either side of the wound, parallel to its borders, and two, three, or more inches from them, through the subcutaneous tissue ; loosen these strips sufficiently to permit of their accurate Fig. 275. approximation; unite them by suture and allow the lateral spaces to heal by granulation (Fig. 276). In many cases the distorted parts may be liberated by detaching them from their underlying 1 T. Billroth. 2 t. D. Mutter. 22 338 OPERATIVE SURGERY. connections sufficiently to allow them to be restored to their nor- mal relations, and then transplanting sound skin from the nearest available locality with which to fill up the space made bare by the restoration.1 Finally, the corded folds that maintain the con- traction may be excised and the edges of the wound divided at every point where any resist- ance still remains which prevents complete exten- sion of the part, or even dissecting up the edges from their underlying connections, the purpose being to give the utmost freedom of motion ; the second step is by mechanical appliances to main- tain parts in their restored position until cicatriza- tion is complete, and for a longer period if neces- sary; the third factor in the cure is to regulate the process of cicatrization so as to keep a smooth and even surface, by repression of the granulations with caustics thoroughly applied, and by adhesive, or better, rubber plaster, applied firmly and so as to overlap each other; if contracting bands form they must be divided; cicatrization may be aided by leaving islets of cicatricial skin on the wound or by transplanting skin to the part.1 The selection of any one method must depend upon the situation and con- dition of the particular cicatrix. In the flexure of joints, simple subcutaneous division of the bands at many points, combined with extension by instruments, will frequently prove successful; where the cicatrix is broad, flat, and dense, transplantation of skin must be prac- ticed; if the lip is destroyed, it may be reconstructed by a series of operations (p. 344, et seq.); if the lower eyelid is injured, the cicatrix may be replaced by the healthy skin of the cheek (Fig. 274); if the lower jaw is depressed and fixed, the cicatrix may vary in extent and firmness so much as to require a judi- cious selection of one or more methods in any individual case. The following operation on a cicatrix of the neck il- lustrates a combination of methods: — This cicatrix generally consists (Fig. 277) of a broad, dense structure, extend- ing from the lower border of the under jaw to the top of the sternum and clavi- cles, and preventing the elevation of the jaw; the saliva escapes from the mouth, and the tongue is exposed to view. Operate as follows :1 first, divide the entire cicatricial band into three serrated angular flaps, by two diverging incisions car- ried from the symphisis menti downward and outward to either lateral margin i G. Buck. Fig. 27 OPERATIONS ON THE TEGUMENTARY SYSTEM. 339 of the band where it joins the clavicles; from these terminal points make in- cisions, one along either margin of the band upwards and outwards to the lower edge of the jaw; dissect up these three flaps from the connective tissue, begin- ning at their apices, and proceeding toward and slightly beyond their bases; the head is thus relieved and can be moved in every direction; readjust the detached flaps to the denuded surface while the head is kept in an elevated position; ex- cise redundant folds and pare off the edges of the flaps, if necessary, to adapt them to each other; incision may be made along the base of the neck to relieve tension; in the subsequent treatment the chin must be maintained elevated by apparatus, as a stock, or a chin-support attached to a spiral brace; if at any time the granulations become exuberant they are reduced by applying the solid nitrate of silver and pressing it firmly into them, or b}' the caustic potassa; if new cicatricial bands form they are divided at two or more points, and entirely through their thickness. The result is, in ordinary cases, complete relief from the effects of the cicatrix. The obliteration of depressed cicatrices after glandular abscesses and exfoliation of bone has been effected by the following opera- tion:1 Subcutaneously divide all of the deep adhesions of the cicatrix with the tenotomy knife introduced a little beyond its margin and carried down its base ; carefully and thoroughly evert the depressed cicatrix, turning it inside out so that the cicatricial tissue remains perma- nently raised; pass two hare-lip pins, or finer needles, through the base, at right an- gles- to each other (Fig. 278), so as to- maintain the cicatrix in its everted and raised form for three days; remove the needles and allow the cicatricial tissue to fall to the level of the sur- rounding integument. Cicatrices predispose to the development of false keloid growths, which belong to the sarcomatous series ; these tumors rather replace a scar, than grow out of one; in the regular course of development of a scar, the presence of round-cell and spindle-cell tissue is only provisional, as they speedily give place to fibroid tissue; but either one of these elements may persist longer than its proper time, and if it accumulates in disproportionate amount, a sarcomatous tumor is produced instead of a scar.2 They appear as nodular hypertrophies of the cicatrix, of a dusky or bluish color. They may give rise to no symptoms, and finally disappear, or they may become very sensi- tive and painful, with intolerable itching. No treatment is required, unless the growth is very troublesome. The most efficient remedies are blisters; these may be followed by friction, with mercurial oint- ment and extract of belladonna. If no relief is obtained, excision of the cicatrix must be performed, to be repeated if the growth returns. 1 W. Adams. 2 E. Rindfleisch. VII. THE DIGESTIVE ORGANS. CHAPTER XXX. THE LIPS. I. WOUNDS. The lips are covered externally by skin, internally by mucous membrane, and contain fat, glands, and muscle. 1. Wounds of the lips gape widely, and can be retained in per- fect apposition only by suture. If the wound is partial, the silk or wire suture, with adhesive strip, will suffice; but if the entire lip is divided the hare-lip pin should be used (Fig. 279). If there is haemorrhage, apply torsion to the artery, or pass the suture-pin through it; re- move the suture on the third or fourth day. Fig. 279. II. CONGENITAL DEFECTS. Hare-lip is a congenital non-union of the cen- tral, or of the central with the lateral portion of the upper lip, the cleft corresponding with the junction of the in- termaxillary, or of the maxillary and intermaxillary bones;1 it is most common in males and is frequently hereditary;2 it may be single, double, or complicated. The fissure 3 may appear as a short notch, but in general it extends to within a little of the nostril, and is often continuous with it; when double it may be of the same size on each side, or there may be a short notch on one side and an extensive one on the other; the substance of the lip always varies much in such cases, being thick and flesh)' in some and in others thin and defective in all re- spects, and the breadth of the gap usually varies in accordance with these char- acters. There is always, even in the worst cases of double cleft, an interme- diate portion of lip which may be broad or narrow, long or short, thin or of the natural thickness of the lip, but generally it is deficient. 1 \V. Froelik. 2 C. Forster. 8 Sir W. Fergusson. THE LIPS. 341 Fig. 280. The general rules of treatment are: (1) If the infant is feeble, delay operation until after the third month ; (2) if healthy, and the cleft single, operate, if it is desired, immediately;1 if there is no special urgency, delay till from the third month to the sixth month;2 the comparative mortality in the different periods favors the latter course;8 (3) when there is inability to take food, operate at the earliest moment; (4) defer the operation, if diarrhoea or eruptive diseases are present during first dentition, and in midsummer months;4 (5) if the hare-lip is double, wait until the child is two or three years old,2 unless the conditions render an earlier operation necessary; (6) chloroform is not necessary in infants. The stages of the operation are : (1) the infant, hav- ing a sheet wrapped around its' body so as to in- close its arms, should be held upright in the arms of an experienced assistant, and its head firmly grasped by a second assistant (Fig. 280); the older child should recline with its head raised; (2) separate thoroughly all adhesions to the gums so that the two flaps move freely; (3) make section of the edges of the cleft with strong scissors (Fig. 281) or with the knife (Fig. 282), and in such form as will most completely oblit- erate deformity when the flaps are placed in perfect apposition; (4) close the wound with hare-lip pins if the tension is great (Fig. 283), and with silver wire su- Fig. 282. ture if it is but slight; introduce the suture so deeply as to reach, but not to penetrate, the mucous membrane: (5) support £^ the flaps with long adhesive strips, or with a well-adapted truss (Fig. 284). 1. Single hare-lip may occur on either side and may FlG-283. vary in extent from a slight indentation to a complete division into the nostril. The two sides of the cleft differ in their regularity, being on different levels, and variously beveled at the angles. If the knife is used, enter it at the angle and cut away a sufficient portion to make the margin straight, and secure easy and perfect ad- justment; at the free border (Fig. 285) ~>e=' turn the edge inward to the cleft and IG' save a portion of the mucous membrane to avoid the notch in the lip. If the scissors are preferred, the same section can be made. If the free borders are irregular and round, the method of saving 1 Sir W. Fergusson. 2 S. D. Gross. 3 T. Bryant. 4 F. H. Hamilton. Fig. 281. Fig. 284. 342 OPERATIVE SURGERY. Fig Fig. 287. the parings 1 should be adopted, namely, make an incision from 1 to 2 (Fig. 286), through the thickness of the lip to the free margin, which should not be divided; on the other side transfix the lip at 3 and separate a flap as far as 4, dividing it at 5 ; bring the two sides together and attach the flap 5, 3, to 1, by a suture, and the flap, 5, 4, to 2; apply two interme- diate sutures, and the result will be a lip nearly double in depth of that obtained by the ordinary method (Fig. 287); the same result follows if the two portions, pared off the sides of the cleft, remain attached to each other (Fig. 288), as well as to the free edge of the lip, and are turned downwards and the two sides are united as before.2 This method is peculiarly appropriate to clefts which do not extend through the whole depth of the lip, but terminate at some distance from the nostril.8 of very extensive cleft, or with a projection of one portion of the jaw, the following operation is ad- vised :8 Cut flaps on either side (Fig. 289) and leave them attached, on one by the lower, and on the other by the upper end, the incision being carried around the nose as far may be deemed necessary; the flap attached by its lower end is then turned downwards so that its red edge forms the border of the lip, while the other is drawn up- wards towards the nostril, and they are thus dovetailed together (Fig. 290) with interrupted sutures.4 In some cases the continuity of the lip border may best be pre- served by the following method:5 Remove the edge of one of the borders clearly throughout; on the other cut a flap (Fig. 291) with its pedicle below; bring the edges together so that the flap is applied from below upwards upon the notch. If the flaps in any case do not promptly unite and the edges con- tinue to granulate, they should be maintained in apposition for the purpose of securing union by granulation.6 2. Double hare-lip may exist with or without defect in the bone. When complicated with fissure of the hard palate, the best conducted operations are very liable to fail.7 If the clefts are limited to the Fig. 289. Fig. 290. Fig. 291. Fig. 292. i M. H. Collis. 4 Giraldes. 2 M. Clemot; J. F. Malgaigne. 5 Mirault. 6 Sir J. Paget. 3 T. Holmes. M. Gucrsant. THE LIPS. 34.3 Fig Fig. 294. lips (Fig. 293), and there is not severe tension, operate upon both sides at the same time (Fig. 294); but if the traction upon the parts is great, operate upon one side at a time, mak- ing a central flap which can be attached at the sides and to the angles of the flaps (Fig. 294). If the intermaxillary bone has not formed ossific union, it projects more or less, according to its attachments to the septum nasi. Ex- cept when it is a mere pendulous mass from the tip of the nose, efforts should be made to save it, both because it contains the sacs of the incisor teeth, and its presence is necessary to maintain the form of the upper jaw and lip.1 In the slighter cases of projection of the intermaxillary bone it is merely necessary to fracture its attachment to the septum, and press the mass back into position, or if it be too large to fit the gap, the exuberant parts must be pared away at the sides, the adjacent sides of the superior maxillary bones refreshed, and any teeth projecting across the cleft removed.1 A wedge-shaped piece may be cut from the septum,2 which allows the mass to recede more readily into the cleft (Fig. 295); a suture may be applied to the sides of this notch to retain the depressed bone in place.3 The bone has been re- \ tained in position by silver sutures passed through it j and the adjoining hard palate,4 but three teeth were destroyed by the penetration of their sacs. The bone has been successfully held in position by at once uniting the clefts in the soft tissues.1 When the flaps are insufficient to close the cleft, be dissected away from the cheek to such * / an extent as to admit of their easy approxi- V'\ mation. If the process is tedious it should be divided into stages, dealing first with the projecting intermaxillary bone, and then with the soft parts.1 When the mass is sus- pended from the tip of the nose (Fig. 296), Fig. 296. it must be removed by careful dissection with strong scis- sors, the soft parts being retained and so placed as to form a col- umna nasi, or to fill the gap in the lip (Fig. 297). III. HYPERTROPHY. Hypertrophy of the mucous glands is characterized by two elevated pendulous portions of tissue appearing on either side of the 1 T. Holmes. 2 G. Blandin. 3 Bruns. 4 Von Langenbeck. the Fig. 297. 344 OPERATIVE SURGERY. middle line (Fig. 298), and is due to an increase of the glands of the part and not of the mucous membrane. Make a straight or elliptical incision in the line of the lip; excise the submu- cous tissue; close the incision with fine sutures.1 2. Hypertrophy of the lip generally occurs in scrofulous subjects, and consists in chronic thickening of the deep structures. It may result from a congenital enlargement of the capillaries constituting a naevus (Fig. 299),- and then has a raspberry discoloration, is flabby, pendulous, and contains hard knots in its sub