NLM OOSSM'm 1 Sf- CrC-jL,a00OCt>0'0^CX3^>0LX0'E£)t!O0 Surgeon General's Office M 6 % II Cfec&'cn, N ? ■ * l /* iQjG0,G0^GQ^&QGQjGaGQ3^GQjGQ,Oz NLM005549919 A MANUAL OF OPERATIVE SURGERY. GOSSELIN'S CLINICAL LECTURES—Now Ready. CLINICAL LECTURES ON SURGERY, delivered at the Hos- pital of La Charite. By L. Gosselin, Professor of Clinical Sur- gery in the Faculty of Medicine, Paris, etc. Translated from the French by Lewis A. Stimson, M.D., Surgeon to the Presby- terian Hospital, New York. In one neat octavo volume of about 390 pages, with illustrations; cloth, $2.50. SUMMARY OF CONTENTS. Part I. Surgical Diseases of Youth—8 Lectures. II. Fractures op the Limbs—18 Lectures. III. Traumatic Osteitis and Necrosis—2 Lectures. IV. Traumatic Fever, Septicemia, axd Pyaemia—4 Lec- tures. V. Diseases of the Articulations—7 Lectures. VI. Phlegmon, Abscess, Fistula—3 Lectures. It will be seen from this brief abstract of the contents that these Lectures treat of subjects which are of daily interest to the practi- tioner, while some of them hardly receive in the text-books the attention which their importance deserves. A MANUAL OF OPERATIVE SURGERY. BY LEWIS A. STIMSON, B.A. (Yale).M.D., BURGEON TO THE PRESBYTERIAN HOSPITAL, PROFESSOK OF PATHOLOGICAL ANATOMY IN THE MEDICAL FACULTY OF THE UNIVERSITY OF THE CITY OF NEW YORK. WITH THREE HUNDRED AND THIRTY-TWO ILLUSTRATIONS. PHILADELPHIA: HENRY C. LEA. 1878. wo S$59r>, in? Entered according to Act of Congress, in the year 1878, by HENRY C. LEA, in the Office of the Librarian of Congress. All rights reserve* COLLINS, PRINTER. TO Professor WILLIAM H. VAN BUREN, IN RECOGNITION OF HIS EMINENT MASTERY OF THE ART AS WELL AS OF THE SCIENCE OF SURGERY, AND TO Dr. EDWARD L. KEYES, IN AFFECTIONATE REMEMBRANCE OF A PERSONAL FRIENDSHIP UNINTERRUPTED FOR TWENTY YEARS, AND OF AN INTIMATE ASSOCIATION IN MUCH PROFESSIONAL WORK, f few folume IS INSCRIBED BY THE AUTHOR. PREFACE. In preparing this Manual, I have sought to render it suffi- ciently complete, as regards both the number of operations de- scribed and the details of the descriptions, to meet the wants of the practitioner and of the student; but, on the one hand, I have excluded operations, such as the removal of tumors, which can be described only in general terms, and on the other I have tried to avoid that minuteness of detail in non-essentials, which Mr. Syme condemned so vigorously in the teaching of the pre- sent day, as "the fiddle-faddle instructions, not only for using, but even for holding, the knife, which sufficiently denote the poverty of intellect whence they proceed, and the lowness in aspiration to which they are addressed." Whenever a knowl- edge of details, however, has seemed essential to the correct understanding and performance of an operation, I have not hesitated to describe them very fully, and the same principle has governed the introduction of descriptions of the anatomical relations of the parts. It goes without saying that in the preparation of a work of this character very large drafts must be made upon the results of the labor of others, and that the efforts of the writer must be limited, except on rare occasions, to making judicious selec- tions and judicial comparisons. The list of methods and pro- cesses is now so large that the surgeon is more likely to advance the science and art of his profession by elaborating the materials and mastering the results already acquired, than by inventing new practices or re-inventing old ones. It is not desirable, even if it were possible, to include in a manual every operation, and still less every modification, that has been sug- gested, and it has been my aim, therefore, either to select for Vlll PREFACE. description in each case that method or process which seemed the best, and then to simply indicate the variations which came well recommended, or which might be required under excep- tional circumstances, or else to describe fully methods which differed radically from each other, and then to indicate their respective merits and disadvantages. It is only proper to add that in making such selections and comparisons, I have not relied solely upon my own judgment and experience, but have fortified them by reference to the practice and opinions of ac- knowledged leaders in the profession. Whenever it was practicable I have gone to original sources; and, while not making the question of priority in the invention of any method a prominent one, or spending much time in solving it, I have placed the credit where it seemed to belong, and have given references to the authority, so that any error can be readily corrected. The works most freely consulted have been those by Sedil- lot, Yelpeau, Guerin, Bell, Dubrueil, and Chauvel on Operative Surgery; Oilier and Yon Langenbeck upon Excisions; Buck and Yerneuil upon Plastic Surgery; Yells on the Eye; Roosa on the Ear; Yan Buren and Keyes on the Urinary Passages; Peaslee on Ovariotomy; Thomas on Diseases of Women; Til- laux and Richet on Topographical Anatomy, and the Bulletins de la Socie'te' de Chirurgie. Many of the illustrations are modifications of those in Du- brueil, Chauvel, and Tillaux; others have been taken from Holmes's and Erichsen's Surgeries, Y^ells, Thomas, Y'ood on Rupture, and Wales on Bandaging; and a few representing instruments have been furnished by Tiemann and Reynders. I have to thank Dr. Vandervoort, the accomplished librarian of the New York Hospital, for many facilities afforded me by him, and Dr. Keyes, Dr. Roosa, and the late Dr. Peaslee, for their kind revision of portions of the manuscript. LEWIS A. STIMSON. 72 Madison Avenue, N. Y., June 7, 1S78. CONTENTS. PART I. THE ACCESSORIES OF AN OPERATION. PAGE PAGE Anesthesia, 25 Treatment of surgical wounds- Local, 25 Guerin's cotton batting General, 26 dressing, 36 Administration of the an- Open treatment, 37 aesthetic, 27 Sutures, 37 Arrest of hemorrhage, 28 Interrupted, 37 Ligature, 28 Continuous, 38 Torsion, 29 Twisted, 38 Acupressure, 30 Quilled, 40 Forcipressure, 31 Serre-finc, 40 Cautery, 31 Bandages, 40 Coagulating applications, 31 Continuous or spiral, 41 Cold, 31 Figure-of-eight or spica, 41 Posture, 31 T-bandage, 43 Artificial ischaeniia, 31 Capelline or scalp, 43 Treatment of surgical wounds 33 Triangular bonnet, 45 Lister's antiseptic method 34 Immovable, 45 Sayre's plaster jacket, 46 PART II. LIGATURE OF ARTERIES. General directions, 50 Anatomy of the supra-clavicu- lar region, 53 Ligature of the innominate artery, 54 Anatomy, 54 Operation, 54 Ligature of the subclavian artery, 56 1st portion, left subclavian, 56 1st portion, right subclavian, 57 2d portion, 58 3d portion, 58 Ligature of the subclavian artery—3d portion, Anatomy, 58 Operation, 58 Ligature of the inferior thy- roid, 59 Anatomy, 59 Operation, 59 Ligature of the vertebral artery, 60 Anatomy, 60 Operation, 60 X CONTENTS. Ligature of the axillary artery, 60 Anatomy, 60 Ligature under the clavicle, 61 Ligature in the axilla, Anatomy, Operation, Ligature of the brachial artery, Anatomy, Operation, Ligature of the radial artery, Anatomy, Operation, upper third, Operation, lower third, Ligature of the ulnar artery, Anatomy, Operation at the junction of the upper and middle thirds, Operation in the lower third, Ligature of the common caro- tid, In its 1st portion, At the place of election, Ligature of the external caro- tid, Anatomy, Operation, Ligature of the internal caro- tid, Ligature of the lingual ar- tery, Anatomy, Operation, Ligature of the facial artery, Ligature of the occipital ar- tery, Ligature of the temporal ar- tery, Ligature of the abdominal aorta, Ligature of the common iliac, Anatomy of the common, internal, and external iliac arteries, Operation, Ligature of the internal iliac, Ligature of the external iliac, Ligature of the gluteal, scia- tic, and internal pudic arte- ries, Ligature of the femoral ar- tery, Anatomy, Operation, At the apex of Scarpa's triangle, In the middle of the thigh, In Hunter's canal, Ligature of the popliteal ar- tery, Ligature of the anterior tibial, Anatomy, Operation, Ligature of the dorsalis pedis, Ligature of the posterior tibial, Guthrie's method, Lateral method, In the lower third and be- hind the ankle, PART III. AMPUTATIONS. Circular method, 87 Flap method, 1st time, 87 Modified Hap, 2d time, 87 Teale's method, (6) Alanson's methoc , 8 7 Long anterior flap, (c) Cutaneous sleeve, 88 i Amputation of the finger 3d time, 88 | Phalanges, Oval method, 89 CONTENTS. XI PAGE Amputation of the fingers— Through the metacarpo- phalangeal articulation, Amputation of the metacar- pal bones, Amputation at the wrist, Circular method, Antero-posterior flaps, External lateral flap, Amputation of the forearm, Amputation at the elbow-joint, Anterior flap, (a) The joint opened from behind, (i) The joint opened from in front, Lateral flap, Circular, Amputation of the arm, Amputation .at the shoulder- joint, General considerations, Oval method (Baron Lar- rey), Double flap method (Lis- franc), Spence's method, Amputation of the toes, Distal phalanx of the great toe, Disarticulation of the great toe, Two adjoining toes, Amputation of a metatarsal bone, Disarticulation of the 1st or 5th metatarsal, Disarticulation of allthe meta- tarsal bones (Lisfranc's amputation), Modifications, Medio-tarsal amputation (Clio- part), . 108 Sub-astragaloid amputation, 110 Amputation at the ankle-joint (Syme), Modifications, A. Internal lateral flap, (lloux), B. Pirogolf's amputa- tion, 92 93 94 94 95 95 95 97 97 97 98 98 99 99 99 99 101 102 103 104 105 105 106 106 107 107 108 111 114 114 PAGE Comparison of the different methods of partial and total amputation of the foot, 118 Ampu tation of the leg, 118 A. Lower third, 118 1. Circular method, 119 2. Modified circular, 119 3. Long anterior flap (Bell), 119 4. Elliptic posterior flap (Guyon), 120 B. Middle third, 121 1. Long anterior curved flap, 121 2. Long anterior rect- angular flap (Teale), 121 3. Long posterior rect- angular flap (Lee), 122 4. Single posterior flap, 122 C. Upper third, 123 1. Circular, 123 2. Rectangular, ante- rior, and posterior flaps, 123 3. External flaps (S6- dillot), 123 4. Modified flap (Bell), 124 Comparison of the different methods, 124 Amputation at the knee, 125 A. Disarticulation, 125 Oval method, 125 Long anterior flap, 126 B. Amputation through the condyles, 127 Anterior flap (Garden), 127 Gritti's modification, 128 Amputation of the thigh, 129 Teale, 130 Carden, 130 Modified flap, in lower third (Syme), 130 Long anterior flap, 130 Amputation at the hip-joint, 131 Anterior oval method (Ver- neuil), 133 Circular, 135 Anterior flap, 135 Modified oval, 136 115 Xll CONTENTS. PART IV. EXCISION OF JOINTS AND BONES. General considerations, Major articulations, Excision of the shoulder- joint, General considerations, Oilier's method, Von Langenbeck' s me- thod, By a transverse incision, Excision of the head of the scapula, Excision of the elbow-joint, General considerations, Central longitudinal inci- sions (v. Langenbeck), Oilier's method, Nelaton's method, Long radial incision (Hue- ter), Partial excision, Excision of anehylosed el- bow, Oilier's method, P. Heron Watson's me- thod, Excision of the wrist, Bilateral incisions (Lis- ter), Radial incision (Oilier) Dorso-radial incision (Von Langenbeck), Excision of the hip-joint, Sayre's method, Oilier's method, Anchylosis of the hip-joint treated by subcutaneous division of the neck of the femur (Adams), Establishment of a false joint (Say re), Excision of the knee-joint, Semilunar incision, Ollier's subperiosteal me- thod, Excision of the ankle-joint, AGE 137 140 140 140 141 142 143 143 143 143 145 146 147 147 148 148 149 149 150 152 155 156 157 158 159 160 161 162 162 163 163 Excision of the ankle-joint- Operation for total exci- sion, Excision of the bones and smaller articulations, Excision of the superior maxilla, General conditions, Operation by one of the median incisions, Subperiosteal excision (Oi- lier), Simultaneous excision of both superior maxillae, Partial and temporary exci- sions of the superior maxilla to facilitate the removal of nasopharyn- geal polyps, Resection of posterior por- tion of hard palate (Xe- latoii), Resection of the upper portion (A"on Langen- beck), Other methods of gaining access to the pharynx through the nose, Boeckel, Oilier, Excision of the inferior max- illa, General considerations, Resection of the anterior portion of the body, lusection of the lateral portion of the body, Resection of the ramus and half the body, Excision of the entire bone, Subperiosteal method, Anchylosis of the jaw, Resection of the sternum, Resection of the ribs, 165 166 166 166 170 171 171 171 172 173 173 173 174 174 177 177 178 179 179 180 180 CONTENTS. Xlll PAGE Excision of the clavicle, 180 Excision of the scapula, 182 Subperiosteal method (Oi- lier), 183 Partial excisions of the scapula, 184 Resection of the humerus, 184 Upper portion, 185 Middle portion, 185 Lower portion, 185 Total excision, 185 Excision of the ulna, 185 Excision of the radius, 186 Partial excisions of the ul- na and radius, 186 Excision of the metacarpal bones and phalanges, 186 Resection of a phalanx, 187 Resection of the bones of the pelvis, 187 Excision of the coccyx, 187 Resection of the shaft of the femur, 188 NEUROTOMY A Division and resection of nerves, 199 Supra-orbital nerve, 199 Subcutaneous division, 200 Excision of a portion, 200 A. Above the eyebrow, 200 B. Below the eyebrow, 200 Superior maxillary nerve, 201 A. Division of the nerve on the face, 201 1. Subcutaneously, 201 2. Through the mouth, 201 3. By external incision, 202 B. Resection of the infra- orbital portion, 202 Tillaux's method, 202 Malgaigne's method, 202 Inferior dental nerve, 203 A. At the mental foramen, 203 B PAGE Resection of the shaft of the tibia, 188 Resection of the fibula, 190 Of its upper extremity, 190 Of the lower portion, 191 Excision of the entire fibula, 191 Excision of the bones of the foot, 191 Calcaneum, 191 A. Holmes's method, 192 B. Subperiosteal method (Oilier), 192 Astragalus, 193 Oilier's method, 193 When dislocated, 194 When shattered, 194 Metatarsal bones and pha- langes, 194 Trephining, 194 Of the cranium, 194 General considerations, 194 Operation, 196 Of the frontal sinus, 198 Of the antrum, 198 Inferior dental nerve— B. Within the canal, 203 C. Before its entry into the canal, 203 Buccal nerves, 204 Lingual nerve, 204 Moore's method, 205 Tenotomy, 205 General considerations, 205 Tendo Achillis, 206 Tibialis posticus, 206 A. Above the malleolus, 206 B. On the side of the foot, 206 Tibialis anticus, 207 . Peronei, 207 Flexor tendons at the knee, 207 Sterno-cleido-mastoid, 207 Levator palpebra?, 207 PART V. \TD TENOTOMY. XIV CONTENTS. PART VI. PLASTIC OPERATIONS ON THE FACE. PAGE The different methods and their history, 208 General princqfles, 209 Cheiloplasty, _ 210 A. Lower lip, 210 1. V-incision, 210 2. Oval horizontal inci- sion, 211 3. Method of Celsus or Serres, 211 4. Dieffenbach, 212 5. Syme-Buchanan, 212 6. Buck's method, 213 7. Square lateral flaps, Malgaigne, 215 8. Square vertical flaps, 215 B. Angle of the mouth (stomatoplasty), 216 Buck, 216 C. Upper lip, 217 1. Vertical flaps, 217 2. Infero-lateral flap, 218 Harelip, 219 Single harelip, simple, 219 1. Double flaps, 219 2. Nelaton's method, 220 3. Single flap, 220 4. Giraldes's method, 221 Double harelip, simple, 221 Complicated harelip, 222 Rhinoplasty, 223 1. Superficial defect, not involving the bones or septum, 224 Lateral, oblique, and vertical flaps, 224 Denonvillier's method, 225 Von Langenbeck's me- thod, 225 Michon's method, 225 Restoration of columna, 226 2. Loss of the septum and nasal bones, the skin remaining entire, 226 Dieffenbach's case, 226 PAGE Rhinoplasty— Oilier's osteoplastic me- thod, 228 Double layer, or super- posed flaps, 229 Pancoast's subcutaneous method, 230 3. Loss of more or less of the surface and the septum, 230 A. Indian method, 230 Modifications, 232 B. Ollier's osteoplastic method, 233 C. Alqui6's method, 235 D. Italian method, 235 Operations upon the eyelids, 236 Blepharoraphy, 236 Canthoplasty, 237 Blepharoplasty, 237 1. In ectropion, 237 Wharton Jones, 237 Alphonse Guerin, 238 Von Graefe, 239 Dieffenbach, Adams, and Ammon, 239 Richet, 239 Knapp, 240 Burow, 241 Dieffenbach, 241 Indian method, 242 Richet, 243 Hasner d'Artha, 243 Denonvilliers, 244 Ectropion due to ex- cess of conjunctiva, 244 2. Entropion, 244 Canthoplasty, 244 Ligature, 244 Excision or cauteriza- tion of a fold of the skin, _ 245 Spasmodic entropion, Von Graefe, 246 CONTENTS. XV Operations upon the eyelids— Operations upon the eyelids— Excision of a portion Ligature, ' 247 of the orbicularis, 246 Arlt's method, 248 Division of tarsal car- Teale's method, 248 tilage, 246 Ledentu's method, 249 Vertical division, 246 4. Pterygion, 249 Longitudinal divi- Excision, 249 sion (Amnion), 246 Ligature, 250 Excision of part of 5. Trichiasis, 250 tarsal cartilage, 247 Von Graefe, 250 3. Symblcpharon, 247 Anagnostakis, 250 PART VII. SPECIAL OPERATIONS. CHAPTER I. OPERATIONS UPON THE EYE AND ITS APPENDAGES. The cornea, 251 Removal of a foreign body, 251 Puncture of the cornea, 252 Removal of a staphyloma, 252 a. Critchett's method, 252 b. Carter's method, 254 The iris, 254 Iridotomy, 254 Simple incision (Che- selden, Bowman), 255 Simple iridotomy, Wecker, 255 Double iridotomy, Wecker, 256 Iridectomy, 256 Antiphlogistic iridectomy, 257 Optical, 259 Iridorhexis, 260 Iridesis, 260 Corelysis, 261 Operations undertaken for the relief of cataract, 262 Depression or couching, 263 Scleroticonyxis, 263 Keratonyxis, 264 Division, Discission, or So- lution, 264 Division through the cor- nea, 265 1 Hvision through the scle- rotic (Mays), 266 Operations undertaken for the relief of cataract— Extraction, 266 Flap extraction, 266 Von Graefe's method, 270 Linear extraction, 273 Scoop extraction, 273 Removal by suction, 274 Removal of the lens in its capsule, 276 Pagenstecher's method, 276 Secondary cataract, 276 Operations for the relief of strabismus, 277 Anatomy, 277 Internal rectus, 278 Subconjunctival method, 279 Secondary strabismus, 280 Enucleation of the eyeball, 281 Extirpation of the contents" of the orbit, 281 Operations upon the lachry- mal apparatus, 281 Extirpation of the lachry- mal gland, 281 Lachrymal sac, duct, and canaliculi, 282 Slitting up the canaliculus, 283 Puncture of the sac, 284 Stricture of the nasal duct, 285 XVI CONTENTS. OPERATIONS UFO PAGE Occlusion of the external au- ditory canal, 285 Introduction of speculum, 286 Paracentesis of the drum- head, 286 CHAPTER II. X THE EAR AND ITS APPENDAGES. Incision of periosteum, and trephining of mastoid pro- cess, Catheterization of the Eu- stachian tube, CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYXX. Excision of the tonsils, Staphyloraphy, Uranoplasty, Fergusson's osteoplastic method, Lannelongue's method, Staphyloplasty, Excision of the tongue, CHAPTER IV. OPERATIONS PERFORMED UPON THE NECK. Bronchotomy, 308 Subhyoid laryngotomy, 308 Thyroid laryngotomy, 309 Crico-thyroid laryngotomy, 309 Laryngo- tracheotomy, 310 De Saint Germain's me- thod, 310 Bronchotomy— Tracheotomy, By galvano- or thermo- cautery, ffisophagotomy, Lateral incision, Median incision, CHAPTER V. OPERATIONS PERFORMED UPON THE THORAX. 287 287 288 Excision of the tongue— 289 Sedillot's method, 303 296 By the ecraseur, 303 Division of the frenum, 306 298 Ranula, 306 299 Salivary fistula, 306 299 Deguise's method, 307 301 Van Buren's method, 307 Amputation of the breast, Paracentesis of the thorax, 3161 Paracentesis of the pericar- 3161 dium, 311 313 314 315 315 318 CHAPTER VI. OPERATIONS PERFORMED UPON THE ABDOMINAL "WALL, STOMACH, AND INTESTIXES. Paracentesis of the abdomen, 319 Gastrotoniy and gastrostomy, 320 General considerations and anatomy, 320 Operation, 323 Laparotomy, 323 Right inguinal enterotomy (Nelaton), 305 CONTENTS. XV11 PAGE Colotomy, 326 Litti-e's operation, 327 Lumbar colotomy, 327 Closure of an artificial anus or fecal fistula, 329 Suture of the intestine, 331 Longitudinal wounds, 332 Reybard, 332 Jobert, 332 Lembert, 332 GeTy, 333 Bouisson, 333 B6renger-F6raud, 334 Dubrueil, 335 Transverse wounds, 335 Herniotomy, kelotomy, 335 General directions, 336 A. Recognition of the sac and bowel, 336 B. Opening of the sac, 337 C. Division of the stric- ture, 338 D. Examination and re- turn of the bowel, 339 E. Treatment of the omentum, 340 Strangulated inguinal her- nia, 341 Herniotomy, kelotomy— Anatomy, 341 Operation, 342 Malgaigne's method, 344 Strangulated femoral her- nia, 344 Strangulated umbilical her- nia, 346 Strangulated obturator her- nia, 347 Radical cure of inguinal hernia, 347 Pin operation, 353 Radical cure of femoral hernia, 356 Radical cure of umbilical hernia, 358 Imperforate anus or rectum, 361 Prolapse of the rectum, 363 Rectotomy, 364 Excision of anus and part of the rectum, 364 A. Removal by the knife, 364 B. Removal by ligature, 366 C. Removal by the §cra- seur, 368 Hemorrhoids, 368 CHAPTER VII. OPERATIONS UPON THE GENITO-URINARY ORGANS OF THE MALE. Castration, 369 Hydrocele, 370 Puncture of the sac, 371 Excision of the sac, 371 Varicocele, 372 Excision of the scrotum, 373 Division and excision of the veins, 373 Compression by pins, 373 Compression by wires, Vi- dal's method, 373 Subcutaneous ligature, 374 Ricord's method, 374 Rigaud's method by expo- sure, 375 Amputation of the penis, 375 Operations for phimosis, 376 Dorsal incision, 376 Circumcision, 377 Paraphimosis, 381 Division of the frenum, 381 Epispadias, 381 Nekton's method, 382 Thiersch's method, 384 Hypospadias, 386 Urethroplasty, 387 Theophile Anger's method, 388 Duplay's method, 389 Urethral fistula, 391 General considerations, 391 Urethroraphy, 392 Urethroplasty, 393 XV111 CONTENTS. •AGE PAGE Puncture of the bladder, 401 394 Above the pubes, 401 Under the pubes, 402 394 Through the rectum, 402 394 A. From without in- 394 wards, 402 394 B. McBurney's method , 402 395 Lithotrity, 404 395 Lithotomy, 410 395 General considerations, 410 395 Lateral lithotomy, 413 Median lithotomy, 418 395 Bilateral lithotomy, 419 395 Pre-rectal lithotomy, 421 397 Recto-vesical lithotomy, 422 398 Supra-pubic lithotomy, 422 399 Perineal lithotrity, 423 Urethral fistula— Nelaton's method, Reybard, Dieffenbach, and Delore, Delpech and Alliot, Sir Astley Cooper, Arlaud, Sedillot, Rigaud, Theophile Anger, Scymanowski, External perineal urethro- tomy, A. With a guide, B. Without a guide, Exstrophy of the bladder, Catheterization, CHAPTER VIII. OPERATIONS UPON THE GENITO-URINARY ORGANS OF THE FEMALE. Catheterization, 425 Lithotomy, 426 Urethral lithotomy, 426 Vesico-vaginal lithotomy, 426 Occlusion, or atresia vagina?, 427 Ruptured perineum; peri- neoraphy, 428 Partial rupture, 430 Complete rupture, 432 Vesicovaginal fistula, 435 Creation of a vesico-vaginal fistula, 440 Obliteration of the vagina; kolpokleisis, 441 Narrowing of the vagina; elytroraphy, 442 Lacerated cervix, 444 Posterior section of the cer- vix, 446 Amputation of the cervix, Bistoury or scissors, Ecraseur, Galvano-cautery, Ovariotomy, Incision, Search for adhesions, Tapping of the cyst and rupture of adhesions, Removal of the sac and treatment of the pedicle, Cleansing of the perito- neum, Closure of the external wound, Vaginal ovariotomv, Hysterotomy (Caesarian sec- tion), Gastro-elytrotomy, 448 448 448 448 448 449 449 450 452 455 455 456 457 458 CHAPTER IX. MISCELLANEOUS OPERATIONS. Splenotomy, 460 Subcutaneous osteotomy, 462 Genu valgum, 462 Shaft of a long bone, 462 Erectile tumors, 463 Birth-mark, 465 Web-fingers, • 466 Cicatricial flexion of the pha- langes, 467 Ingrown toenail, 4Cg LIST OF ILLUSTRATIONS. NO. PAGK NO. PAGE 1. Artery forceps, 28 38. Ligature of axillary and bra- 2. Square knot, 29 chial arteries, 61 3. Torsion forceps, 29 39. Transverse section of the 4. Effects of torsion upon the arm, 63 coats of an artery, 29 40. Ligature of brachial artery, 64 5. Acupressure, 30 41. Ligature of radial and ulnar 6. Acupressure, 30 arteries, 65 7. Acupressure, 30 42. Ligature of common carotid 8. Tourniquet, 32 at place of election, 67 9. Tourniquet, 32 43. Ligature of lingual, external 10. Tourniquet, 32 carotid, occipital, temporal, 11. Interrupted suture, 38 and facial arteries, 70 )2. Continuous suture, 38 44. Anatomical relations of lin- 13. Twisted suture, 38 gual and facial arteries, 72 14. Harelip pin, 38 45. Ligature of iliac and femoral 15. Harelip pin with movable arteries, 76 point, 38 46. Ligature of gluteal, sciatic, 16. Buck's pin-conductor, 39 and pudic arteries, 78 17. Nippers for cutting off pins, 39 47. Ligature of femoral artery, 80 18. Twisted suture, with rubber 48. Transverse section of leg, 83 ring in place of thread, 39 49. Ligature of anterior tibial 19. Quilled suture, 40 artery, 84 20. Serre-fine, 40 50. Ligature of posterior tibial 21. Continuous or spiral bandage, 41 artery, 85 22. Reversing the turns, 42 51. Amputations of fingers, me- 23. Spica of the groin, 42 tacarpal bones, and wrist, 93 24. Spica of the shoulder, 42 52. Amputation at elbow-joint, 98 25. Four tailed bandage for knee, 43 53. Disarticulation at the shoul- 26. T-bandage, 43 der, 101 27. Capelline or scalp bandage, 44 54. Disarticulation at the shoul- 28. Four-tailed bandage for head, 44 der, Spence, 103 29. Triangular bonnet, 44 55. Relations of the web and me- 30. Suspensory bandage, 45 tatarso-phalangeal joint, 104 31. Suspensory apparatus for plas- 56. Amputations of toes and me- ter jacket, 47 tatarsal bones, 105 32. Tripod, 47 57. Amputation of great toe, 105 33. Patient suspended ready for 58. Lisfranc's and Chopart's am- the plaster, 49 putations, 108 34. Three steps of ligature of an 59. Chopart's, Syme's, and sub- artery, 50 astragaloid amputations 35. Aneurism needle, 51 (outer side), 109 36. Inner coat of artery ruptured 60. Chopart's, Syme's, and sub- by ligature, 52 astragaloid amputations 37. Ligature of innominate, sub- (inner side), 119 clavian, vertebral, and 61. Amputation at ankle by in- axillary arteries, 55 ternal flap (Roux), 115 XX LIST OF ILLUSTRATIONS. NO PAGE 62. Amputation at ankle (Piro- goff), outer side, 63. Amputation at ankle (Piro- goff), inner side, 64. Amputation of leg, 65. Amputation of leg, 66. Amputation of leg, 67. Amputations at knee and lower third of thigh, 68. Amputations at knee and of thigh, 69. Excision of the shoulder. Oi- lier, 70. Excision of the elbow-joint, Oilier, Von Langenbeck, 71. Excision of the elbow-joint, Nelaton, Hueter, 72. Excision of wrist, Lister. Portions of bone removed, 151 73. Excision of wrist, Lister. Relation of incisions to tendons, 74. Excision of wrist, Lister, Oilier, Von Liingenbeck, 75. Excision of the hip, 76. Subcutaneous division of neck of femur, 77. Adams's saw for subcutane- ous division of neck of fe- mur, 78. Lines of section in Sayre's operation for anchylosis of hip-joint, 79. Excision of the knee-joint, cutaneous incisions, 80. Excision of the knee-joint, lines of section of bone, 81. Excision of the knee-joint, lines of section of bone, 82. Excision of ankle, 83. Excision of superior maxilla, 169 84. Excision of superior maxilla, 170 85. Removal of naso-pharyngeal polyp, Oilier, 174 86. Excision of inferior maxilla, 178 87. Excision of scapula, 183 88. Resection of tibia, protection of periosteum against chain saw, 89. Excision of calcaneum and astragalus, 90. Trephine, 91. Iley's saw, 92. Resection of supra-orbital and superior maxillary nerves, 93. Cheiloplasty, V-incision, 116 116 119 120 121 126 129 141 145 147 153 160 161 161 162 164 164 165 189 192 197 197 NO. 94. 95. PAGE Cheiloplasty, oval horizon- tal incision, 211 Cheiloplasty, Celsus's in- • • 911 cisions, *Li 96. Cheiloplasty, Celsus's flaps in place, 211 97. Cheiloplasty, Dieffenbach, 212 98. Cheiloplasty, Syme-Buch- anan, incisions,. 212 99. Cheiloplasty, Syme - Buch- anan, flaps in place, 212 100. Restoration of lower lip, Buck's incisions, 213 101. Restoration of lower lip, Buck's flaps in plnce, 213 102. Cheiloplasty, Malgaigne, 215 103. Cheiloplasty, Sedillot, 215 104. Lengthening of the mouth, Buck, 216 105. Cheiloplasty, upper lip, Se- dillot, incisions, 217 106. Cheiloplasty, upper lip, Se- dillot, flaps in place, 217 107. Cheiloplasty, upper lip, Buck, 108. Simple single harelip, 109. Simple single harelip, Ne- laton, 110. Harelip, single flap, 111. Harelip. Giraldes, 112. Double harelip, 113. Cheek compressor, 114. Rhinoplasty, lateral flaps, 115. Rhinoplasty, lateral flap, Von Langenbeck, 116. Rhinoplasty, Denonvilliers, 225 117. Rhinoplasty, Dieffenbach's operation, 227 118. Rhinoplasty, double layer or superposed flaps, Ver- neuil, 229 119. Rhinoplasty, Indian me- thod, 231 120. Rhinoplasty, Ollier's osteo plastic method, 121. Rhinoplasty, Italian me thod, 122 Canthoplasty, 123. Ectropion, Wharton Jones, 238 124. Ectropion, AlphonseGuerin, 238 125. Ectropion, Von Graefe, Knapp, 126. Ectropion, Dieffenbach, Adams, Ammon, 240 127. Ectropion, Richet, 240 128. Ectropion, Burow, 241 129. Ectropion, Dieffenbach, 242 218 219 220 220 221 221 222 224 225 234 235 237 239 LIST OF ILLUSTRATIONS. XXI NO. . PAGE NO. PAGE 130. Ectropion, modified Indian, 173. Bowman's scoop, 274 Richet, 242 174. Bowman's scoop, 274 131. Ectropion, Hasnerd'Artha, 243 175. Curette and mouthpiece for 132. Ectropion, Denonvilliers, 244 removal of cataract by 133. Entropion, ligature, 245 suction, 275 134 Entropion, lower lid, 245 176. Fine-toothed forceps for 135. Entropion, upper lid, 245 strabotomy, 278 136. Pope's forceps, 247 177. Strabotomy hook, 278 137. Entropion, Streatfeild, 247 178. Mode of estimating the de- 138. Symblepharon, 248 gree of squint, 280 139. Symblepharon, incisions, 248 179. Double operation for stra- 140. Symblepharon, flaps in bismus, 280 place, 248 180. Extirpation of lachrymal 141. Pterygion, 249 gland, 282 142. Eye speculum, 251 181. Sharp-pointed canaliculus 143. Stop needle and probe for director, 284 cornea, 252 182. Bowman's probe-pointed 144. Staphyloma, line of in- canaliculus knife, 284 cision, 253 183. Puncture of the lachrymal 145. Staphyloma, after removal, 253 sac, 284 146. Beer's knife, 254 184. Stilling's knife, 285 147. Iridectomy knife, straight, 257 185. Tonsilotome, 289 148. Iridectomy knife, bent, 257 186. Smith's gag, 291 149. Iridectomy forceps, 258 187. Staphyloraphy, 292 150. Iridectomy forceps, 258 188. Staphyloraphy, incisions, 292 151. Iridectomy scissors, 258 189. Staphyloraphy, sutures, 292 152. Iridectomy, incision of cor- 190. Staphyloraphy, division of nea, 258 muscles of soft palate, 293 153. Iridectomy, excision of iris, 259 191. Staphyloraphy, passing the 154. Tyrrell's hook, 259 sutures, 295 155. Broad needle for incising 192. Lee's clamp for the tongue, 302 cornea, 259 193. Ecraseur, 304 156. Canula forceps, 260 194. Hutchinson's gag, 304 157. Iridesis, 261 195. Bivalve canula, closed, 313 158. Streatfeild's spatula hook, 262 196. Bivalve canula, with tube 159. Couching needle, 263 in place, 313 160. Depressing cataract, 264 197. Vacca-Berlinghieri's oeso- 161. Bowman's fine stop needle, 265 phageal sound, 314 162. Hays's knife needle, 265 198. Paracentesis of thorax, 317 163. Sichel's knife, 267 199. Anatomical relations of 164. Von Graefe's cystotome and stomach with reference to curette, 267 gastrotomy, 321 165. Flap extraction of cataract. 200. Right inguinal enterotomy, Fixing the eye and making Nelaton, 326 the incision, 268 201. Dupuytren's enterotome, 330 166. Flap extraction of cataract. 202. Suture of intestines, Lem- Removal of lens by pres- bert, 332 sure, 269 203. Suture of intestines, Gely, 333 167. Von Graefe's cataract knife 270 204. Suture of intestines, Bouis- 168. Iridectomy forceps, 270 son, 334 169. To show method of making 205. Suture of intestines, Beren- Von Graefe's incision, 271 ger-Feraud, 334 170. Line of Von Graefe's in- 206. Suture of intestines, Jobert cision, 271 (transverse wound), 335 171. Diagram of correct and 207. Hernia knife, 339 faulty sections of iris, 272 208. Inside view of internal ab- 172. Critchett's scoop, 274 dominal and femoral rings 341 xxn LIST OF ILLUSTRATIONS. NO. PAGE 209. External abdominal ring and abdominal layers, 342 210. Variations in origin and course of obturator artery 345 211. Wood's knife and needle for radical cure of hernia, 212. Wood's radical cure of in- guinal hernia; 1st punc- ture, 213. Wood's radical cure of in- guinal hernia ; 3d punc- ture, 214. Radical cure, of large her- nia ; withdrawing needle, 351 215. Radical cure of inguinal hernia ; wires in place, 216. Radical cure of inguinal hernia; vertical section, 217. Pins used in the pin opera- tion for radical cure, 218. Placing the 1st pin, 219. Pins in place, 220. Radical cure of femoral her- nia. Wires in place, 221. Radical cure of femoral hernia. 1st and 2d punc- tures, 222. Radical cure of umbilical hernia. Instruments, 223. Radical cure of umbilical hernia. Passing 1st wire, 224. Radical cure of umbilical hernia. Passing 2d wire, 359 225. Radical cure of umbilical hernia. Passing second ends of wires, 226. Radical cure of umbilical hernia. Wires in place, 227. Extirpation of anus. Reca- mier, 228. Method of surrounding rec- tum with ligatures, 229. Extirpation of rectum. Maisonneuve, 230. Vidal's operation for vari- cocele, 231. Vidal's operation for vari- cocele, 232. Vidal's operation for vari- cocele. The wires, 233. Ricord's method of tying veins in varicocele, 234. Circumcision. 1st incision, 378 235. Circumcision. Raw surface left by retraction, 379 236. Circumcision. Delavan. 1st incision, 379 348 349 350 353 353 354 354 355 356 357 358 359 360 360 366 367 367 374 374 374 375 237 238. 239. 240. 241. 242. 243. 244. 245. 246. 247. 248. 249. 250. 251. 252. 253. 254. 255. 256. 257. 258. 259. 260. 261. 262. 263. 264. 265. 266. 267. 268. 269. 270. 271. 272. 273. Circumcision. Delavan. Fitting in the triangle, Circumcision. Keyes, Epispadias. Nelaton, 2d 379 380 383 384 385 Epispadias. Thiersch, Epispadias. Thiersch. step, Epispadias. Thiersch. Transverse section, Hypospadias. Theophile Anger, Hypospadias. Duplay, Urethroplasty, Urethroplasty. Nelaton, Syme's staff, Tunnelled staff and whale- bone guide, Exstrophy of bladder. In- cisions, Exstrophy of bladder. Flaps in place, Mercier's elbowed catheter, 401 McBurney's instruments for puncture of bladder per rectum, Thompson's lithotrite, Fenestrated jaw of litho- trite, Scoop lithotrite, Bigelow's lithotrite, Bigelow's lithotrite, Bigelow's evacuating tubes, 408 Bigelow's evacuating appa- 409 ratus, Position of viscera at outlet of pelvis, Lateral lithotomy. Extent of incision of urethra, Lateral lithotomy. Incision of neck of bladder, Lateral lithotomy staff, Lateral lithotomy scalpel, Lateral lithotomy. Bliz- ard's knife, Lateral lithotomy. Blunt gorget, Lateral lithotomy, scoop, Lateral lithotomy, forceps, 414 Lateral lithotomy, forceps, 414 Lateral lithotomy, forceps, 414 Shirted canula, 414 Lateral lithotomy, Position of patient and incision, Lateral lithotomy. Rela- tions of the incisions to each other and to the pros- tate, 416 385 389 390 393 393 396 396 399 399 403 404 404 405 406 406 406 410 411 412 413 413 413 413 413 415 LIST OF ILLUSTRATIONS, XX111 274. 275. 276. 277. 278 279, 280 281 282 283. 284, 285. 286, 287. 288, 289. 290. 291. 292- 296, 297, 298. 299. 300. 301. 302. 303, PAGE 418 Median lithotomy. Staff, Median lithotomy. Ball- pointed director, Median lithotomy. Double- edged scalpel, Median lithotomy with rect angular staff, Dupuytren's double litho- tome cache\ Dolbeau's dilator, Gouley's lithoclast, Guyon-Duplay dilator, Catheterization of the fe- male ; holding the cathe- ter, Sims's speculum, Perineal body perfect, Perineum improperly re- paired, Curved scissors, Emmet's scissors, Thomas's toothed forceps, Sponge holder, Profile of perineum, Perineoraphy. Sutures in position, ■295. Diagrammatic of method of closing complete rup- ture of perineum, 433 Ruptured sphincter. 1st suture, 434 Ruptured sphincter. 1st and 2d sutures in place, 434 Vesico-vaginal fistula. Line of paring, 435 Vesico-vaginal fistula. Drawing the uterus down 436 Vesico-vaginal fistula. Needle holder, 437 Vesico-vaginal fistula. Course of the needle, 437 Vesico-vaginal fistula. Passing the needle, 437 Vesico-vaginal fistula. Shield, 438 418 418 419 420 423 423 424 425 427 429 429 430 430 430 430 431 431 NO. 304. Vesico-vaginal fistula. Fork. 305. Vesico-vaginal fistula. Blunt hook, 306. Vesico-vaginal fistula. Twisting sutures, 307. Vesico-vaginal fistula. Simon's method of placing sutures, 308. Vesico-vaginal fistula. Incision united, 309. Sims's catheter, 310. Obliteration of the vagina; kolpokleisis, 311. Narrowing of the vagina; elytroraphy, 312. Thomas's dilating forceps, 313. Toothed clamp, 314. Lacerated cervix, side view, 445 315. Lacerated cervix, denuded surface and sutures, 316. Sims's knife for section of the cervix, 317. Posterior section of the cer- vix, 318. Spencer Wells's trocar, 319. Spencer Wells's clamp, 320. French clamp, 321. Dawson's clamp, 322. Ligatures of the pedicle in- cluding each other, 323. Method of passing the liga- ture, 324. Genu valgum; section of in- ternal condyle, 325. Genu valgum; internal con- dyle forced upwards, 326. Subcutaneous ligature of naevus, 327. Ligature of nsvus, 328. Lignture of naevus, 329. Ligature of nsevus, 330. Ligature of naavus, 331. Web fingers, 332. Ingrown toe-nail, 431 438 438 439 440 440 441 443 443 444 445 447 447 450 452 453 453 454 454 462 463 464 464 465 465 465 466 468 OPERATIVE SURGERY. PART I. THE ACCESSORIES OF AN OPERATION. ANAESTHESIA. Local ancestJiesia may be obtained (1) by the action of cold, or (2) by the application of an agent which exerts locally a benumbing effect upon the nerves. (1) The low temperature which produces local anaesthe- sia may be obtained by the application to the parts of a freezing mixture (ice and salt), or by the vaporization of ether. The former is applicable to larger surfaces than the latter. A mixture of cracked ice and salt is put in a muslin bag and laid upon the part, and a folded compress or towel laid over it to intensify its action. After it has been in place two or three minutes it should be removed, the sensibility of the skin tested, and the bag reapplied if the desired effect has not been produced. When chilled to insensibility the skin is white and puffy. When ether is used for local anaesthesia it should be di- rected upon the parts in a fine spray, or its rapid vapor- ization should be aided by fanning or blowing upon the surface. It is inefficient when the skin is very vascular. (2) Carbolic acid is an efficient and convenient means of producing local anaesthesia. A cloth thoroughly wet with a three per cent, solution of the acid should be kept upon the skin for fifteen minutes, and then the undiluted acid applied with a brush along the line of the proposed incision. This is applicable to the opening of abscesses, felons, etc., and to many minor operations. 3 26 THE ACCESSORIES OF AN OPERATION. General Ancesthesia.—The agents in common use for producing general anaesthesia are (1) ether, (2) chloro- form, and (3) nitrous oxide. The great merit of ether is its safety. Chloroform is more rapid in its action at first, as usually given, at least, less liable to cause vomiting, less disagreeable in its after- effects, but it is certainly more dangerous. On account of its inflammability, ether should not be used at night. Ni- trous oxide is suitable only for very short operations. Its use to obtain anaesthesia for any length of time is as danger- ous as that of chloroform, perhaps more so. Ether endangers life through suffocation, which may be the result of paralysis of the respiratory muscles, or of obstruction of the air-passages by the tongue, or by a for- eign body, such as vomited matter. Chloroform kills by exerting a special influence upon the ganglionic nerve-cen- tres presiding over respiration and circulation. Arrest of the breathing and lividity of the surface give timely notice of danger from ether. Chloroform may kill without a moment's warning. If during anaesthetization by ether the respiratory mus- cles cease to act, artificial respiration should be kept up, and stimulants administered ; but the patient should be kept quiet, should not be whipped or excited to muscular action. The danger comes from the weakness of his muscles, and they must not be called upon for any extra exertion. If, as is much more common, the diaphragm acts, but the air- passages are obstructed, and the face becomes livid, the obstruction must be removed, and the breathing will then take care of itself. If the obstruction is due to the pre- sence of a foreign body in the glottis or trachea (false teeth, vomited matter) the shoulders and head must be lowered, and the hips raised. It may become necessary to resort to tracheotomy. If the obstruction is due to the falling back of the tongue in consequence of the relaxation of the muscles of the pharynx and floor of the mouth a stout piece of wood should be put between the patient's teeth and his tongue drawn forward. The most prompt and efficient way of doing this is for the operator to hook the terminal joint of his forefinger behind the root of the tongue ANAESTHESIA. 27 and draw it forward, or the fingers should be pressed up- ward and inward from below the angles of the jaw. When operating upon the mouth and nasal passages, hemorrhage may interfere seriously with respiration and anaesthetization. By placing the patient on his back, and allowing his head to hang down over the end of the ope- rating table, the blood will be made to flow away through the nostrils, and the larynx will remain clear. During the inhalation of chloroform, death may occur either suddenly by syncope, or more slowly with signs of cerebral congestion and arrest of hsematosis. In the first case the heart stops, the patient becomes pale, the respira- tion superficial; the other usually happens after conscious- ness has returned, the face suddenly becomes livid, the patient loses consciousness again, and dies within half an hour. In the first variety, death can generally be averted by lowering the head, slapping the breast and face with wet towels, and applying the galvanic or faradic current. When the galvanic current is used, the negative pole may be placed in the mouth, and the positive pole at the anus. The faradic current should be applied only over the chest; its application to the phrenic or pneumogastric nerves in the neck is dangerous. In the second variety death is appa- rently inevitable. Administration of the Ancesthetic.—Chloroform should be given upon a compress folded twice longitudinally and once transversely, so as to be about six inches square. The upper fold is then thrown back, a drachm of chloroform poured upon the lower one, and the upper one replaced to prevent evaporation from that side. The compress is then held be- fore the mouth and nostrils of the patient, and whenever necessary the upper fold is thrown back, and additional chloroform poured upon the lower one. No special instru- ment is needed to prevent the administration of too much at a time. It has been demonstrated that the amount of the vapor of chloroform in the air never exceeds 4| per cent. To give ether successfully three points must be provided for: the evaporating surface must be large, the air inspired by the patient must pass across it, the supply of ether must be abundant so as not to require frequent renewal. The 28 THE ACCESSORIES OF AN OPERATION. ordinary cone, with certain modifications, meets these wants very well. Three or four thicknesses of stout brown paper, or ten of newspaper, measuring twelve by fifteen inches, should be covered with a thick towel well pinned on, and rolled into the form of a cone, a foot long and five inches in diameter, and fastened with long pins. A hole should be left at the apex of the cone large enough to admit the little finger, and the corners at the base should be turned back. If the towel is thick it will hold all the ether that is needed, and if the base is pressed closely against the chin, cheeks, and nose, all the air breathed by the patient will have to enter by the hole left at the apex, and pass across the large evaporating surface of the inside of the cone. If the cone is held at first at a short distance from the mouth and then brought gradually nearer, complete anaesthesia may be ob- tained in two or three minutes without having caused any strangling, or provoked any resistance. ARREST OF HEMORRHAGE. Hemorrhage is arrested: (1) by ligature ; (2) by tor- sion ; (3) by temporary mechanical occlusion, without in- jury to the walls of the vessels (acupressure, forcipressure) ; (4) actual cautery; (5) coagulating applications; (6) cold. Li ge Hare-lip pin. Fig. 15. Hare-lip pin with movable point. SUTURES. 39 passed either in the usual manner, or Avith the aid of Buck's pin-conductor (Fig. 16). Their points should be cut off Fig. 16. Buck's pin conductor. Avith nippers (Fig. 17), after they have been inserted, and the skin protected at each end by a strip of adhesive plaster. Instead of thread, a rubber ring is sometimes used (Fig. 18). Fig. 18. Twisted suture. A rubber ring is used in the place of thread. 40 THE ACCESSORIES OF AN OPERATION. 4. The quilled suture (Fig. 19), in which the wire or thread is passed double .and tied over pieces of gum cathe- ter or ivory rods. This is Fig. 19. employed when the tension is great, or Avhen the deep parts tend to drag asunder, and alloAV the secretions to collect. The points of entry and emer- gence of the sutures should be at a considerable distance from the incision. The serre-fine (Fig. 20) may be used Avhen the tension Fig. 20. Serre-fine. is slight, and Avhen the edges of the incision Avill not need to be held together for more than tAventy-four hours. It is a small self-retaining for- ceps, with toothed blades, and is made of silver Avire. The blades are separated by pressing upon the sides, and spring together Avhen the pressure is removed. For other kinds of sutures see Wounds of the Intestines. Quilled suture. BANDAGES. Ordinary roller bandages should be made of strips of strong unbleached muslin from 2| to 3^ inches in Avidth and about four yards long, rolled up snugly from one end. Narrower and shorter strips may be required for the smaller and more irregular portions of the body. The selvage edge should ahvays be removed. " Double-headed" rolls are made of longer strips rolled from each end toAvards the middle; they are used only for compound dressings in Avhich the turns cross each other at right angles (Fig. 27). A bandage should be so applied that it Avill press evenly BANDAGES. 41 upon all portions of the part covered by it, and not so tightly as to cause oedema of the distal portion when applied to a limb. When firm pressure is needed at any point on a limb, the Fig. 21. bandaging should begin at its loAver extremity and be carried up to the necessary height. The me- thods of application in common use are the continuous or spiral, the figure of-S or spica, the T'-bandage, the capelline, and the triangular' bonnet. The continuous or spiral band- age (Fig. 21), Avhen applied to a limb, should be fixed by one or two circular turns about the foot or hand, and then carried regularly up the limb, each turn covering the upper half of the preceding one. The increase in the thick- ness of the limb makes it necessary to reverse the turns in order that they may lie snug and keep their place ; this is done by fixing the centre of the band with the finger (Fig. 22), and turning over that edge of the bandage Avhich lies upon the thicker side. The fgure-of-8, or spica, band- age is represented in Figs. 23 and 24; successive turns are taken about tAvo adjoining parts, crossing from one to the other over the point Avhich it is especially desired to secure. At the groin the band- age is fixed by one or two turns about the thigh, then carried around behind the back and across the hypogastrium to the thigh again, and thence over the same COUrse as often as is necessary. Continuous or spiral bandage. 4* 42 THE ACCESSORIES OF AN OPERATION. Fig. 22. ' Reversing" the turns. Fig. 23. Fig. 24. Spica of the groin. Spica of the shoulder. 99 BANDAGES. 43 The knee or shoulder can be dressed by means of over- lapping turns of a figure-of-8 bandage, or in the manner shown in Fig. 25, by tearing an oblong piece of muslin Fig. 25. Fig. 26. Four-tailed bandage for the knee. doAvn the middle at each end, leaving a square undivided portion in the centre. The square portion is placed over the knee, and the four ends crossed under it brought in front and tied. The T-bandage (Fig. 26) is composed of a transverse and one or tAvo vertical bands. Sometimes the transverse band covers the dressing, and the vertical band serves only to keep the other in place; but generally the reverse is the case, and the vertical band supports a dressing or an instrument, and is itself supported by the transverse one. This bandage is most commonly employed in dressings applied to the anus, perineum, and lower portion of the trunk. The capelline or scalp band- age (Fig. 27) is applied by means of a double-headed roller bandage, the centre of Avhich is placed upon the forehead and the two ends carried horizontally around the head to meet at the occiput, Avhere they cross, and the lower one is brought forward over the vertex, while the other is con- tinued around horizontally. When they meet again in front T-bandage. 44 TI1E ACCESSORIES OF AN OPERATION the one that crosses the vertex is carried under the other and then back across the vertex to the occiput, and so on Fig. 27. Capelline or scalp baudage. until the entire scalp is covered. This bandage is difficult to apply, and easily disarranged, but it is useful when pres- sure must be applied at several points. In other cases it may be advantageously replaced by the triangular bonnet, or four-tailed bandage (Fig. 28). Fig. 28. Fig. 29. Hi i/ II im^ i!i|iU|| n< ill Four-tailed bandage for the head. Triangular bonnet. BANDAGES. 45 The triangular bonnet is made of a large square piece of muslin folded diagonally (Fig. 29). When applied to a stump the end of the limb is placed in its centre, the long folded border brought around trans- versely and tied, and the angle Fig. 30. brought up in front and made fast to it. When used as a suspensory for the testicles (Fig. 30), tAvo or three turns of a bandage are passed around the abdomen and fastened; the square angle of the triangle is made fast to this band in front, and its body brought down in front of the scrotum, car- ried back behind it, and the ends tied to the transverse band. Immovable bandages are used mainly in fractures, dislocations, sprains, and after operations that suspensory bandage. have involved a joint or destroyed the continuity of a bone. They are usually made by soak- ing roller bandages before their application in solutions of starch, dextrine, plaster of Paris, silicate of soda or potash, or in glue. Plaster of Paris is the material most commonly employed, for it is cheap and easily obtained and prepared. The most convenient method of using it is to make roller bandages of some thin, open-meshed material, such as cross- barred muslin or crinoline, and rub the dry plaster Avell into them before rolling them up. When required for use the roller is thoroughly Avet by placing it in a basin of water, gently squeezed, and then rapidly applied to the limb, while the successive turns are rubbed smooth Avith the Avet hand. Before the plaster is applied the limb should be covered with a thin layer of raw cotton, or with a few turns of an ordinary bandage. If crinoline cannot be obtained ordi- nary bandages must be unrolled, drawn through a thin mix- ture of plaster, rolled up again, and rapidly applied before the plaster has had time to set. Starch should be spread upon strips of coarse paper, which are then applied longitudinally to the limb ; silicate of soda or potash, dextrine, and glue are employed by first 46 THE ACCESSORIES OF AN OPERATION. rolling up the ordinary bandages in the solution, and then applying them in the usual manner, or the band may be applied dry and the mixture rubbed on each successive layer. The skin must be protected by a layer of cotton or a few turns of a dry bandage. The silicates and the glue dry quite rapidly, the starch and the dextrine much more slowly. The dextrine can only be dissolved by first mixing it with alcohol, and then adding hot water and stir- ring it until it is reduced to the proper consistency. Two, or at most three, layers of bandage are usually sufficient. A convenient method of employing plaster in the form of splint Avithout covering the limb entirely, is one in general use in the Paris hospitals. A strip of crinoline, folded in six or eight thicknesses, of the proper length and breadth, is drawn through the liquid plaster, stripped doAvn rapidly to remove the excess, applied to the limb, and fixed Avith a feAv turns of an ordinary roller bandage. Instead of a single strip tAvo may be used and applied on opposite sides of the limb. Such a splint fits the limb accurately, and will not make undue pressure at any point. Say re's Plaster of Paris Jacket.1—In this connection, and in vieAV of the importance and recent origin of this method of treating spinal disease, it has been thought proper to add a description of the method of applying the plaster of Paris jacket. The bandages are made of strips of crinoline three yards long and from tAvo and a half to three inches Avide, accord- ing to the size of the patient, filled Avith dry plaster as before described, and put up in rolls Avhich are moistened by setting them on end in a basin of Avater just before they are to be applied. For the purpose of strengthening the jacket and diminishing the amount of plaster required, narrow strips of tin, roughened on both sides like a nutmeg grater, are placed longitudinally around the body at inter- vals of two or three inches between the turns of the plaster bandage. The skin should be protected by an elastic, closely- fitting undershirt of some soft woven or knitted material, Avithout arms, but Avith tabs to tie over the shoulders. 1 Spinal Disease and Spinal Curvature, by Prof. L. A. Say re, 1877. BANDAGES. 47 As it is difficult for an assistant to hold the patient sus- pended during the application of the dressing, the apparatus shown in Fig. 31 has been devised. It consists of a curved iron cross-bar, to which are attached an adjustable head and chin collar and axillary bands. To a hook in the cen- ter is attached a compound pulley, the other end of which is secured either to a hook in the ceiling or to the top of a tripod eight or ten feet high (Fig. 32). Fig. 31. Fig. 32. Suspensory apparatus. Tripod. The collar and bands having been carefully adjusted, the patient is drawn up until the feet swing clear of the floor, 48 THE ACCESSORIES OF AN OPERATION. and a wedge-shaped pad of raw cotton folded in a handker- chief is placed over the abdomen between the shirt and the skin, its thin edge directed downwards. This is intended to leave room, when removed, for the distension of the abdo- men after meals. It is important to make the pad thin where it lies under the lower edge of the jacket, for other- wise the latter would fit too loosely. If the skin covering any bony prominences has become irritated, it must be protected by small pads of raAv cotton or cloth placed on either side ; and it is Avell also to place pads of tAvo or three thicknesses of cloth, three or four in- ches long, over each anterior iliac spine, removing them before the plaster has set. If the patient is a female, and especially if she is just entering the age of puberty, a pad of cotton in a handker- chief must be placed over each mamma, and withdraAvn before the plaster has set. The undershirt having been tied over the shoulders, pulled doAvn, and kept stretched by means of tapes fastened to its lower edge in front and behind, and tied together tightly over a handkerchief placed on the perineum, the patient is sloAvly drawn up by means of the apparatus until he feels perfectly comfortable, and never beyond that point, and kept in this position (Fig. 33) until the bandage has been applied. The bandage is first carried around the smallest part of the body, then around and around doAvmvards to and a little beyond the crest of the ilium, and after Avards from beloAV upwards spirally until the entire trunk from the pelvis to the axilla has been encased. It must be applied smoothly and not draAvn tight; it should be simply unrolled with one hand, while the other folloAvs and brings it into smooth close contact Avith all the irregularities of the surface of the trunk. After one or two thicknesses of bandage have been thus applied, the strips of tin are laid on, and another layer placed over them. In a very short time the plaster sets with sufficient firmness to alloAv the patient to be removed from the suspending apparatus, and laid upon his face or back on a firm mattress. The abdominal, iliac, and breast pads are then removed, and the plaster gently pressed in with the hand in front of each spinous process of the ilium. BANDAGES, 49 If any Aveak spots appear they must be strengthened by Avetting the surface and dusting on more plaster. Fig. 33. OUAYLE Albany. Patient suspended ready for the plaster. If abscesses or ulcers are present they must be covered Avith a large piece of oil-silk, and a hole cut in the under- shirt at the proper point before the bandage is applied. Then, before the plaster has entirely hardened, a fenestra is cut with a knife, the oil-silk cut in strips from the centre of the opening to the edge, and the strips turned back and glued fast to the plaster with shellac. 5 PART II. LIGATURE OF THE ARTERIES GENERAL DIRECTIONS. A point for the application of the ligature should be chosen, if possible, not nearer than half an inch to any collateral branch above or below it. The operator should Fig. 34. This diagram represents three distinct operations. A. Opening the sheath. B. Drawing ligature round the artery. C Tying artery. make himself thoroughly familiar Avith the anatomical rela- tions of the parts and the landmarks of the operation ; he should proceed methodically, in accordance with a definite GENERAL DIRECTIONS. 51 plan, and seek for and recognize each layer, each landmark in its order. It is well to mark upon the skin Avith ink or iodine the line of the proposed incision ; the incision should be free, and, so far as possible, its centre should correspond with the point at Avhich the ligature is to be applied. The first incision should go fairly through the skin, and then be car- ried down to the enveloping fascia by repeated applications of the knife. The fascia should be pinched up, nicked, and divided upon a director if the vessels lie immediately beloAV it, or upon the finger if a muscular interstice is to be sought for. The division of the fascia should equal in length the external incision. The knife is then laid aside and the artery sought for by separating the tissues Avith the fingers or a director. The sheath is recognized by the communicated pulsation, and by the absence of the pinkish white color and smooth shining surface Avhich characterize the artery. When found, it is gently pinched up with the forceps, the flat of the knife laid upon it, and a hole one-quarter of an inch long care- fully made in it. A distinct sheath is found only about the main trunks, and is replaced in the others by a layer of cellular tissue, Avhich is more readily Fig. 35. separated by tearing Avith the point of a director or Avith tAvo forceps. When the pinkish Avhite coat of the vessel has been fairly exposed, each edge of the hole in the sheath is grasped in turn Avith forceps, and the sides of the vessel gently separated from the sheath by tearing through the slight attachments with the point of a director. A threaded aneurism needle is then entered on that side Avhere the parts lie that are most to be avoided, and passed behind the artery, care being taken not to raise the latter from its bed, until its eye appears upon the other side ; the thread is then picked up with forceps and draAvn through while the needle is Avithdrawn. The precaution should never be omitted of trying if compression of the vessel betAveen the finger and the ligature Aneurisi arrests pulsation in its distal branches, for the best needle. 52 LIGATURE OF THE ARTERIES. surgeons have mistaken a nerve or strip of fascia for the artery. The main trunks can be readily distinguished from the veins by their appearance, the veins resembling a leech Avhile the arteries are Avhite, and feel like a cord or band under the finger, and by their knoAvn anatomical relations; but it is often very difficult to recognize the smaller arte- ries, since they closely resemble the veins. The operator has to depend upon three indications: 1, the fact that when there are tAvo satellite veins the artery is placed be- tween them; 2, pulsation; 3, alternate compression of the vascular bundle at the tAvo ends of the incision. Pres- sure at the proximal end causes the artery to shrink and the veins to SAvell; pressure at the distal end has the con- trary effect. The ligature is then tied Avith a square knot (Fig. 2), tightly enough to cut the inner coats of the vessel, and one or both ends cut short, Fig- 36. according to the material used. If carbolized cat- gut, or silk prepared Avith carbolized Avax, 1 part of the acid to 4 or 5 of bees- Avax, is used, both ends may be cut short and the Avound closed. The cat- gut is soon absorbed, and it has been proved that silk thus prepared is un- irritating, and does not cause suppuration. The lymph thrown about these ligatures gives strength to the Avail of the vessel and additional security against secondary hemorrhage. Primary union, at least of the deep parts of the wound, may be confidently expected. If non-carbolized silk is used only, one end of the ligature is cut short; the other is brought out through the Avound Avhich then remains open until after the ligature has cut through the artery and been thrown off by suppuration. a a. Inner coat of an artery ruptured by a ligature. ANATOMY OF SUPRA-CLAVICULAR REGION. 53 While making the incisions the position of the parts should be such that the muscles Avhich serve as guides shall be tense, but while seeking for the artery the muscles should be relaxed so as to give more room. ANATOMY OF THE SUPRA-CLAVICULAR REGION. The superficial fascia underlies the platysma, and incloses the sterno-cleido-mastoid in a reduplication of itself. The middle, or sterno-clavicular, fascia has a common origin Avith the superficial fascia in the linea alba betAveen the two sterno-thyroid muscles, divides into three layers to form sheaths for the sterno-thyroid and sterno-hyoid, unites, and again divides to form a sheath for the omo-hyoid, unites again and finally joins the superficial fascia betAveen the trapezius and sterno-cleido-mastoid. This middle fascia is strong and resisting, and incloses all the vessels of the region except the external jugular vein, which is subcuta- neous throughout its course until it turns inward to join the subclavian above the clavicle. These tAvo fasciae are sepa- rated from each other and from the skin by loose cellular tissue, in which a large amount of fat may be deposited, and it is of prime importance therefore that they should be recognized in the search for the vessels. The vessels Avhich are approached through this region are the innominate, the subclavian, and the common carotid. The bifurcation of the innominate corresponds with the sterno-clavicular articulation, and in old people, as well as in exceptional cases, rises from five to ten millimetres above it. It lies in front and on the right side of the trachea, and is crossed anteriorly by the left innominate vein. At the bifurcation the subclavian lies behind and to the outer side of the carotid, and is crossed by the pneumogastric and phrenic nerves close to its origin, the former giving off the recurrent laryngeal Avhich turns under the artery and rises again behind it. The carotid, Avhich at first lies behind the sterno-cleido-mastoid, soon reaches its anterior edge, and at the same time increases its distance from the trachea. While the internal jugular lies wholly Avithin the middle cervical fascia, the subclavian vein is enveloped by a redu- 5* 54 LIGATURE OF THE ARTERIES. plication of it and held closely against the clavicle thereby. It is therefore more superficial, and on a lower plane than the curved portion of the subclavian artery, and need not be uncovered in the search for the latter. The branches of the subclavian, seven in number, arise (Avith one exception, the transversalis colli) from its first portion, that comprised betAveen its origin and the inner border of the scalenus an- ticus. The transversalis colli may arise from the first part, or the second (between the scaleni), or even the third (beyond the scaleni). The supra-scapular crosses in front of the scalenus anticus and runs doAvmvards and outwards to the clavicle, lying beloAv the line of the incision made in tying the subclavian in its third portion. LIGATURE OF THE INNOMINATE ARTERY. Anatomy.—The artery is in relation in front with the innominate veins and the pneumogastric nerve; on the inner side Avith the trachea; on the outer side and behind Avith the pleura. It lies immediately behind the sterno- clavicular articulation. Five different incisions have been proposed. A vertical one in the middle of the neck (King); a horizontal one 4| inches long, beginning in the middle line and passing out- Avard parallel to and half an inch above the clavicle (Ma- nec) ; an oblique one in the interval betAveen the sternal and clavicular attachments of the sterno-cleido-mastoid (Se'dillot) ; an oblique one from the anterior border of the left sterno-cleido-mastoid 2| inches above the clavicle doAvn to and a little beyond the left sterno-clavicular articulation (Velpeau) ; a V-shaped one, of Avhich one side lies OA^er the anterior edge of the sterno-cleido-mastoid, and the other is parallel to and a little above the clavicle (Mott). The single incisions do not give sufficient room, and although they are more brilliant they should give Avay to the more prudent and practical one proposed by Mott. Operation.—An incision 3J inches in length is carried along the anterior edge of the right sterno-cleido-mastoid, ending half an inch above the sternum (Fig. 37). Another, of the same length, is carried outwards from the loAver end LIGATURE OF THE INNOMINATE ARTERY. 55 of the first, half an inch above and parallel to the right clavicle. These incisions are carried down to the superficial fascia, and the triangular flap betAveen them dissected up. If the anterior jugular is encountered it must be draAvn doAvnwards. The sternal and part of the clavicular attach- ments of the sterno-cleido-mastoid are noAV divided half an inch above the bone on a director or Avith forceps and knife, and the muscle draAvn upwards and outwards, uncovering the sterno-thyroid and sterno-hyoid and the middle cervical Ligature of arteries. A. Innominate. B. 2d or 3d portion of subclavian. C. 2d or 3d portion of subclavian (Skey). D. Vertebral or inferior thyroid. E. Ax- illary below the clavicle. fascia which here is very dense and covered by the inferior thyroid veins. The outer fibres of the sterno-hyoid and sterno-thyroid are iioav divided, the thyroid veins draAvn aside, and the underlying or middle fascia torn through Avith the director, or'opened very carefully with the knife. The common carotid is noAV seen at the bottom of the Avound and traced doAvirwards to the innominate. The internal jugular is carefully pressed outAvards with a retractor; the left forefinger, passed into the wound betAveen the artery 56 LIGATURE OF THE ARTERIES. and the innominate veins, presses the latter against the sternum, and the operator proceeds carefully to clean the artery with a director half an inch beloAv its bifurcation. The needle, guided by the finger, is passed from the outer side so as to avoid the vein, nerve, and pleura. The innominate has been tied only for aneurism of itself, of the subclavian, or of the primitive carotid. With one exception, the case of Dr. Smyth of NeAV Orleans, the ope- ration has terminated fatally in every case; and, as it has been shoAvn1 that the treatment of aneurism by distal liga- ture yields satisfactory results, this operation is no longer justifiable. It may be rendered necessary by hemorrhage from the subclavian or carotid, but the attempt should always be made to tie the injured vessel in the wound before resort- ing to so dangerous a method as ligature of the innominata. LIGATURE OF THE SUBCLAVIAN ARTERY. The anatomical difference between the right and left sub- clavian is confined to the first portion of the artery, Avhich in the left is much longer, more vertical in its direction, and situated more posteriorly even than the innominate; a sepa- rate description therefore is required only for the first portion. 1st Portion. Left Subclavian.—This operation, attempted unsuccessfully by Astley Cooper about 1820, has been generally considered as unjustifiable on account of the sup- posed impossibility of avoiding the thoracic duct and the pleura. It was, hoAvever, tied successfully by Dr. J. Kearny Rodgers of New York in 1845, the patient dying on the fifteenth day from hemorrhage; and recently McGill2 of Leeds, England, laid bare the artery after a tedious and difficult dissection and applied metallic compression just below the origin of the vertebral artery for eight hours. The aneurism was quite filled by a firm coagulum, but unfortunately the pleura had been perforated during the 1 Prof. W. H. Van Buren, On Aneurism. Paper read before the International Medical Congress, Philadelphia, 1876. 2 Med. Chir. Trans., vol. 58, p. 338. LIGATURE OF THE SUBCLAVIAN ARTERY. 57 operation, and the patient died of pleurisy on the sixth day. Dr. Rodgers's case shoAvs that the artery can be tied Avithout injury to the pleura or thoracic duct, and Mr. McGrill's shoAvs that its temporary occlusion is sufficient to consolidate the aneurism. In Air. McGill's case the artery seemed to be abnormally placed, and Avas found Avith much difficulty at a depth of about three inches. Under more favorable cir- cumstances the artery might be exposed as successfully as was done by Dr. Rodgers, and metallic compression or a temporary catgut ligature, not draAvn tightly enough to injure the inner coats of the vessel, might cause consolida- tion of the aneurism Avithout exposure to the danger of secondary hemorrhage. Operation.—xV V-shaped incision similar to that described for ligature of the innominata (Fig. 37) is made upon the left side, and carried through the sterno-cleido-mastoid and outer fibres of the sterno-thyroid and sterno-hyoid muscles and the middle cervical fascia as before described. The carotid is then recognized, and, together Avith the internal jugular, drawn outAvards Avith a blunt hook. The muscles are noAV relaxed by bending the head and neck forward, and the cellular tissue torn through Avith forceps and direc- tor. The knife should no longer be used, on account of the risk of injury to the thoracic duct, which is imbedded in the loose tissue betAveen the vessels and the vertebrae, and is rendered very difficult of recognition by its small size and thin Avails. It runs directly across the route to the artery while passing from the bodies of the vertebrae to the ante- rior border of the scalenus anticus, and can be best avoided by making the search beloAv and to the outer side of it in the lower angle of the Avound. The finger, passed doAvmvards and baclovards behind the carotid, soon feels the artery by pressing it against the side of the spinal column, the loose cellular tissue surrounding it is easily separated Avith the director, the vessel cleaned, and the needle passed from the inner side. The needle should have a short curve, and its point should be kept close against the vessel so as to avoid injuring the pleura. 1st Portion. Bight Subclavian.—The first portion of the right subclavian has been tied unsuccessfully by Colles, 58 LIGATURE OF THE ARTERIES. Mott, and Liston. It is exposed in the same manner as the innominate artery, and the ligature passed from the outer side, the pneumogastric and phrenic nerves being pressed imvard towards the carotid. The great danger of this ope- ration lies in the proximity of collateral branches. 2d Portion.—This operation, first proposed and per- formed by Dupuytren, is rendered dangerous by the fact that one, and sometimes several large branches are given off from this part of the artery. The preliminary steps are the same as those employed in ligature of the 3d portion; after the middle cervical fascia has been divided, the tu- bercle of the first rib and the external border of the scalenus anticus are sought, the muscle bared and divided upon a director, the phrenic nerve Avhich lies upon its anterior aspect being carefully avoided. As soon as the muscular fibres are cut they retract and leave the artery in full vieAV. 3cZ Portion. Anatomy.—The 3d portion of the subcla- vian lies between the outer border of the scalenus anticus and the tubercle of the first rib in front and the brachial plexus behind, and below the posterior belly of the omo- hyoid ; it is crossed on a much more superficial plane by the external jugular, which enters the subclavian near the middle of the clavicle. In muscular subjects the clavicular insertions of the trapezius and sterno-cleido-mastoid muscles lie near to, or may eAren join, one another; in others, they are from tAvo to three inches apart. Ordinarily the vessel lies at a depth of one or one and a half inches beloAV the surface, but in very fat persons, or when the clavicle has been pushed upAvards by an axillary aneurism, this distance may be increased to three inches. Operation.—Beginning an inch outside of the sterno- clavicular articulation, make an incision three or four inches long parallel to and half an inch above the clavicle (Fig. 37, J9). Divide the skin and the platysma ; Avhen the ex- ternal jugular is exposed draAv it to the inner side or divide it betAveen tAvo ligatures. Divide on a director the super- ficial fascia, and the clavicular portion of the mastoid muscle if necessary, and seek the posterior belly of the omo-hyoid. DraAv this muscle outAvards and upwards, and feel for the LIGATURE OF THE INFERIOR THYROID. 59 tubercle of the first rib, following down the outer border of the scalenus anticus. Depress the shoulder as much as possible, denude the artery Avith the finger-nail or the point of a director, and pass the needle from below, taking care not to include the loAvest bundle of the brachial plexus in the ligature. In order to avoid mistaking this bundle for the artery, the tubercle of the first rib should always be found; the artery lies against it, betAveen it and the nerve. Skey prefers, in difficult cases, a curved incision " com- menced about tAvo and a half or three inches above the clavicle, upon, or immediately on the outer edge of, the mastoid muscle. This incision is carried slightly outAvards and doAviiAvards, toAvards the acromion, and then curved in- wards along the clavicular origin of the mastoid muscle." (Fig. 37, (7). Ordinarily the external jugular is left to the outer side of the incision. LIGATURE OF THE INFERIOR THYROID. Anatomy.—After passing vertically upward, the artery curves inward to reach the under surface of thyroid gland. The highest point of its curve is half an inch below the prominence on the transverse process of the sixth cervical vertebra, named by Chassaignac the carotid tubercle. In old people it is somewhat higher. It lies behind the com- mon carotid and internal jugular, and is separated from them by more or less dense cellular tissue. The guides to the vessel are the carotid and Chassaignac's tubercle. Operation.—Make an incision three and a half or four inches in length along the anterior border of the sterno- cleido-mastoid, ending an inch above the clavicle (Fig. 37, i>). Lay bare the border of the muscle, and draw it out- wards, tear through or divide the middle fascia and draw the carotid and internal jugular outwards Avith a retractor. Flex the head slightly to relax the parts, feel Avith the finger for the carotid tubercle, and seek the artery below it, separat- ing the cellular tissue with a director. Pass the needle betAveen the artery and vein. 60 LIGATURE OF THE ARTERIES. LIGATURE OF THE VERTEBRAL ARTERY. Anatomy.—The vertebral artery passes from the first portion of the subclavian upAvards and baclovards to the transverse process of the sixth cervical vertebra. It is ac- companied by a vein Avhich lies in front, and is covered by the deep cervical fascia. The guide to it is the carotid tubercle. Operation.—The first incision is the same as for ligature of the inferior thyroid (Fig. 37, D). The anterior edge of the sterno-cleido-mastoid is exposed and draAvn outAvard. The middle fascia is diAdded, and the carotid and jugular drawn inward. The gap betAveen the longus colli and the scalenus anticus is then felt for about half an inch below the carotid tubercle, the deep fascia covering it torn through, the muscles separated, the vertebral vein pushed aside, and the artery exposed. Chassaignac prefers an incision along the posterior border of the mastoid muscle, and reaches the carotid tubercle by drawing the muscle and vessels inwards. If the muscle is very broad some of its clavicular fibres must be divided. LIGATURE OF THE AXILLARY ARTERY. Anatomy.—The axillary extends from the middle of the clavicle to the lower edge of the tendon of the teres major. The axillary vein lies on the inner side and in front of it, and the brachial nerves invest its loAver portion closely. It can be tied beloAv the clavicle in the clavi-pectoral triangle formed by the clavicle, inner border of the pectoralis minor and the thorax, or in the axilla. The strong fascia Avhich unites the coracoid process and clavicle, and forms the sus- pensory ligament of the axilla, the costo-coracoid fascia, sends a prolongation about the upper portion of the axillary vein which keeps its Avails from sinking in ; the cephalic vein ascending in the groove betAveen the deltoid and pec- toralis major perforates this fascia and joins the axillary vein at the inner border of the tendon of the pectoralis minor, close by the origin of the acromial thoracic artery. LIGATURE OF THE AXILLARY ARTERY. 61 A. Ligature under the Clavicle.—(Fig. 37, IJ). Make an incision extending from the summit of the coracoid pro- cess four or four and a half inches along the loAver border of the clavicle. Divide successively the skin, subcutaneous tissue, superficial fascia, and. pectoralis major, and then tear carefully through the costo-coracoid fascia, avoiding injury to the cephalic vein at the outer part of the Avound. The pectoralis minor is noAV exposed, and after separating the cellular tissue with the point of a director the axillary vein is seen crossing from the upper edge of the muscle to the clavicle. The artery is completely hidden by it, lying on the outer side and a little behind. The vein must noAV be draAvn imvards, the needle entered between it and the artery, and the ligature applied as near as possible to the clavicle on account of the proximity of the acromial thoracic branch. B. Ligature in the Axilla. Anatomy.—The tissues and organs on the outer side of the axilla are arranged in the following order: 1, the skin ; 2, the subcutaneous cellular tissue ; 3, the fascia ; 4, the axillary vein ; 5, the internal cutaneous and ulnar nerves; 6, the axillary artery; 7, the median nerve ; 8, the coraco-brachialis; 9, the humerus and Fig. 38. A. Ligature of the axillary artery. B. Ligature of the brachial artery. articular capsule. The old rule for exposing the artery here Avas to make a longitudinal incision at the junction of the anterior and middle thirds of the axilla, find the vein, count two nerves, and look for the artery just beyond the 6 62 LIGATURE OF THE ARTERIES. last one. This is a difficult and dangerous method, and a much simpler one has been substituted by Malgaigne, who was the first to point out that the coraco-brachialis muscle is the real guide to the artery. Operation.—The arm is abducted completely, the incision commenced at the inner border of the coraco-brachialis over the head of the humerus and carried two and a half or three inches doAvn the arm parallel to the course of the artery. It should involve the skin only, so as to avoid injury to the basilic vein. If the edge of the coraco-brachialis cannot be distinguished, the incision should be made according to the old rule, at the junction of the inner and middle thirds of the axilla. The aponeurosis is now divided upon a direc- tor over the caraco-brachialis, and the fibres of the inner border of this muscle exposed. The parts are then relaxed by bringing the arm nearer the trunk, and the posterior side of the Avound, including the vein, ulnar and internal cutane- ous nerves, is draAvn back Avith a retractor; and the artery, overlain by the median nerve, usually appears at the bottom, covered perhaps by the posterior part of the sheath of the coraco-brachialis. LIGATURE OF THE BRACHIAL ARTERY. Anatomy.—The brachial artery runs from the junction of the anterior and middle thirds of the axilla to the middle of the anterior aspect of the elboAV. It occupies, Avhen the forearm is supinated, the groove between the biceps and triceps, being partly covered by the former in muscular sub- jects, and, separated from the bone by the inner edge of the coraco-brachialis, and of the brachialis anticus. It lies in the anterior loge of the arm, Avhich is bounded posteriorly on this side by a prolongation of the enveloping aponeurosis, extending doAvn to the bone betAveen the biceps in front and the triceps behind. It lies, consequently, Avithin the sheath of the biceps, and the inner edge of this muscle is the sure guide to it. It lies betAveen tAvo satellite veins, Avhich anastomose frequently, and has the median nerve in immediate relation with it on the side next the skin. The basilic vein directly o\rerlies it between the skin LIGATURE OF THE BRACHIAL ARTERY. 63 and the aponeurosis. The artery presents frequent anoma- lies. The most common is its premature bifurcation into the radial and ulnar, Avhich may take place as high as in the axilla, in which case one of the branches is superficial, perhaps even subcutaneous, Avhile the other folloAvs the usual Fig. 39. Transverse section of the arm at its middle (Tillaux). 1. Skin. 2. Subcutaneous tissue. 3. Enveloping aponeurosis. 4. Aponeurosis separating the anterior and posterior loges ou the inner side. 5. Division on the outer side. 6. Brachial artery and veins. 7. Median nerve. S. Basilic vein. 9. Internal cutaneous nerve. 10. Vlnar nerve. 11. Its artery and veins. 12. Muscular cutaneous nerve. 13. Mus- cular spiral nerve. 14. Superior profunda artery. 15. Cephalic vein. course. The median nerve occupies the same sheath Avith the artery, lying first on the outer side and then crossing, in front or behind, very obliquely to the inner. The ulnar nerve, accompanied by an artery and tAvo veins, lies in the 64 LIGATURE OF THE ARTERIES. substance of the triceps immediately behind the brachial artery and median nerve, separated from them only by the above-mentioned prolongation of the enveloping aponeurosis, and as they form a group differing from the other only in size, the artery may be mistaken for the brachial if met Avith (Fig. 39). This error Avill not be made if the fibres of the biceps alone are exposed, and the incision confined to the anterior loge. Operation.—Arm abducted, forearm supinated. Make an incision three inches long in the middle third of the arm, along the inner border of the biceps through the skin and subcuta- neous cellular tissue, taking care not to in- jure the basilic vein, which should be kept posterior to the in- cision. Divide the aponeurosis and ex- pose the fibres of the biceps. If the muscle is large draAv it forward, and the sheath inclosing the artery, nerve, and veins will be dis- closed. This is torn through carefully Avith a director, the median nerve separated and pushed aside, the artery sepa- rated from its veins, and the ligature passed from the side of the nerve. Ligature of brachial artery. LIGATURE OF THE RADIAL ARTERY. Anatomy.—The radial artery extends in a straight line from a point half an inch beloAv the centre of the fold of the elboAV to the ulnar side of the styloid process of the radius; it occupies the groove bounded on one side by the supinator longus, on the other by the pronator radii teres and flexor carpi radialis. It is covered only by the skin, cellular tis- sue, and aponeurosis; but in muscular subjects the muscular interstice in Avhich it lies may be very deep. It is accom- panied by tAvo veins, and by no nerve. It occupies in its upper third the sheath of the pronator, and consequently LIGATURE OF THE ULNAR ARTERY. 65 Fi Amputation of the great toe. scribed for the other toes, or Avith a large internal flap. In the latter case an incision (Fig. 57, A) is begun on the outer side of the ex- tensor tendon just beloAV the joint, and carried straight down to the head of the first phalanx. From its loAver end a transverse incision is carried around the inner side of the toe to the outer edge of the flexor tendon, and, the toe being then forcibly extended, a plantar incision is carried from the end of the transverse incision (Fig. 57, B), along the outer side of the flexor tendon to the digito-plantar fold, and thence transversely around the outer side of the toe to rejoin the first incision near its centre. The internal flap is then dissected from beloAV upwards, the extensor tendon divided high up, the lateral ligaments divided, the knife passed through the joint, and the remain- ing soft parts cut from Avithin outAvards. The same incisions made somewhat loAver doAvn may be used for amputation in continuity, but usually the shape Amputation of the toes and metatarsal bones. 106 AMPUTATIONS. and position of the flaps will be determined by the nature and extent of the injury which makes the operation neces- sary. Amputation of two adjoining Toes.—The dorsal incision should begin in the intermetatarsal space just above the level of the joint (Fig. 56, B), extend doAvn to the begin- ning of the web, diverge obliquely to the adjoining Aveb, cross the plantar surface in the digito-plantar fold of both toes, and return through the other adjoining Aveb to the point of divergence. Each toe is then removed separately after division of its tendons and lateral ligaments. AMPUTATION OF A METATARSAL BONE. Amputation in continuity is much to be preferred to dis- articulation on account of the extent of some of the syno- vial sacs, the attachments of certain muscles, and the im- portance of some of the bones in preserving the relations of the others. The synovial sac Avhich forms part of the articulation betAveen the first cuneiform and first metatarsal bones is isolated from the others, but the attachment of the peroneus longus to the base of the latter bone renders its preservation especially important. There is also a separate synovial sac for the articulation betAveen the cuboid and the fourth and fifth metatarsals. The base of the fifth meta- tarsal is easily recognized by the prominence Avhich it forms on the outer side of the foot; that of the first metatarsal is three-fourths of an inch anterior to the other, and is the first prominence encountered by the finger Avhen it is passed from before backward along the inner side of the bone. The incision begins on the dorsal aspect at, or a little be- low, the point at Avhich the bone is to be diArided, is carried doAvn well beloAV the metatarso-phalangeal joint (Fig. 56, C), diverges into the Aveb, crosses the plantar surface in the digito-plantar fold, and returns through the other web to the point of divergence. A short transverse incision is made through the skin at its upper end to facilitate division of the bone, which is then effected Avith cutting pliers or a chain saw after the soft parts have been separated on both DISARTICULATION OF METATARSAL BONES. 107 sides. The toe is then pressed baclovard, the cut end of the bone raised, the knife passed behind it, and the opera- tion completed by cutting from within outAvards. The first and fifth metacarpal bones should be cut obliquely so as to diminish the prominence of the stump. For disarticulation of the first or fifth metatarsal bones the only modification needed is to begin the incision at a correspondingly higher point—at or a little beloAV the tarso- metatarsal joint (Fig. 56, D). After the flaps have been dissected up, the joint is opened by dividing the dorsal and interosseous ligaments, and the bone raised and separated from the remaining soft parts. DISARTICULATION OF ALL THE METATARSAL BONES. (TARSO- METATARSAL DISARTICULATION; LISFRANc's OR HEY'S AMPUTATION.) The position and general direction of the tarso-metatarsal articulations, as Avell as the peculiarity presented by the base of the second metatarsal bone are sufficiently Avell shoAvn in Fig. 58 to render a detailed description unneces- sary. The guides to the articulation are the projecting bases of the first and fifth metatarsal bones. The skin being retracted by an assistant, the surgeon makes with a scalpel a curved incision across the dorsum of the foot from the base of the fifth to the base of the first metatarsal bone. (For the left foot the direction of this incision must be reversed.) The incision should involve the skin only, its centre should lie half an inch or more be- Ioav the centre of the line of the articulations, and it should begin and end upon the sides of the foot at their junction Avith the sole. (Fig. 58.) A plantar flap should then be marked out by a curved incision beginning and ending at the same points as the first and crossing the sole near the origin of the toes. The dor- sal skin flap is then dissected back to the line of the articu- lation, the tendons and muscular fibres of the short extensor divided, the joints betAveen the fifth, fourth, and third meta- tarsals, and the corresponding bones of the tarsus opened 108 AMPUTATIONS. Fig. 58. successively from the outer side, and that between the first meta- tarsal and first cuneiform from the inner side. With the point of the knife directed transversely across the dorsal aspect of the base of the second metatarsal, the joint between that bone and the second cuneiform is sought from beloAV upAvards, and after it has been found and opened the interosseous ligaments uniting the second to the first and third metatarsals are divided by thrust- ing the point of the knife Avell down between them, the flat of its blade being held parallel to the long axis of the foot, and the toes being for- cibly depressed. After the bone has been thus disengaged, the knife is passed through the articulation, and the plantar flap cut from Avithin out- wards. A. Lisfranc's amputation Chopart's amputation Modifications.—The plantar flap may be cut (1) from Avithout in- Avards, or (2) by transfixion, before the articulations have been opened. Instead of disarticulating it, the base of the second metatarsal may be cut off Avith pliers or a saAV and left in place. Hey saAved off' the projecting part of the first cuneiform after disarticulating, but this Aveakens the attach- ment of the tibialis anticus, a disadvantage Avhich is not off- set by the improvement in the outline. MEDIO-TARSAL OR CHOPART S AMPUTATION, This name is given to the operation of disarticulation through the joints formed by the astragalus and calcaneum behind, the scaphoid and cuboid in front. The guides to the joint are the tubercle of the scaphoid on the inner side MEDIO-TARSAL OR CHOPART'S AMPUTATION. 109 of the foot, the head of the astragalus on the dorsum, and the anterior end of the calcaneum on the outer border. The first named is one-eighth of an inch in front of the articu- lation, and is the first bony prominence felt on draAving the finger from the inner malleolus forward along the side of the foot; the sharp edge of the second can be readily felt Avhen the anterior portion of the foot is forcibly depressed; the latter can usually be made out by adducting the toes and inverting the sole, nearly midAvay betAveen the tip of the external malleolus and the base of the fifth metatarsal bone, or nearer the latter. When the foot is at right angles Avith the leg, the anterior articular surfaces of the astragalus and calcaneum are in the same plane, one crossing the foot transversely at the points indicated. Operation. (Figs. 58, 59, 60.)—The surgeon places the thumb and forefinger of his left hand upon the tubercle Fig. 59. Outer side. A. Chopart's amputation. B. Syme's amputation. C. Line of section of the bones hi Syme's amputation. D. subaV draAving the foot forward and depressing it a narroAV 116 AMPUTATIONS. Butcher's or a chain saAV can be passed through the joint, and applied to the calcaneum behind the posterior lip of the Fig. G2. . Pirogoff's amputation. A. Cutaneous incision (outer side). B. Line of section of the bones. astragalus, and the bone sawn through doAvnwards and for- Avards in such a direction that the section will terminate half Fig. 63. Pirogoff's amputation. A. Cutaneous incision (inner side). B. Parallel section of the bones (Sedillot's modification). an inch behind the lower edge of the cancaneo-cuboid articu lation. The malleoli and a slice of the tibia are then re AMPUTATION AT THE ANKLE-JOINT. 117 moA-ed as in Syme's operation, and enough of the anterior angle of the calcaneum removed to make the length of its surface of section correspond Avith that of the tibia. Some surgeons prefer to reverse this order, and remove the mal- leoli before saAving through the calcaneum.1 The cut surface of the calcaneum must then be brought up against that of the tibia, and if the section of the former has been sufficiently oblique, and has commenced far enough back, this can be done Avithout making excessive tension upon the tendo Achillis, othenvise another slice must be removed from one of the bones or the tendon divdded subcutaneously. Suturing together of the bones has been occasionally tried, but its value has not yet been determined. Several modifications of this operation have been sug- gested, but they can hardly be considered as improvements. Vertical division of the calcaneum, as originally proposed by Pirogoff and Ure,2 deprives the stump of the advantages of the heel pad by SAvinging the latter too far forward, and bringing the Aveight of the body upon the thinner skin cover- ing the insertion of the tendo Achillis. It also causes undue tension of the tendon when the bones are brought together. Sedillot suggested an obliqite section of the tibia upAvards and backwards, parallel to that of the calcaneum (Fig. 63, B). This avoids any stretching of the tendon, and insures a Avell-placed pad under the heel, but it shortens the limb someAvhat, and places the point of support behind the axis of the leg. Pasquier saAVS both tibia and calcaneum hori- zontally ; this is difficult of execution, endangers the flap, and also leaves the point of the heel too far back. The sug- gestion Avhich is occasionally made to retain the malleoli is unsurgical and unprofitable,-—unsurgical, because union between tAvo cut surfaces of cancellous bone is speedier, stronger, and not exposed to greater risks than Avhen one surface is covered with articular cartilage ; unprofitable, be- cause nothing is gained in accuracy of adjustment or length of limb. 1 Pirogoff's incisions were nearly identical with Syme's. He also divided the calcaneum vertically, and left in the articular surface of the tibia unless it was diseased. 2 Ure's conception of the operation seems to have been original with him. His case was published in the Lancet about the time of the appearance of Pirogoll's book at Leipzig, 1854. 118 AMPUTATIONS. Comparison of the Different Methods of Partial and Total Amputation of the Foot.—As an offset to the advan- tage of their less extensive mutilation, Lisfranc's and Cho- part's amputations are open to the great objection that the unopposed action of the muscles of the calf is almost certain to raise the heel permanently, and bring the weight of the body upon the end of the stump and the cicatrix; and, fur- thermore, Avhen these amputations have been performed for disease of the bones, those bones Avhich were left behind, even if entirely healthy at the time of the operation, have ultimately become affected. Syme's amputation gives an excellent stump, and the shortening of the limb is no more than is necessary to per- mit the adaptation of an artificial foot and a spring under the heel, but it is comparatively difficult of execution, and the flap is liable to pouch and favor retention of the pus. Pirogoff's method is easier of execution and gives a longer limb, but an artificial foot cannot be fitted to it so advanta- geously, and in cases of amputation for disease it is contrary to sound principles of surgery to leave in the stump any bone which is apt to become subsequently affected ; it brings the heel pad a little too far forward, and requires a longer time for recovery from the operation. The subastragaloid disarticulation gives a longer limb and a good stump, but disease is very apt to recur in the astragalus. AMPUTATION OF THE LEG. A. Loaver Third.—This may be done by the pure cir- cular or by a modified circular method, Avith a long anterior flap made to overhang the square-cut posterior segment of the limb, or Avith a long elliptic posterior flap, including the whole of the tendo Achillis. The two former result in a central adherent cicatrix; in all the coverings are liable to be thin and tender, and the artificial limb must be so ad- justed that the weight will be received by the sides of the leg and not upon the face of the stump. The compensatory advantages are that the control of the limb is more perfect than Avith a shorter stump, and the mortality consequent upon the operation less. AMPUTATION OF THE LEG. 119 Fig. 64. 1. Circular Method.—A circular incision is made through the skin, and a cutaneous sleeve one inch long behind, tAvo inches in front, is dissected up ; the soft parts are cut straight through to the bone at the base, and then retracted Avith a tAvo- or three-tailed band, according to the breadth of the interosseous membrane, and the bones sawn through, beginning and ending with the tibia. 2. Modified Circular. Fig. 64, A.—Circular incision through the skin, met by a liberating longitu- dinal one on the antero-external as- pect. The soft parts of the posterior portion are divided rather lower than those of the anterior portion, and all are dissected back to the line at which the bones are to be divided. Instead of a single liberating in- cision two may be made, one on each side ; and then by rounding off' the corners Ave may have double skin flaps Avith circular division of the muscles, the " modified flap" operation. 3 .Long Anterior Flap (Bell). Fig. 65, ^4.—An anterior flap, equal in length to the diameter of the leg at its base, is marked out by a curved incision through the skin, beginning at the posterior edge of the tibia on the inner side, a little beloAV the point at which the bones are to be divided, and ending at a point directly opposite over the fibula. The anterior muscles are divided transversely half an inch above the lower end of the flap, and carefully dissected off the bones and interosseous membrane as high as the base of the flap. The separation Amputation of leg. .4. Modi- fied circular. B. Rectangular flaps, Teale. C Antero-poste- rior flaps, upper third, Bell. 120 AMPUTATIONS. Fig. 05. from the interosseous membrane should be made with the finger or handle of the knife, in order that the anterior tibial artery which lies immediately upon the membrane may not be injured. The posterior flap is. then made by transfixion and cutting transversely outAvards, and, the soft parts being retracted, the bones are sawn across a little higher up. The resulting cicatrix is poste- rior and not adherent to the end of the bone. Bell1 reports five cases, in all of which there was complete and rapid recovery, Avith a useful stump. 4. Elliptic Posterior Flap (Guyon2). Figs. 6o and Q6, B. —The incision is made in the form of an ellipse, Avhose loAver end crosses the heel beloAV the in- sertion of the tendo Achillis, and Avhose upper end is about an inch above the anterior articular edge of the tibia. Beginning at the lower end and dividing the tendo Achillis at its insertion, and hug- ging the bone all the Avay, the flap is dissected up posteriorly as high as the upper end of the ellipse. The anterior muscles are then divided by transfixion, the bones saAvn through, and the posterior tibial nerve resected. In this operation the sheath of the tendo Achillis is not opened, Amputation of leg. a. Long and the tendon itself serves after- anterior flap. b. supra-maiieo- wards as a covering for the end of lar amputation by long posterior ^ b()ne< rphe retraction "of tne flap, Guyon. C. At the upper . third siduiot. muscles ot the call tends, m course 1 Manual of Surg. Operations, 3d ed. p. 85. Fdinburg, IS74. 2 Bulletins de la Sociele de C'hirurgie, 1SGS, page 337. AMPUTATION OF THE LEG. 121 of time, to draw the cicatrix doAvmvards and backAvards, and Faraboeuf has proposed to meet this tendency by carry- ing the anterior end of the ellipse still further up the leg, so that that Fin. 66. part of the incision through the skin shall be an inch or so above the line of division of the bones and anterior muscles. B. Middle Third.—1. Long an- tenor curved flap. 2. Long anterior rectangular flap (Teale). 3. Long posterior rectangular flap (Lee). 4. Simple posterior flap. 1. The long anterior curved flap is made according to the method de- scribed for its use in the loAver third. The principal points to be borne in mind are to separate the anterior muscles from the interosseous mem- brane >vith the finger or handle of the knife, to make the flap long enough to fall over and cover the broad posterior surface of section Avithout tension, and to saAV off ob- liquely the prominent angle made by the crest of the tibia. 2. Long Anterior Recfant/ular Flap (Teale).1 Fig. 64, B.—From each end of the transverse diameter of the leg at the point at which the bones are to be divided an incision, equal in length to half the circum- ference of the,leg at that point, is made doAvmvards and slightly back- Avards, so that the tAvo shall be as far apart at their loAver as they are at their upper ends, measuring across the front of the leer. Their lower Amputation of the leg and at the knee. A Long poste- rior rectangular flap, Lee. B. Supra-malleolar, Guyon. C. At the upper third, SeMillot. D. Disarticulation at the knee, oval incision. 11 1 See also page 90. 122 AMPUTATIONS. extremities are then united by a transverse anterior incision carried through to the bones and interosseous membrane. The flap thus marked out is dissected up to its base, the separation from the interosseous membrane being made Avith the finger or handle of the knife so as not to injure the anterior tibial artery. A posterior flap, one-fourth the length of the anterior one, is next cut by a transverse incision straight down to the bones, and dissected back to the same point, the inter- osseous membrane divided, the bones cleaned and saAvn through. The long flap is then doubled back upon itself, its lower end seAved to that of the posterior flap, and the edges of the lateral incisions fastened together. 3. Long Posterior Rectangular Flap (Lee). Fig. QQ, A.—The incisions are similar to those used in Teale's method, but they involve only the skin, and the long flap is posterior, the short one anterior. The remainder of the operation is described as folloAvs:1 "When the skin had somewhat retracted by its natural elasticity, an incision Avas made through the parts situated in front of the bones, Avhich were reflected upAvard to a level with the upper extremities of the first longitudinal incisions. The deeper structures at the back of the leg were then freely divided in the situa- tion of the loAver transverse incision. The conjoined gas- trocnemius and soleus muscles Avere separated from the subjacent parts and reflected as high as the anterior flap. . . . . The deeper layer of muscles, together Avith the large vessels and nerves, Avere divided as high as the incisions would permit, and the bones sawn through in the usual Avay. The flaps Avere then adjusted in the manner recommended by Mr. Teale. " The long flap thus formed is thicker than when taken from the front of the leg, and consequently less liable to slough." In muscular subjects and Avhen amputating high up, it is sufficient to retain the gastrocnemius alone. 4. Single Posterior Flap.—When the muscles have be- come atrophied a single posterior flap may be safely made. 1 Medical Times and Gaz., June 3, 1865. AMPUTATION OF THE LEG. 123 A transverse incision is made across the front of the leg from the posterior edge of one bone to that of the other, and a long posterior flap cut from Avithin outAvards, by trans- fixion. Its length should be equal to the diameter of the leg at its base. C. Upper Third. (" Place of Election.")—-The bones should never be divided above the attachment of the liga- mentum patellae to the tuberosity of the tibia, and it is better to divide tAvo inches beloAV it, when possible, so as not to open the sheaths of the flexor muscles of the thigh. Baron Larrey preferred to make the section obliquely upAvards and backAvards, beginning at the middle of the attachment of the ligamentum patellae. He claimed that this could be done Avithout opening the knee-joint, and that the greater vitality of the spongy tissue made recovery more rapid. The head of the fibula should not be removed, because in a certain proportion of cases the upper tibio- fibular articulation communicates Avith that of the knee. The circular and the various flap methods may be employed. 1. Circular.—At a distance beloAV the point at Avhich the bones are to be divided one inch greater than half the diameter of the leg at that point, an incision involving only the skin is begun upon the anterior aspect and carried around the leg, crossing the posterior aspect half an inch loAver than in front. After dissecting the skin upwards for a short distance the gastrocnemii and part of the soleus are diAided transversely, and the dissection, including the parts thus divided, carried up to the line of division of the bones, where the remaining muscles and the interosseous mem- brane are then divided transversely, a three-tailed retractor applied, and the bones sawn through. 2. The long rectangular and the single anterior and posterior flaps, described for the middle third, are also applicable here. The directions already given in the pre- ceding section are sufficient. 3. External Flap (Sedillot). Figs. 65 and Q6, C—The point of the knife is entered a finger's breadth external to the crest of the tibia, carried backwards and upwards, grazing the fibula, and brought out posteriorly as far to the inner side as possible, and at a point an inch higher than that at Avhich it Avas entered. While the soft parts are 124 AMPUTATIONS. draAvn tOAvards the outer side Avith the left hand, a gently- rounded flap, four finger-breadths in length, is cut, and its extremities aftenvards united by an incision slightly convex downwards, across the front and inner side of the limb, involving the skin only, which is then reflected, and the anterior and remaining posterior muscles divided trans- versely at its base. The operation is completed by the division of the bones in the usual manner, and by carefully stitching the edges of the flaps together, leaving the pos- terior angle open for drainage. 4. Modified Flap (Bell). Fig. 24, C.—Two equal semi- lunar flaps of skin three inches long, one antero-external, the other postero-internal, their extremities meeting at opposite points about two inches beloAV the tuberosity of the tibia. These must be reflected up, and Avith them another inch of skin, embracing the Avhole circumference of the limb, must be dissected up. The anterior muscles must be cut as high as exposed, and the posterior ones about the middle of their exposed surface. The bones must then be saAvn as high as exposed, the fibula being finished first, and the sharp prominence of the edge of the tibia removed. COMPARISON OF THE DIFFERENT METHODS. Amputation in the lower third is less fatal than amputa- tion at a higher point, and gives better command of the limb, but the coverings of the stump are liable to be too thin and tender. The circular and double-flap methods give central cicatrices and stumps that can bear no Aveight upon their face, and are sometimes so sensitive that even the pressure of a stocking can hardly be borne. Guyon's long posterior flap taken from the heel promises Avell; in the first case reported the cicatrix, six Aveeks after the ope- ration, was tAvo inches above the end of the stump, upon which forcible pressure could be made Avithout causing any pain.1 1 In a letter to me, dated June, 1877, Prof. Guyon states that he has amputated four times by this method, and has every reason to be satisfied with the result. The patients bore their weight upon the stump as freely as upon the other foot. Two cases are reported in the Bull, de la Soc. de Chirnrgie, 1877, p. 321.—L. A. S. AMPUTATION AT THE KNEE. 125 The long anterior flap also yields a cicatrix which is placed posteriorly and out of the way of pressure, and in short it may be said that the reasons which made the upper third the place of election have lost their force since ampu- tation by a long single flap has been shown to be practicable at any point. In the middle and upper thirds Teale's method has proved very satisfactory, but it requires division of the bones at a higher point than is necessary in the single anterior flap. Lee's modification of the posterior flap has removed the dangers due to the redundancy of muscle and the presence of the main nerves and vessels in the flap, while careful dressing and attention to posture will diminish or entirely remove those clue to the posterior position of the flap and its mechanical defects. After amputation in the upper third the weight of the body may be borne upon the tough skin below the patella, the patient kneeling upon his artificial leg; or the stump may fit into the holloAv end of an artificial limb, the upper edge of Avhich will receive the weight from the lower edge of the patella and the broader bony surfaces near the joint. In either case motion at the joint is preserved, and there is no pressure upon the cicatrix. AMPUTATION AT THE KNEE. Under this head are ranged pure disarticulations and amputations through the condyles of the femur. In dis- articulating, the lateral and crucial ligaments should be divided near their attachments to the femur, and the semi- lunar cartilages removed. The coats of the popliteal vein are unusually thick and stiff, and its relations to the artery are so intimate that the pulsations of the latter are liable to be communicated to it and to lead to secondary venous hemorrhage, unless the tAvo vessels are separated upAvards for about an inch. A. Disarticulation. Oval Method (Baudens). Fig. 66, D.—An OAral incision crossing the front of the leg five finger-breadths below the end of the patella, and the back 11* 126 AMPUTATIONS. Fig. 67. three finger-breadths higher than in front, is made through the skin, and the anterior flap, including the flexor tendons on the inner side of the tibia and their fibrous connections, dissected up and reflected until the lower end of the patella is exposed. Then flexing the leg the operator divides the ligament immediately below the patella, and Avith it all the anterior part of the capsule. He next divides the lateral ligaments and then the crucial liga- ments, taking care not to injure the popliteal vessels Avith the point of his knife. The tibia is then draAvn forward, the knife passed through to the posterior border of the joint, its edge directed doAvmvards, and the remaining soft parts divided from within outAvards. If necessary the popliteal artery can be compressed by an assistant in the flap behind the knife before its division. Long Anterior Flap. Fig. 61, A. —A tongue-shaped flap is marked out by an incision beginning half an inch beloAV the line of the arti- culation nearly as far back as the posterior border of the condyle on one side, and ending at the cor- responding point on the other, after crossing the leg five inches below the patella. A transverse poste- rior incision unites the sides of the first an inch beloAV its ends. The flap is dissected up and the disarti- culation completed as before. Amputation at the knee and -r-. -r» tti \*t i , • t , i lower third of thigh, a. ms- Dr- R- F- Weir has noticed that articulation, long anterior flap, the lateral synovial bands favor b. Amputationthroughthecon- retention of the discharges in the dyles.Carden. C. Modifiedflap synovial enl dp <, C). While the soft parts are re- tracted, and after the bone has been cleared circularly, he elevates the femur so as to project it fully, and divides it tAvo inches above the base of the flap. AMPUTATION AT THE HIP-JOINT. The affections Avhich render this most serious operation , necessary are often of such a nature that the surgeon's choice of a method of performing it is greatly restricted; 132 AMPUTATIONS. he must take his flaps where he can get them, and must regulate his incisions by existing lesions. Moreover, the problem is not to obtain a flap that will bear pressure, but to remove the limb in the manner that involves the least risk to life. This risk, Avhich has proved very great, is due not only to the gravity of the lesions Avhich render surgical in- terference necessary, but also to three causes Avhich origi- nate in the operation itself. These are loss of blood, shock, and septicaemia; the first tAvo being together responsible for about as many deaths as the third. The opinion, held by many, that the amount of shock varied directly Avith the length of time employed in remov- ing the limb, led to the introduction of operative methods characterized by extreme rapidity of execution, not more than thirty seconds being alloAved for the removal of the limb from the body; the type of these is the method by a long anterior flap made from Avithin outAvards by transfixion. To prevent hemorrhage many expedients have been em- ployed : the same rapidity of execution; compression of the femoral artery upon the pubis, or Avithin the flap by an assistant who passes his fingers into the Avound behind the knife; compression of the aorta; preliminary ligature of the femoral artery; ligature of each vessel Avhen encountered in the wound. The hemorrhage most to be feared is that from the numerous vessels of the posterior segment of the thigh, for, Avhile the femoral artery can usually be controlled without much difficulty, there is no way of preventing the floAv of blood from the others except by compression of the aorta through the Avails of the abdomen, or of the internal iliac through the rectum. There is no record that the latter deArice, first suggested as a means of hemostasis during ope- ration for gluteal aneurism, has ever been employed in an amputation; and compression of the aorta, although effectual and entirely harmless in some cases, has proved dangerous or impracticable in others1 by exciting peritonitis or inter- fering with respiration. In a Avell-written paper read before the Academie de M6de- 1 See Erskine Mason, Two successful Cases of Amputation at the Hip-joint, K. Y. Med. Jovm., Dee. 1876. AMPUTATION AT THE HIP-JOINT. 133 cine, 30th October, 1877, Prof. Yerneuil1 reported four disarticulations at the hip-joint performed by himself, and expressed himself strongly in favor of " operating as if for the removal of a tumor," that is, by cutting from without imvards, and tying each vessel when it is encountered ; by this means he thinks the proportion of deaths occurring Avithin the first feAV hours or days as the result of hemor- rhage or shock (which last, by the Avay, he thinks is itself largely the result of hemorrhage) could be greatly dimin- ished. The third cause of fatal results, septicaemia, Avas thought by Verneuil to be engendered especially by the retention of decomposing secretions in the anfractuosities of the wound, a retention Avhich the ordinary means of drainage cannot prevent; and as the tAvo methods of dressing wounds Avhich claim to prevent decomposition of the secretions, Lister's and Guerin's, cannot be properly applied to so short a stump, Verneuil sought to overcome the difficulty by leaving the Avound open and not placing any sutures, in order that the drainage might be free, and also by dressing the Avound Avith some antiseptic. For the sake of drainage he rejected the anterior flap and the modified oval methods, and gave the preference to the lateral flaps, or, still better, the so-called " anterior oval," in which the raAv surface is directed fonvard. The dressing was as folloAvs: 1st, a layer of small pieces of tarlatan covering the entire raAv surface ; 2d, a thick layer of charpie saturated Avith an antiseptic solution, alcohol, carbolic acid, or camphor; 3d, a layer of cotton batting covered Avith oil silk, and a simple retaining bandage. The cotton is turned back several times during the day, and the lint moistened Avith the disinfecting solution. The position of the joint may be determined by that of the anterior inferior spine of the ilium, Avhich is three- quarters of an inch above its upper margin. Anterior Oval Method (Verneuil2).—The patient having been anaesthetized and placed upon the table, an Esmarch's 1 Bulletin de PAcad6mie de Medecine, 187 7, p. 1132. 2 Ibid., p. 1159. 12 131 AMPUTATIONS. elastic band is applied from the toes as far upAvard as is allowed by the nature of the lesion and the line of the pro- posed incision. 1. An incision, beginning a finger's breadth beloAV Pou- part's ligament, is carried doAvn along the course of the femoral artery for about tAvo inches ; thence outwards and doAvmvards, crossing the great trochanter near its base, to the gluteal fold ; thence transversely along this fold to the inner side of the thigh, and thence obliquely upwards two full finger-breadths beloAV the genito-crural fold to the point Avhere it diverged from the line of the artery. The incision should involve only the skin and the cellular tissue ; any vessels that are divided should be immediately tied. 2. The sheath of the vessels is'opened, the artery isolated and denuded, and its point of bifurcation determined. A ligature is then applied methodically to the vessel above the origin of the profunda, and a second, lower doAvn, including both branches en masse, and the artery divided betAveen them. The femoral vein is also carefully denuded and divided betAveen tAvo ligatures at about the same level. Verneuil considers the ligature of the femoral vein indis- pensable, but it must be done with the utmost care and gentleness, in order that the phlebitis may remain limited to as small a portion of the vessel as possible. 3. The incision is carried doAvn through the muscles, beginning on either the outer or inner side, as is most con- venient ; on the inner side, after having cut through the adductors at the junction of their fleshy and tendinous por- tions, seek and tie the obturator vessels, divide the pectineus and psoas on a line Avith the neck of the femur, and secure all the bleeding points. On the outer side, divide the sartorius and the fascia lata, and then adduct the thigh so as to throAV the great trochanter fonvard and facilitate the division of the muscles attached to it. 4. Open the articulation in front and divide the posterior portion of the capsule as close as possible to the femur, together Avith the remaining tendons that are inserted in the great trochanter. 5. Division of the posterior segment of the limb. De- press the thigh beyond the border of the table, so as to make the Avound gape Avidely, and divide the remainder of AMPUTATION AT THE HIP-JOINT. 135 the adductors and the muscles attached to the ischium Avith gentle strokes of the knife, tying each vessel Avhen it is recognized or divided. It is Avell also to resect the extre- mity of the sciatic nerve. The resulting wound is conical and gapes widely, for, notAvithstanding the laxity of the tissues, there is not enough material left to alloAV the sides of the Avound to be brought together Avithout undue tension, if the surgeon should Avish to do so. Verneuil considers this a positive advantage, for not only does cicatrization go on rapidly, but septicaemia is less likely to occur in a Avell-exposed Avound from Avhich the secretions escape freely. Circular Method.—The patient lying upon his back Avith his thigh overhanging the end of the table, a circular inci- sion is made through the skin, six inches beloAV the anterior superior spine of the ilium, the skin retracted, and the muscles divided successively at higher levels, until the femur is reached. The capsule is then divided in front and on the sides, close to the edge of the cotyloid cavity, the head of the femur dislocated forwards, the knife passed behind it, dividing the ligamentum teres, the remainder of the cap- sule, and the muscles attached to the neck and trochanter. Anterior Flap.—The position of the patient being the same, and the thigh slightly flexed and abducted, the point of a long amputating knife is entered midAvay betAveen the anterior superior spine of the ilium and the top of the great trochanter, and passed imvards and backwards to a point one inch beloAV and in front of the tuberosity of the ischium, grazing the anterior surface of the neck of the femur, and certainly opening the capsule of the joint if its edge is kept turned obliquely toAvards it. (The direction may be reversed for the right thigh, the knife being entered on the inner side.) A Avell-rounded flap ending at the junction of the upper and middle thirds of the thigh is then cut with rapid saw- ing movements of the knife, and reflected upAvards. The limb is forcibly depressed, and if the capsule has been Avell divided this movement Avill throAV the head of the femur fonvards out of the socket; if not, a single cut Avith the 136 AMPUTATIONS. knife across the head of the bone will free it. The leg is then rotated imvards so as to bring the trochanter fonvards, the surgeon passes the knife behind the head of the bone and cuts a short posterior flap from Avithin outwards. Prof. Van Buren divided the posterior segment from without inwards by a sweep of the knife as in a circular amputation, and then disarticulated and divided the rotator muscles with a scalpel. In the flap operation by transfixion the assistant who compresses the artery against the pelvis Avith one hand should folloAV the knife Avith the other, and grasp the vessel in the flap betAveen his fingers and thumb, and his control of it should be such that the surgeon can give his attention first to securing the numerous vessels of the posterior seg- ment, the bleeding from which may be partly checked by pressure Avith dry sponges or cloths while the ligatures are being applied. Or the bleeding points may be caught up rapidly with artery forceps, and the ligatures not applied until after all have been thus secured. Modified Oval Method. Fig. 68, D.—The patient is laid upon his side, his hips at the foot of the table. A straight incision three inches long is begun one inch above the sum- mit of the great trochanter, and carried along its posterior border, and a circular incision is then carried from the loAver end of the first around the thigh, passing three inches beloAV the tuberosity of the ischium. These incisions should interest the skin only, their borders should be dissected up for about an inch, and the muscles of the outer aspect divided obliquely upAvards tOAvards the joint. In front this division should not be carried beyond the outer edge of the rectus muscle, but posteriorly it should be as extensive as possible and close to the bone. The thigh being flexed and adducted, the capsule is opened, first longitudinally on the finger as a guide, then fonvards and backAvards along the edge of the cotyloid cavity, the head of the femur dislocated backwards and outAvards, the knife passed around it and brought doAvn along the inner side of the bone nearly to the level of the circular incision, and then made to cut its Avay rapidly out on the inner side. PART IV. EXCISION OF JOINTS AND BONES. Excision of a joint may be (1) complete or (2) partial. In the former case the articular ends of all the bones composing it are removed; in the latter, one or more are retained. Again, partial excision may consist of (1) par- tial or (2) total resection of the articular end of one of the members of the joint. The former is ahvays unadvisable; the latter, to Avhich Oilier1 has given the name of semi- articular resection, has given good results in traumatic cases. Partial excision is seldom employed for disease except at the shoulder and hip. Excision of a bone may be total or partial, and, in the case of the long bones, with or Avithout either or both epi- physes. The term resection is often employed in this connection as a synonym of excision. In the narroAver sense it refers to the removal of a portion of a bone, including hoAvever its entire thickness ; thus, a joint is excised by the resection of the bones composing it. Joints are excised on account of injury, disease, or an- chylosis in a faulty position; and Avith the object of obtain- ing a movable joint, as in the upper extremity, or anchylosis, as at the knee and ankle. The operative procedures may vary Avith these causes and these objects. Thus, Avhen anchylosis is sought for, the division of the muscles and tendons about the joint is of no moment; but if the joint is to be re-established, the muscles Avhich control its movements must not be disabled. In any case the main bloodvessels and nerves must be respected; the incisions, whenever prac- ticable, should be parallel to the long axis of the limb ; and 1 Congres Medical de France, 4th session, 1872, p. 224, and Bull. de la Soc. de Chirurgie, 1873. 138 EXCISION OF JOINTS AND BONES. Avhen it is necessary to divide a tendon or muscle, the line of section should be oblique rather than transverse, so as to favor re-union. The incisions should be sufficiently free to allow the bone to be thoroughly inspected Avith a vieAV to the removal of all the diseased portion. It is better to make a clean divi- sion Avith the saAV than to remove the bone piecemeal, but the use of the gouge is proper for the removal of small circumscribed areas of disease found upon the surfaces of section. Roughening of the outer surface of the bone due to healthy plastic processes must not be mistaken for caries. The synovial membrane does not require special attention. In cases of chronic thickening, Avhite SAvelling, etc., it is well to cut and scrape aAvay as much as can be conveniently removed, the remainder will take care of itself and not interfere with the process of repair. Spence recommends that it be washed Avith a solution of chloride of zinc, 1 to 30 or 40. The propriety of retaining the periosteum is still a sub- ject of discussion, and one in which the decision will pro- bably vary Avith the articulation and the circumstances of the case. Certain facts have, hoAvever, been already estab- lished. Its retention is a safeguard against injury to neighboring tissues during the operation; after excision of a bone it gives firmness to the cicatrix, diminishes the shortening of the limb, and insures the proper attachment of the muscles; and in the case of an articulation, if its relations with the capsule are maintained (periosteo-capsular excision), it favors the reproduction of the joint Avith arti- cular cartilages and ligamentary support. On the other hand, the reproduction of bone is not always desirable, and may be excessive or irregular, unduly limiting the motions of the joint, or even causing anchylosis ; and finally, the bruising received by the periosteum during the operation may cause it to slough, or the reproduction of bone may fail entirely. Von Langenbeck1 has shown that in excision of the shoulder-joint it is of the utmost importance to preserve the relations of the periosteum, the capsule, and the tendons Archiv fur Klinische Chirurgie, vol. xvi. EXCISION OF JOINTS AND BONES. 139 of the capsular muscles, but in all other joints, except per- haps the hip, the importance is not so great, or, at least, so Avell established. Complete restoration of the shoulder- joint and re-establishment of the control of the muscles over it has never been accomplished except by the subperiosteal method. The periosteum can be removed Avithout difficulty except Avhen it is actively inflamed; its connection Avith the bone is very slight in cases of chronic osteitis and synovitis. The tendons, on the other hand, are so firmly attached to the bone that the elevator, or rugine, is sometimes insuffi- cient to remove them properly, and the knife must then be used, its edges being kept as close as possible to the bone. Von Langenbeck goes so far as to say that the success of a periosteo-capsular excision depends in great part upon the proper alternation in the use of the knife and elevator. As a general rule, to Avhich there are feAv exceptions, the articular ends of all the bones forming the joint should be entirely removed ; any articular cartilage that is left is almost certain to become necrotic and fall off in shreds, Avhich act as foreign bodies in the Avound and prolong the period of suppuration. The exceptions to this are found in some traumatic cases (Oilier, Hueter), and in the hip and shoulder; the cotyloid and glenoid cavities should not be interfered Avith unless actually diseased. Excision of single bones may be required on account of injury or disease. The latter is by far the most common cause, and its most common examples are caries of the small spongy bones and necrosis of the long ones due to acute osteomyelitis or periostitis. The incisions should be made from the side Avhere the coverings of the bone are feAvest and of least importance ; the periosteum should be left be- hind, and all the diseased bone should be removed. When the entire shaft of a bone has become necrotic, it must be divided with the chain saAV or cutting pliers, and each piece pulled or cut away from its epiphysis. The term evidement de Vos has been given by the French Avriters to a procedure upon Avhich Se'lillot attempted to establish a method of treatment. It consists in the removal by the gouge of all the central portion of a carious spongy bone, an epiphysis, or even the shaft, leaving only the pre- sumably healthy shell attached to the periosteum. Although 140 EXCISION OF JOINTS AND BONES. it has proved faulty as a method, it is a useful adjunct to excision. In cutting doAArn upon carious bone or a sequestrum it is well to keep a probe in the sinus leading to it, as it is some- times very difficult to find the hole in the bone after the blood has begun to Aoav. MAJOR ARTICULATIONS. EXCISION OF THE SHOULDER-JOINT. As formerly performed, excision of the shoulder-joint Avas an operation the results of Avhich, to quote Holmes,1 were " probably inferior—certainly not superior—to those of natural anchylosis." If anchylosis did not folloAv, the joint Avas loose, under slight control, and, at the best, could not be raised above the horizontal line. During the last ten or fifteen years, hoAvever, Oilier2 and Von Langenbeck3 have shoAvn that the periosteo-capsular method furnishes a much larger measure of success. In a case operated upon by the former Avhere four inches of the humerus Avas removed, the ultimate shortening was only half an inch, and the motions Avere quite full; and the latter reports several cases in Avhich the arm could be raised to the vertical line, and the control of the limb Avas perfect. In all of Von Langenbeck's cases the operation Avas undertaken on account of gunshot injury. As the capsular muscles are attached to the greater and lesser tuberosities, the capsule and periosteum must be divided betAveen these tAvo bony prominences, that is, in the direction of and near to the tendon of the long head of the biceps. An anterior incision beginning at the acromio- coracoid triangle is the best one for this purpose, and has, moreover, the advantage of sparing the posterior circumflex ■ artery and nerve. The cephalic vein lies in the groove betAveen the deltoid and pectoral muscles, and is avoided by making the incision incline outAvards. When the soft 1 Surgery, its Principles and Practice, p. 929. Lea, Phila., 187G. 2 Traite de la Regeneration des Os, and Des Resections des Grandes Articulations. 3 Archiv fiir Klinische Chirurgie, vol. xvi. EXCISION OF THE SHOULDER-JOINT. 141 parts are much thickened and consolidated, this incision needs to be supplemented by a short transverse one (Fig. 60, B) running outAvards from its upper end parallel to and just beloAV the edge of the acromion, dividing the fibres of the detoid transversely in its course ; sometimes the condi- tion of the parts is such, and the sinuses so placed that a large external flap, Avith its base directed upAvards, has to be made by a triangular or curved incision, and raised up so as to freely expose the outer aspect of the head of the humerus. In any case the trunk of the posterior circumflex artery should be spared. It is imbedded in loose cellular tissue, and Avhen cut may retract so far that a ligature can- not be easily placed upon it. The condition of the glenoid cavity seems to affect the prognosis seriously. In eight fatal cases collected by Hodges,1 it had been interfered Avith in all but one. Con- sequently it should not be touched unless actually diseased, and the interference should, if possible, be limited to the use of the gouge. Spence makes a counter-opening behind for drainage, but this seems to be unnecessary. Operation (Oilier). Fig. 60.—The arm is abducted and rotated imvards. The point of the knife is entered at the beak of the coracoid process, and carried four inches doAvmvards and out- Avards in the general direc- tion of the fibres of the del- toid, or as much further as may be necessary. The incision thus made Avill be external to the inner border of the deltoid, and should comprise all the tissues doAvn to the bone. The edges of the Avound are held apart Avith retrac- tors, and the capsule and . t • -i -i Excision of the shoulder (Oilier). A. periosteum are divided Regular incision. B. Supplementary. 1 Excision of Joints, Boston, 1861. 142 EXCISION OF JOINTS AND BONES. along the outer edge of the tendon of the long head of the biceps and the bicipital groove to the full extent of the ex- ternal incision. The outer edge of the incision is raised, and the periosteum, together Avith the capsule and tendons of the muscles inserted upon the greater tuberosity, is care- fully detached Avith the elevator and knife, while an assistant rotates the arm inwards to increase the extent of and facili- tate the dissection. The tendon of the biceps is then raised from its groove and held out of the way, the arm rotated outAvards, and the periosteum, capsule, and tendon of the subscapular dis- sected off in the same Avay on the inner side. The head of the humerus is then dislocated fonvards, the posterior attachments of the capsule separated Avith the elevator or knife, the periosteum peeled off the posterior face of the neck and shaft of the humerus, and the bone saAvn through transversely Avith an ordinary or a chain saw. If the articular surface of the glenoid cavity is affected, it must be scraped ; if the bone itself is diseased, it should be gouged out until healthy bleeding bone is reached, or the neck may be cut through with strong cutting pliers after removal of its periosteum. Von Langenbeck's method differs slightly from the above. He begins his incision at the anterior border of the acro- mion just outside of the acromio-clavicular junction, and carries it directly doAvmvards, the arm being so held as to bring the outer condyle of the humerus in front. This sacrifices the inner fibres of the deltoid by severing their nerves. He carries the incision through the muscle doAvn to the capsule and bone, then raises the sheath of the ten- don of the biceps, Avhich presents in the line of the incision, with pronged forceps, and opens it carefully from Avithout imvards. As soon as the shining tendon is seen he slits the sheath throughout the entire length of the incision, opening the capsule quite up to the acromion, and exposing the articular end of the humerus Avith the tendon lying upon it. He then raises the periosteum on the inner side until the lesser tuberosity is reached, lays aside the elevator, and EXCISION OF THE ELBOW-JOINT. 143 peels off the tendon of the subscapular with knife and pronged forceps, taking the greatest pains to maintain its relations with the capsule and periosteum. After this dis- section has been carried as far as possible on the inner side, he lifts the tendon of the biceps from its sheath, carries it inwards, drops it into the joint, and denudes the bone on the outer side Avith the same precautions, using the knife instead of the elevator to detach the capsule, tendons, and ligaments. The rest of the operation as above. If only the articular head of the bone is to be resected, near the upper end of the tuberosities, there is no perios- teum to be removed. The ligamentous and muscular at- tachments are approached from Avithin the joint, and the bone divided Avith the chain or key-hole saw, without rais- ing it from its place. By a Transverse Incision. (Nelaton, Pen-in.) ■—A transverse incision three and a half or four inches long is made parallel to and half an inch below the edge of the acromion, beginning in front betAveen it and the coracoid process. The fibres of the deltoid are divided close to the acromion, and by their retraction expose the capsule largely. The capsule is divided along the outer edge of the tendon of the biceps, and then transversely in the direction of the external Avound; the bone is approached and denuded through this opening, and the operation completed as before. The vessels and nerves are Avell protected by this method, but it is very difficult of execution. Excision of the Head of the Scapula.—When the disease is confined to the glenoid cavity and the neck of the scapula, the affected parts can be removed by a longitudinal posterior incision extending from the base of the acromion to the fold of the axilla. EXCISION OF THE ELBOAV-JOINT. Partial excision of the elbow-joint for disease, even Avhen the portions left behind are entirely healthy, is more dan- 144 EXCISION OF JOINTS AND BONES. gerous and gives less satisfactory results than complete ex- cision. The humerus should be saAvn through at or just above the epicondyles, the ulna at the base of the coronoid process, and the radius through its neck. The extent of the disease may make it necessary to surpass these limits, but the result will then be less perfect, and in any case every effort should be made to preserve the continuity be- tAveen the periosteum and the tendons of the brachialis anticus and biceps so as to provide for future flexion of the forearm. Reproduction of bone takes place less completely at the elbow-joint than at any other of the major articulations, and consequently the greater the amount removed the greater the danger of the formation of an imperfect, loose, and in- efficient joint, even when the subperiosteal method has been thoroughly carried out. Von Langenbeck1 removed four and a half inches of the humerus and tAvo inches of the ulna subperiosteally in a case of gunshot injury, and says the result Avas the worst he ever saAV, the connection be- tween the arm and forearm being so very loose that the patient Avas obliged to use a supporting brace, by the aid of Avhich he Avas able nevertheless to make excellent use of his hand. Ordinarily anchylosis is to be preferred to a very loose joint. In cases of gunshot injury Von Langenbeck and Oilier remove as little as possible, making a partial (semi-articular) excision when either the humerus or the bones of the fore- arm alone are injured. The English authors think the danger in cases of excision for disease is rather of removing too little than too much, and recommend that the humerus be saAvn through above the condyles. As the joint is covered anteriorly Avith soft parts, among Avhich lie nearly all the principal arteries and nerves, and is almost subcutaneous posteriorly, it must be approached from the latter side, and the incisions must be made with especial reference to the safety of the ulnar nerve, Avhere it runs betAveen the olecranon and the epitrochlear. The ori- ginal method, and the one used almost exclusively for many years, Avas the Il-incision, composed of tAvo longitudinal in- 1 Loc. cit., p. 443. EXCISION OF THE ' ELBOAV-JOINT. 145 cisions connected midway by a transverse one crossing the tip of the olecranon. It has the disadvantage of dividing the_ ulnar nerve or exposing it in the wound during the period of suppuration, and, having been superseded by less complicated ones, does not need to be described. Although excellent joints have been obtained by the old operations the preference should be given to the modern sub- periosteal method, not only on account of the greater cer- tainty of the re-establishment of a useful limb, but also because the danger of diffuse inflammation and purulent infiltration is much less Avhen it is employed. These dangers are greater at the elbow than at any other joint, except°the hip, and secondary amputation is more frequently required. The other methods have been devised with the vieAV of sparing the nerve, preserving the attachment of the triceps and the continuity of the lateral ligaments Avith the perios- teum, and facilitating the operation. Although the central longitudinal incision has been extensively used the prefer- ence seems noAV to be clue to methods of approach from the radial side, such as Ollier's, Nelaton's, and Hueter's. Central Longitudincd Incision. Fig. 70, A. (Von Langenbeck.)—The fore- arm being slightly flexed, a longitudinal incision 3 J inches long is made a little to the inner side of the median line of the triceps and ulna, and carried doAvn to the bone. The inner edge of the di\rided periosteum is raised from the ulna, the corresponding half of the ten- don of the triceps detached Avith it, and the dissection continued tOAvards the in- ternal condyle, the knife being kept con- stantly against the bone, and the flexion of the arm increased as the dissection advances. As the epitrochlear is ap- proached the greatest care is needed to preserve the connection between the pe- riosteum, the muscular attachments, and the internal lateral ligament, and it 13 Fip-. 70. Excision of the elbow- joint. A. Von Langen- beck. B. Oilier. 146 EXCISION OF JOINTS AND BONES. may be necessary to prolong the first incision upAvards so as to get more room. After the inner half of the joint has been thus laid open and the epitrochlear bared, the soft parts are replaced and a similar dissection made upon the outer side Avith the same precautions. The humerus is then dislocated backAvards through the Avound and sawn through at, or as near as possible to, the epicondyles, according to the lesion. If the condition of the soft parts does not alloAV of this projection of the humerus the chain or keyhole saw must be used. The ulna is then cleaned circularly as far as necessary and sawn through, and the head of the radius removed with the saw or cutting pliers. Oilier's Method.1 (Fig. 70, B.)—The forearm is slightly flexed, and an incision is commenced tAvo inches above the tip of the olecranon on the outer side of the arm at the interstice betAveen the triceps and supinator longus. This incision, involving the skin only, is carried doAvmvards to the epicondyle, thence dowmvards and imvards in the line of the upper border of the anconaeus to the olecranon, and thence, the point of the knife touching the bone, directly doAvmvards along the inner side of the posterior aspect of the ulna for one or tAvo inches. The fascia is then diAdded in the line of the incision, and the interstice betAveen the triceps on one side and the supi- nator longus, radial extensor, and anconaeus on the other, followed down to the capsule and bone. The capsule is opened, and the humerus denuded on its anterior and poste- rior faces as far inward as possible, care being taken to maintain the relations of the muscular and ligamentary attachments. The tendon of the triceps and the periosteum of the ulna are next detached, and in separating the former it is better to begin inside the joint at the free edge of the olecranon. The denudation of the external condyle and tuberosity of the humerus is then completed, and the external lateral b>a- ment entirely detached, the forearm flexed on its inner side, 1 Traite de la Regeneration des Os, p. 340. EXCISION OF THE ELBOW-JOINT. 147 and the end of the humerus dislocated outAvards into the wound, thus rendering the difficult dissection of the project- ing epitrochlear easier. When this latter has been com- pleted, the periosteum of the humerus is raised circularly to the proper height, and the bone saAvn through. The head of the radius is then removed, the denudation of the ulna completed, and the bone saAvn through perpendicularly to its axis. 71. \ i B Nelaton's Method. (Fig. 71, A.)—A longitudinal in- cision is begun on the outer border of the humerus betAveen the triceps and supinator longus, 1J inches above the end of the olecranon, and carried doAvmvards for a distance of 3 inches. A transverse incision cutting through to the bone is next made, from the lower end of the first, across the ulna to its inner border. The triangular flap thus formed, including the periosteum of the ulna, is dissected up, the external lateral and orbicular ligaments divided, and the head of the radius removed. The tendon of the triceps is detached and the denudation of the ulna completed. The ulna is projected through the incision by bending the forearm to- Avards its inner side, and is saAvn off. The humerus is then easily turned out through the incision, denuded from beloAV upAvards Avith the usual precautions, and saAvn off at the de- sired height. Excision of the elbow- joint. A. Nelaton. B, C. Hueter. Long Jiadial Incision (Hueter).1 (Fig. 71, B and C.) —A preliminary longitudinal incision, half an inch long, is first made directly down upon the tip of the epitrochlear, or rather on its anterior side, so as to avoid more surely the ulnar nerve Avhich lies close behind it, and the muscular 1 Deutsches Zeitschrift fur Chirurgie, 2d vol., p. 68. 148 EXCISION OF JOINTS AND BONES. attachments and the internal lateral ligament separated by cutting around this prominence. The main incision is then made by entering the knife above the point of the external epicondyle and carrying it straight doAvn over it, thus opening the joint and exposing the head of the radius by dividing the external lateral liga- ment longitudinally and the orbicular ligament transversely. The head of the radius is then removed after saAving through its neck. The operator then passes his left forefinger through the wound, first to the anterior surface of the humerus to make the capsule tense, and guide the detachment of it and the periosteum, and then along the posterior surface under the tendon of the triceps with the same object. It is not necessary to carry this dissection very far to- wards the inner side, because by dislocating the ulna forci- bly imvards the end of the humerus can be made to project through the radial incision, and then its denudation can be easily and safely completed, and the bone sawn through. The end of the olecranon is then brought into the centre of the incision, and the separation of the triceps begun at the upper free edge of the process Avith vigorous short cuts into the substance of the bone, so that it is, as it Avere, peeled out of its tendinous envelope. When the proper point is reached the bone is saAvn through. Partial Incision.—Ollier's and Hueter's methods are especially applicable to that form of semiarticular excision in which the loAver end of the humerus is resected. N61a- ton's or Von Langenbeck's, or the loAver part of Ollier's, can be used for the removal of the ends of the ulna and radius. EXCISION OF ANCHYLOSED ELBOAV. When there is anchylosis of the joint, Von Langenbeck's incision can be used, and the ulna divided Avith a chain saAV after it has been denuded. The detachment of the capsule and periosteum is then proceeded with upAvards, and the loAver end of the humerus, with the attached ends EXCISION OF ANCHYLOSED ELBOAV. 149 of the bones of the forearm, projected through the Avound and sawn off. Or either of the tAvo following methods may be employed. Excision of Anchylosed Elbow (Oilier).—An incision two and a half inches long is first made on the outer and posterior side of the limb and carried through to the bone, its centre being on a level with the tip of the olecranon. A second incision one and a half inches long, involving the skin only, is made on the inner side of the ulnar nerve at the level of the internal border of the humerus. The nerve is found on dividing the fascia, is draAvn aside together Avith the posterior lip of the Avound with a blunt hook, and is then entirely out of the Avay of injury. The lips of the two Avounds are separated, the periosteum detached, a narrow saAV passed under the triceps, and the humerus saAvn nearly through from behind forwards, leaving a thin shell of bone in front Avhich is then broken. The conditions are noAV those of a movable joint, and more or less of the loAver fragment or of each fragment is removed, according to the condition of the bone. The triceps should be detached before the olecranon is divided. Excision of Anchylosed Elbow (P. Heron Watson1).— This method is intended only for the removal of the arti- cular end of the humerus, in cases of more or less complete anchylosis folloAving injury. The advantages claimed for it are that it leaves the attachments of the triceps and brachialis anticus undisturbed, and limits the area of the operation almost exclusively to Avithin the capsular ligament, and thereby seems to secure a more speedy healing of the Avound. Watson has used it in six cases, in all of Avhich the results Avere satisfactory. 1. A linear incision is made over the ulnar nerve at the inner side of the olecranon. 2. The nerve is carefully turned over the inner condyle. 3. A probe-pointed bis- toury is introduced into the elboAV-joint in front of the hu- merus and then behind that bone, and carried upAvards so as to divide the upper capsular attachments in front and 1 Edinburgh Med. Journ., Mav, 1873, p. 986. 13* 150 EXCISION OF JOINTS AND BONES. behind. 4. A pair of bone forceps are next employed to cut off the entire inner condyle and trochlea of the humerus [from above doAvmvards], and then introduced in the oppo- site direction [from beloAV upAvards and outAvards] so as to detach the external condyle and capitulum of the humerus from the shaft. 5. The angular end of the humerus is turned out through the incision and saAvn off square. 6. The external condyle and capitulum are removed partly by twisting, partly by dissection, without any division of the skin on the outer side of the arm. If there is dense osseous union that cannot be overcome by flexion and extension under chloroform, the humerus must be divided through the condyle Avith bone pliers, and the operation completed as above. EXCISION OF THE AVRIST. In 1863 Prof. Lister Avas called upon to treat a case of compound fracture and dislocation of the Avrist in a youth of seventeen, in which the ends of the bones of the forearm projected one and a half inches through a Avound on the palmar aspect. He resected the ends of the bones and replaced the parts ; five months aftenvards the injured wrist Avas as useful and as freely movable as the other, although considerably smaller. Other surgeons had had a similar experience and had reported it,1 but to Prof. Lister belongs the credit of detecting the principle involved and of estab- lishing upon it a neAV and highly successful method of ope- ration, one Avhich has practically superseded all others. He has not formulated the treatment of traumatic cases, but in excision for chronic disease he advises the removal of all the carpal bones, except possibly the pisiform and the hook- like process of the unciform, and of the articular surfaces of those of the metacarpus and forearm if the bones them- selves are not more than superficially affected ; if on exami- nation they prove to be more deeply involved, he uses the cutting pliers and gouge freely. In one instance he hol- 1 Just: De resect, epiphys. cum deeap. radii exemplo., Leipzig, 1840. Yerbeeck, Bull de l'Acad. de Med. de Belgique, vol. iii. EXCISION OF THE WRIST. 151 loAved out the entire shaft of the third metacarpal bone, leaving it a mere shell, and the case did well. In his earlier operations he divided the radius and ulna trans- versely about an inch above the joint, but as these bones are usually affected but slightly, he now removes only a thin slice from the end of the radius, and cuts through the ulna obliquely, so as to take aAvay all the part that is covered Avith cartilage and leave the styloid process (Fig. 72). Fig. 72. Excision of the wrist, Lister. A. Beep palmar arch. B. Trapezlnm. 0. Arti- cular surface of ulna. The dotted lines iuclude the amount removed in the earlier operations ; the unshaded portions represent those removed when the disease is limited to the carpus. The principles involved in the treatment of traumatic cases, especially after gunshot injury, are not yet Avell established. Von Langenbeck1 inclines tOAvards primary excision Avhenever the injury is severe, and thinks it may safely be partial instead of complete. The exuberant growth of bone Avhich characterizes this locality occurs during con- servative treatment as Avell as after excision, and its inter- 1 Langenbeck's Archiv, vol. xvi. 4999999584 152 EXCISION OF JOINTS AND BONES. ference with the function of the member is likely to be even greater in the former than in the latter case. Posteriorly and laterally the wrist is covered only Avith skin and tendons, Avith no arteries or nerves of importance except the radial artery, Avhich winds around the outer side to pass again through the first metacarpal space to the pal- mar aspect of the hand, and form the deep palmar arch just below the bases of the metacarpal bones. BetAveen the extensor tendons of the thumb and of the forefinger exists a triangular interval, shoAvn in figure 73, the apex of Avhich is directed upAvard and lies near the middle of the dorsal aspect of the epiphysis of the radius. Within this space are found only the tendons of the long and short ex- tensores carpi radiales, Avith their insertions into the second and third metacarpals, and as experience has shoAvn that these tendons can be detached or divided without prejudice to the subsequent usefulness of the hand, the articulation can be safely approached through this space. The extensor tendons are lodged in deep grooves upon the surface of the radius from Avhich it is very difficult to raise them Avithout opening their sheaths, and therefore if it is necessary to take more than a thin slice from the bevelled end of the bone, it should be done Avith a gouge and as a late step in the operation. In this Avay it is possible to leave the tendons unhurt, and even unseen. On the inner side" the tendon of the extensor carpi ulnaris covers the ulna, in front of it passes the flexor carpi ulnaris on its Avay to its insertion into the pisiform bone and the base of the fifth metacarpal. The anterior aspect is occu- pied by the numerous and important flexor tendons, the median and ulnar nerves, and several arteries or arterial branches of considerable size. ToAvards the outer side the tendon of the flexor carpi radialis passes through a groove on the surface of the trapezium, to be attached beyond the base of the second metacarpal. An ulnar incision should pass betAveen the flexor and extensor carpi ulnaris at the anterior border of the ulna. Bilateral Incisions (Lister1). Figs. 73 and 74, A, B. —All adhesions are first broken doAvn by freely movin^ all 1 Lancet, 1865, p. 335, slightly abridged. EXCISION OF THE AVRIST. 153 the articulations of the hand. The radial incision is made in the situation indicated by the line L L in Fig. 73, or Fig. 74, A. It commences above at the middle of the dorsal aspect of the radius on a level with the styloid pro- cess. Thence it is at first directed toAvards the inner side of the metacarpo-phalangeal articulation of the thumb, run- ning parallel to the tendon of the extensor secundi inter- nodii; on reaching the radial border of the second meta- carpal bone it is carried doAvmvards longitudinally for half the length of the bone. Excision of the wrist, Lister. A. The radial artery. B. Extensor secundi in- ternodii pollicis. D. Ext. coinm. digitorum. E. Ext. min. dig. F. Ext. prim. int. pol. O. Ext. oss. met. pol. H. I. Ext. carp. rad. long, and brev. K. Ext. carp. uln. L, L. Line of radial incision. The soft parts on the radial side of the incision are next detached from the bones Avith the knife guarded by the thumb-nail, so as to divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal, and raise it along Avith that of the extensor brevior, previously cut across, and the extensor secundi in- ternodii, Avhile the radial artery is thrust someAvhat out- Avards. The trapezium is then separated from the rest of 154 EXCISION OF JOINTS AND BONES. the carpus by means of cutting forceps applied in a line with the longitudinal part of the incision. The removal of the trapezium is reserved till the rest of the carpus has been taken away. The soft parts on the ulnar side of the incision are now dissected up as far as is convenient, the extensor tendons being relaxed by bending back the hand. The knife is next entered on the inner side of the arm, two inches above the end of the ulna, immediately anterior to the bone, and is carried doAvnwards between it and the flexor carpi ulnaris, and on in a straight line as far as to the middle of the fifth metacarpal bone at its palmar aspect (Fig. 74, B). The dorsal lip of the incision is raised, and the tendon of the extensor carpi ulnaris cut at its insertion into the fifth metacarpal, and dissected up from its groove in the ulna, care being taken to avoid isolating it from the integuments, and thus endangering its vitality. The ex- tensors of. the finger are then readily separated from the carpus, and the dorsal and internal ligaments divided, but the connections of the tendons Avith the radius are purposely left undisturbed. The anterior surface of the ulna is then cleared by cut- ting towards the bone, so as to avoid the artery and nerve; the articulation of the pisiform is opened, if that has not been already done in making the incision, and the flexor tendons are separated from the carpus. While this is being done the knife is arrested by the process of the unciform bone which is clipped through at its base with pliers. The knife must not be carried further doAvn the hand than the bases of the metacarpal bones, so as not to injure the deep palmar arch. The anterior ligament of the Avrist-joint is divided, after which the junction betAveen the carpus and metacarpus is severed Avith cutting pliers, and the carpus extracted through the ulnar incision by seizing it Avith strong forceps and touching Avith the knife any ligamentous con- nections that may remain undivided. The hand being now forcibly everted the articular ends of the radius and ulna will protrude at the ulnar incision. If they appear sound or only superficially affected, the arti- cular surfaces only are removed. The ulna is divided ob- liquely with a small saAV, so as to take aAvay the cartilage- covered rounded part over Avhich the radius sweeps, Avhile EXCISION OF THE WRIST. 155 the base of the styloid process is retained. The end of the radius is then cleared sufficiently to alloAV a thin slice to be saAvn off parallel to the general direction of the inferior artieular surface, and the articular facet on the ulnar side of the bone is clipped aAvay Avith bone forceps. If, on the other hand, the bones prove to be deeply carious the pliers or gouge must be used Avith the greatest freedom. The metacarpal bones are next dealt Avith on the same principle. If sound only the articular surfaces are clipped off. The trapezium is next seized Avith forceps and dissected out, so as to avoid cutting the tendon of the flexor carpi radialis Avhich is firmly bound into the groove on its palmar aspect, the knife being also kept close to the bone elsewhere to preserve the radial artery. The articular end of the first metacarpal is then removed. Lastly, the articular surface of the pisiform is clipped off, the rest of the bone being left if sound. The process of the unciform is also left if sound. The radial wound may be closed with sutures, but the ulnar one must be kept open for drainage, and the limb must be bound upon a splint in such manner that while the Avrist is firmly fixed passive motion can be given regu- larly to the fingers. lladial Incision (Oilier). Fig. 74, C.— An incision involving only the skin is begun on the outer side of the Avrist an inch beloAV the styloid process of the radius and carried upAvards along the outer border of the bone for a greater or less distance according to the amount to be re- moved. A cutaneous branch of the radial nerve is exposed and drawn aside, the fascia divided, and the extensor ten- dons of the thumb recognized. These tendons are a guide which is easily found. They are superficial, and contained in a separate groove. On opening the sheath and drawing them aside, the insertion of the supinator longus is exposed, on the outer side of which, and parallel to the tendon, the periosteum of the radius must then be divided. Using a straight sharp elevator the surgeon next detaches the tendon of the supinator, preserving its relations Avith the periosteum, and then denudes the loAver end of the radius imvards, removing periosteum and capsule. Then, bending 156 EXCISION OF JOINTS AND BONES. the hand forcibly towards its inner side, he separates the remaining fibrous attachments and dislocates the loAver end of the radius outwards. The ulna can be protruded through Fig. 74. Excision of the wrist. A. Lister's radial incision. B. Lister's ulnar incision. C. Oilier. D. Von Langenbeck. the same wound and denuded from below upAvards, but it is better to make a longitudinal incision on the inner side for this purpose. The ends of the radius and ulna are then saAvn off, and through the gap thus left the carpal bones are successively removed with gouge and forceps. Dorso-radial Incision (Von Langenbeck). Fig. 74, D. —The hand is bent toAvards the inner side, and an incision is begun at the ulnar border of the second metacarpal bone near its middle and carried upwards four inches, crossing the ulnar edge of the tendon of the extensor carpi radialis brevior, Avhere it is inserted into the base of the third meta- carpal bone, and splitting the dorsal ligament of the Avrist exactly betAveen the tendons of the extensor secundi inter- nodii and extensor of the forefinger. This incision should be carried down to the bone, and the soft parts detached on EXCISION OF THE HIP-JOINT. 157 the radial side with an elevator; the tendons, where they lie in the grooves, are raised bodily with the periosteum, and their sheaths are not opened. The hand is flexed so as to make the first toav of carpal bones present in the wound ; the scaphoid is separated from the trapezium and taken out, and followed in turn by the semilunar and cuneiform, the interosseous ligaments being cut and the bones pried out Avith a small elevator. The trapezium and pisiform are left if possible. To take out the second toav the operator steadies the round articular end of the os magnum with the fingers of his left hand, and Avhile an assistant abducts the thumb he divides Avith a knife the connection betAveen the trapezium and trapezoid, passes the knife into the carpo-metacarpal joint, and cuts the ligaments on the dorsal side of the ends of the metacarpal bones Avhile an aid flexes them. In this way the trapezoid, magnum, and unciform can be brought out together. The lateral ligaments are then carefully separated from the radius and ulna, the bones protruded and sawn through. EXCISION OF THE niP-JOINT. In this joint, as in the shoulder, the disease is often con- fined to the head of the bone, and under such circumstances partial excision should be performed. When the acetabulum is diseased the loose pieces must be picked out, and the gouge applied to the roughened surface. The line of sec- tion of the femur should pass beloAV the great trochanter, however limited the disease may be, for if this process is left it is liable to protrude through the Avound and obstruct the escape of the secretions. If the disease extends be- yond this point additional slices must be removed, or the gouge used until healthy bone is reached. The anatomical disposition of the parts is such that the joint is best approached from the outer and posterior aspect, the incision passing over the top of the great trochanter. Different surgeons have inclined the upper part of the inci- sion forwards and backAvards at various angles, or have 14 158 EXCISION OF JOINTS AND BONES. Fk dissected up a triangular flap, its apex directed sometimes upwards, sometimes doAvmvards. Sayre's .Method. (Fig. 75, A.)—Enter the point of the knife midway betAveen the anterior superior spine of the ilium and the top of the great trochanter, and drive it doAvn to the bone ; then, keeping it firmly in contact Avith the bone, draAv it in a curved line to the top of the trochanter, midAvay betAveen its centre and posterior border, thence for- Avard and imvard, making the Avhole length of the incision from four to eight inches, according to the size of the thigh. Make sure that the periosteum is divided throughout. Then, draAving aside the soft parts, divide the periosteum transversely just opposite to, or a little above, the lesser trochanter, carrying the division as far as possible around the bone. Beginning at the angle formed by the tAvo inci- sions, raise the periosteum on each side together Avith its membranous attachment as far as the digital fossa. Then, substituting a knife for the periosteal elevator, divide the insertions of the muscles at this point, keeping close to the bone, and aftenvards separate the remaining pe- riosteum as far as can be done Avithout tearing it. Then adduct the leg slightly and raise the head of the femur gently out of the ace- tabulum; this Avill detach the last of the periosteum, and allow the finger to be passed around the bone as a guide for the saAV, Avhich should be applied just above the lesser trochanter. If the bone cannot be readily dislocated saw it through first, and then re- : ■ move the head with the Excision of the hip. A. Sayre. B. Oilier, forceps 01* elevator. ANCHYLOSIS OF THE HIP-JOINT. 159 If the acetabulum is perforated the edges must be chipped off very carefully doAvn to the point at Avhich the periosteum on the pelvic side is still adherent. Ollier's Method. (Fig. 75, B.)—Oilier makes a some- Avhat similar incision. It begins four finger-breadths be- Ioav the crest of the ilium, and the same distance behind the anterior superior spine, runs doAvnwards to the most prominent part of the great trochanter, and thence directly doAvn the shaft of the femur. Its upper part should involve the skin and fascia only. The posterior lip, including the glutaeus maximus, is drawn back, exposing the glutaeus medius, the fibres of Avhich are then separated Avithout cut- ting them. This permits the attachments of the glutaeus medius to be preserved, and the glutaeus minimus can be exposed by draAving apart the edges of the opening made in the other, and then divided in the same manner or drawn fonvard Avith a blunt hook. The capsule is split from the edge of the cotyloid cavity to the digital fossa, and detached together Avith the ten- dinous insertions. The head of the femur is dislocated backwards, the ligamentum teres dhdded, and the denuda- tion continued doAvmvards to the lesser trochanter. The bone is then protruded and saAvn off Avith a chain or common saw. ANCHYLOSIS OF THE HIP-JOINT.1 When the anchylosis is not associated Avith the loss of a great part of the head and neck of the femur, that is, Avhen it follows inflammation of the joint due to rheumatism, pyaemia, traumatism, or chronic disease that has been ar- rested at an early stage, Mr. Adams's operation of sub- cutaneous diArision of the neck of the femur is applicable, but Avhen there has been loss of the head and neck of the bone the difficulties in the Avay of performing this operation are so great that division below one or both of the trochan- ters is to be preferred. 1 This subject, which properly belongs under osteotomy, is placed here on account of its intimate relations with excision of the joint. 160 EXCISION OF JOINTS AND BONES. Division beloAV the lesser trochanter is only undertaken to remedy a faulty position of the limb, for there can be no question of establishing a neAV joint beloAV the insertion of the psoas and iliacus. It is doubtful also if a permanently Fig. 76. Subcutaneous division of the neck of the femur. movable joint can be obtained by division at a higher point; it certainly cannot unless a portion of the bone is removed, and probably not even then, for the tendency of the cut ends to unite after a time is very great. Subcutaneous Division of the Neck of the Femur (Adams1).—The only special instrument needed is a saw somewhat resembling a tenotomy knife, the cutting part being one and a half inches long and three-eighths of an inch wide, and the shank about two and a half inches long. (Fig. 77.) A tenotomy knife is entered a little above the top of the great trochanter and pushed straight in to the neck of the femur, dividing the muscles and opening the capsule freely. The soft parts being fixed by the thumb and fingers of 1 A new operation for bony anchylosis of the hip-joint with mal- position of the limb, by subcutaneous division of the neck of the thigh-bone, by William Adams. London, 1871. Leprinted from the British Medical Journal for December 24th, 1870. ANCHYLOSIS OF THE HIP-JOINT. 161 the left hand, the knife is AvithdraAvn and the saw passed promptly down to the bone through the track made by it. Fig. Adams's saw for subcutaneous division of the neck of the femur. The bone is then saAvn through from before backwards, so that the line of section shall be at right angles to the long axis of the neck, care being taken to avoid cutting obliquely through the neck, or in a direction parallel Avith the shaft of the bone. Maunder1 uses a chisel instead of the saAV, and divides the bone beloAV the trochanter. Operation for Establishment of a False Joint (Sayre).— A longitudinal incision six inches in length is made over the great trochanter, commencing just above its crest and as near as possible to its centre, and carried directly down to the bone. A transverse incision is then made through the skin and fascia only at the centre of the posterior lip of the first. The anterior surface of the bone is next cleaned Avith an elevator until the trochanter minor can be felt Avith the finger, the posterior surface similarly treated, and the chain-saAV passed just above this process. A curved section of the bone is made by saAving first upAvard and outAvard, then outward, and finally outAvard and doAvmvard. The saAV is passed a second time around the bone, and the loAver fragment di- vided transversely one-eighth of an inch beloAV the beginning of the first line of section. (Fig. 78.) The portion of bone thus removed is about three-fourths of an inch thick at its thickest part. Lines of section in Sayre's operation for anchylosis of hip-joint. Medical Times and Gazette, June 17th, 187G. 14* 162 EXCISION OF JOINTS AND BONES. Probably tAvo parallel sections one-half or three-quarters of an inch apart Avould ansAver equally well. EXCISION OF THE KNEE-JOINT. This should always be complete. It is recommended by Spence and some others that the patella should be retained if not diseased, but experience has shoAvn this to be unwise, for it does not add materially to the strength of the subsequent union, and the bone itself is likely to become carious. As anchylosis should ahvays be aimed at, the incision may cross the front of the joint and divide the ligamentum patellse. The original H incision has given place to others which involve less extensive injury of the soft parts, the one most commonly used being a curved one passing just below the patella. Some surgeons provide for drainage by mak- ing a dependent opening in the popliteal space, but this seems to be unnecessary. Fig. 79. Excisionof the knee-joint. A. Semilunar incision. B. Ollier's incision. Semilunar Incision. (Fig. 79, A.)—The knife is entered on one side of the limb at the posterior part of the condyle, and carried across midAvay betAveen the patella and the tuberosity of the tibia to a corre- sponding point upon the other side. This incision should extend down to the bone throughout, dividing the ligamentum patellae. The flap is re- flected, the crucial ligaments divided close to their attachment to the tibia, the lateral ligaments divided, the end of the femur cleared as far as may be necessary, with especial care for the safety of the popliteal vessels, pro- truded through the Avound, and saAvn off at the point indicated in Figs. 80 and 81. The line of section must b( EXCISION OF THE ANKLE-JOINT. 163 parallel to the line of the articulation, not at a right angle to the axis of the shaft, for that is directed inwards and doAvmvards. If necessary, additional slices of the bone are removed, or the gouge is used. All the articular cartilage should be removed. The end of the tibia is next projected, cleaned, and saAvn off about half an inch below its upper surface. In saAving the bones it is best not to make a complete section with the saw, but to stop a little short of the poste- rior surface and complete the separation by fracturing what is left. Finally, the patella is taken out, and diseased portions of the synovial membrane scraped or clipped off. Ollier's Subperiosteal Method. (Fig. 79, B.)—An in- cision is begun tAvo inches above and to the outer side of the patella, and carried doAvn to the upper and outer angle of that bone, thence along its outer edge and that of the liga- mentum patellae to and beyond the tuberosity of the tibia. If the subject is exceptionally muscular, or the internal con- dyle very prominent, the incision should be begun nearer the median line (Fig. 79, B'). The knife should penetrate to the bone throughout, and open the capsule of the joint. The periosteum of the outer condyle of the femur with the attachments of the external lateral ligaments and exter- nal gastrocnemius is next detached, and then the anterior surface of the femur cleared. The crucial ligaments are cut, and the patella carried over the internal condyle Avith the aid of blunt hooks. The leg is then bent baclovards and imvards, the end of the femur protruded through the Avound, cleared posteriorly, and sawn off. The upper end of the tibia is then cleared from above doAvmvards as far as may be necessary, and a slice taken off. If the patella is diseased he removes it, leaving the peri- osteum that covers its anterior surface. EXCISION OF THE ANKLE-JOINT. The results of excision of the ankle-joint have been, on the Avhole, so unfavorable that the English and German 164 EXCISION OF JOINTS AND BONES, surgeons are inclined to abandon it entirely. When the operation has been undertaken on account of caries, the dis- Fkr. 80. Fig. 81. Sections to show the position of the epiphyseal cartilage at the knee and the points at which the section ought to be made in excision. ease has usually returned in the tarsal bones, and rendered secondary amputation necessary. When, on the other hand, EXCISION OF THE ANKLE-JOINT. 165 it has been performed on account of injury, the mortality has been great, secondary amputation has been frequently required, and the position of the foot in the cases that re- covered has usually been faulty. The results of conservative expectant treatment have been no better, and, in part, for the same reasons. In corre- spondence, as has been pointed out, Avith the late consolida- tion of the epiphysis, inflammation of this extremity is likely to be severe, and its destructive results extensive; the re- production of bone is also very abundant and leads almost necessarily to anchylosis, so that, unless great attention is given to maintaining the foot in a proper position during the whole period of treatment, it will unite at a faulty angle with inversion or eversion of the sole, and inability to sup- port the Aveight of the body. As anchylosis is to be expected, the rule in excision is to remove the smallest possible amount of bone, and to make partial instead of complete excision Avhen the disease does not extend to the Avhole joint. The retention of one or the other malleolus is a great help in preventing shortening and in the use of a plaster splint. The interosseous membrane between the Fig. 82. tibia and fibula must be preserved carefully. It not only has a great tendency to ossify, but also seems to favor the reproduction of bone. Operation (total excision).—An incision involving only the skin is begun tAvo inches above the exter- nal malleolus and a little behind the middle of the fibula, carried directly doAvn to the end of the bone, and thence fonvards and slightly up- wards toAvards the instep for an inch (Fig. 82). The periosteum covering the fibula is divided throughout and dissected up from the bone Avith the attachment of the lateral ligaments, especial care be- ing taken not to open the sheath of the peroneal muscles at the poste- 166 EXCISION OF JOINTS AND BONES. rior border of the malleolus, and to remove all the thick periosteum and the interosseous membrane on the inner side. If necessary, a transverse liberating incision may be made through the periosteum at the upper end of the cut. The bone is then divided Avith a keyhole or chain saAV, the upper end of the loAver fragment draAvn out of the wound to expose and facilitate the separation of the remaining attachments, and the piece removed. The soft parts are then held out of the Avay Avith retrac- tors, and the upper articular surface of the astragalus saAvn off Avith the keyhole saw, but not remoA^ed. The foot is next turned upon its outer side, and a longi- tudinal incision tAvo or three inches long made along the side of the tibia, ending half an inch beloAV the tip of the malleolus, Avhere it is then crossed by a short horizontal one involving the skin only. The periosteum of the tibia is divided in the line of the incision and transversely at its upper end, and dissected off, the bone saAvn through, and the piece removed. Langenbeck makes the line of section oblique downwards and outAvards, because it is easier to do so, but most surgeons prefer to have it transverse. The upper part of the astragalus, Avhich has been previously saAvn off, is then removed through the same incision. The gouge is used to scrape aAvay any'diseased parts found on the cut surface of the astragalus, or the bone may be seized Avith strong forceps and dissected out entirely. If the injury has affected the astragalus only (as in some gunshot wounds), its splinters are best removed through a longitudinal incision upon the dorsum of the foot betAveen the extensor tendons of the first and second toes. EXCISIOX OF THE BOXES AND SMALLER ARTICULATIONS. EXCISION OF THE SUPERIOR MAXILLA. This operation may be required on account of malignant tumors of the bone or antrum, or of suppurative osteitis and necrosis, or to give access to the base of implantation of a naso-pharyngeal polyp. In the first case the periosteum EXCISION OF THE SUPERIOR MAXILLA. 167 should not be retained; in the second its separation from the bone is in great part accomplished by the inflammatory pro- cess; in the third it should be carefully retained so as to diminish the subsequent deformity. ^ In total excision the bony connections that require to be divided are: (1) The one Avith the malar bone beloAV the outer angle of the orbit. (2) That with the opposite bone along the centre of the hard palate. (8) Those formed by the nasal process near the inner angle of the orbit; and (4) that Avith the palate bone and pterygoid process of the sphenoid. The first may be divided by nicking the ante- rior surface of the bone Avith a saAV, and completing the division Avith cutting forceps, or Avith chisel and mallet, or by passing a chain saw around it, through the sphenomaxil- lary fissure in the orbit and zygomatic fossa. The second is divided, after having draAvn one or both incisor teeth, by means of a saAV passed into the nostril, or Avith cutting for- ceps with long narrow blades, or a chisel. The third is easily divided Avith forceps or a chisel, and the fourth by twisting the bone doAvmvards after all the other connections have been severed. The periosteum, covering the floor of the orbit, is thick and easily detached; that on the hard palate is thick and difficult of removal, on account of the irregularities of the surface. There is but little danger of injury to the internal maxillary artery, and it is seldom necessary to apply more than one or two ligatures to its divided branches. Oozing is arrested by a plug of lint, aided, perhaps, by persulphate of iron. In partial excision the orbital plate is left, the line of division of the b.one passing through the anterior Avail of the antrum from the nostril to the loAver corner of the union Avith the malar bone. The remaining attachments arc then broken as before. There are also other varieties of partial excision for the removal of naso-pharyngeal polypi; removal of the nasal process with the nasal bone ; removal of part of the hard palate (Nelaton); and temporary removal of dif- ferent portions, preserving the connection with the soft parts, and replacing them after the polyp has been removed. The incisions that have been proposed may be classed as (1) external and (2) median; the former extending from 168 EXCISION OF JOINTS AND BONES. the angle of the mouth upAvards and outAvards to the malar bone; the latter passing from or near the middle of the lip up toAvards the inner angle of the eye. The former are open to the objections that they divide the branches of the facial nerve, endanger Steno's duct, and leave a conspicuous scar. The preference is noAV generally accorded to the median in- cisions. These follow the outline of the side of the nose more or less closely, and some of them are supplemented by a transverse incision, passing quarter of an inch beloAV the loAver margin of the orbit. For partial excision Gudrin re- commends an incision passing from the side of the Aving of the nose, along the naso-labial fold to the angle of the mouth (Figs. 83 and 84). In order to avoid the swalloAving of blood, it is Avell not to carry the incision through the lip or divide the gingivo- labial fold until after the anterior face of the bone has been denuded as far as possible. It is possible to remove the superior maxilla through the mouth without making any cutaneous incisions, but it is a very difficult and painful operation, and the hemorrhage is most embarrassing. Larghi has removed both bones through the mouth, upon the cadaver, and says it is easier to remove both together than one alone in this Avay. In simultaneous excision of both superior maxillae, the same incisions may be made on both sides, as for the removal of only one, or Dieffenbach's median incision may be made along the ridge of the nose and the middle of the upper lip. Operation by one of the Median Incisions. (Fig. 83.) —The incision is made in the direction selected, the knife penetrating to the bone throughout, except at the lip. The cartilage of the nose is separated from the bone and reflected imvards Avith the small internal flap, the edge of the orbit cleared, and the external flap dissected outwards as far as to the malar bone above and the tuberosity of the maxilla below if possible, the infra-orbital nerve being divided at its point of emergence from the foramen. The periosteum of the floor of the orbit is then detached Avith the handle of the knife, as far as the spheno-maxillary fissure, the malar process or bone cut through Avith the saAV or forceps, and the thin plate of bone forming the floor of EXCISION OF THE SUPERIOR MAXILLA. 169 the orbit divided with the knife obliquely inwards and for- wards from the anterior end of the spheno-maxillary fissure. The superior maxillary nerve, which can be readily distin- guished through the bone, should also be divided as far back as possible. Finally, the nasal process is divided. Fig. h:;. Excision of superior maxilla. A. External incision. B. Nfelaton's incision. C. Boec'.tel's incision. The incision is then carried through the lip, and the de- tachment of the external soft parts completed. The mucous membrane of the roof of the mouth is divided transversely on a line Avith the last molar tooth, and longi- tudinally in the median line. An incisor tooth is then drawn, and the hard palate divided with saAV or forceps close to the septum. If the mucous membrane of the roof of the mouth is not diseased it may be retained. Instead of the incisions through it just mentioned, one is made along the inner bor- der of the alveolar process, its edge raised, and the mem- brane detached inwards and backAvards to the median line. After the removal of the bone it unites Avith the cheek, closes in the mouth as before, and may become strengthened by a deposit of bone. Finally, the bone is grasped with strong forceps, tAvisted doAvmvards to break its posterior connections, and removed, generally bringing with it part of the palate bone,- the 15 170 EXCISION OF JOINTS AND BONES. hamular process of the pterygoid and some attached mus- cular fibres. Subperiosteal Excision (Oilier).—This method can be employed with any of the median incisions above mentioned, but Oilier prefers an external one (Fig. 84, B). 1. Cutaneous Incision.—An incision is made from the middle of the malar bone to a point on the upper lip one- Fig. 84. Excision of superior maxilla. A. Guerin's incision. B. Ollier's incision. C. Dieffenbach's incision for removal of both bones. third of an inch from the angle of the mouth. If necessary, a second incision must be made at the middle of the lip and carried upAvards around the nostril. 2. Incision of the Mucous Membrane.—The incision is begun on the outer surface at the interval betAveen the second incisor and the canine tooth (he does not remove the intermaxillary bone, that which supports the incisor teeth) close to the edge of the gum, carried back around the last molar, then forwards on the inside to a point corresponding to that at which it Avas begun, and thence obliquely back- wards to the median line. A short incision through the periosteum is next made from the anterior external extremity of the former upwards and imvards to a point a quarter of an inch external to the anterior nasal spine. 3. Separation of the Periosteum.—The periosteum of the EXCISION OF BOTH SUPERIOR MAXILL.E. 171 anterior surface is then detached with an elevator, care being taken, hoAvever, to divide the infra-orbital nerve with a knife at its point of emergence, and the denudation is car- ried along the floor of the orbit. Unless it is necessary to remove the nasal process of the maxilla, the lachrymal sac and duct can be left uninjured and adherent to the perios- teum. The periosteum of the roof of the mouth is then separated from Avithout imvards as far as to the median line. 4. Section of the Bone.—The nasal and malar processes are divided Avith forceps, chisel, or chain saw as before de- scribed, the canine tooth draAvn, the edge of the chisid in- serted in the gap left by it, and pressed gently backAvard and imvard to the median line, thence directly backward along the suture. The bone is then tAvisted out, the palatal sutured to the external periosteum, and the wound closed. SIMULTANEOUS EXCISION OF BOTH SUPERIOR MAXILLA. An incision may be made from each angle of the mouth to the malar bone and the broad flap reflected toAvards the forehead, or Dieffenbach's incision made along the ridge of the nose (Fig. 84, C), Avith or Avithout a transverse one passing across it and beloAV the loAver margin of each orbit. The bones are removed together, not separately. The malar processes or bones are divided in the usual manner, the nasal processes divided Avith a chain saAV passed from one orbit to the other through the lachrymal bones, and the vomer separated with cutting forceps. The periosteum of the hard palate is separated from the gums by a semi- circular incision and dissected back, the posterior connec- tions broken and the bone removed by tAvisting it doAvmvard and fonvard. PARTIAL AND TEMPORARY EXCISION OF THE SUPERIOR MAXILLA TO FACILITATE THE REMOA^AL OF NASO-PHARYNGEAL POLYPS. Resection of Posterior Portion of Hard Palate (Nela- ton).—The soft palate is first divided from before back- 172 EXCISION OF JOINTS AND BONES. Avards along the median line, and the incision prolonged fonvards through the periosteum of the hard palate as far as may be judged necessary. A transverse incision is next made on one side from the anterior extremity of the first toward the teeth, and the flap, including half the soft palate, dissected off the bone from the .median line outAvards. The mucous membrane on the floor of the corresponding nostril is then divided close to the septum, the bone perforated at the anterior corners of the denuded surface, and the sepa- ration of the quadrilateral piece accomplished Avith cutting forceps. After removal of the polyp the soft parts are replaced and stitched together. The bone is sometimes reproduced. Resection of the Upper Portion, leaving the Hard Palate and Alveolar Process (Von Langenbeck).—The folloAving is somewhat abridged from the description in the Deutsche Klinik, 1861, page 283 :— An incision, convex doAvmvards, from the ala of the nose to the malar bone, and along the zygoma backwards. A second incision from the nasal process of the frontal along the loAver border of the orbit, meeting the first at the middle of the malar bone. He Avorked doAvn to the bone through the first incision and separated the attachments of the masseter to the malar bone. As soon as the tense fascia buccalis Avas cut the tumor appeared. DraAving the inferior maxilla aAvay with a speculum, he easily passed his finger betAveen the tumor and the superior maxilla through the pterygo-maxillary fissure into the spheno-maxillary fossa, both of Avhich had been enlarged by pressure, and then through the dilated foramen spheno-palatinum to the cavity of the nose. A fine elevator and then a fine keyhole saAV Avere passed by the same route, and the superior maxilla saAvn through horizontally from behind fonvards, Avhile the left forefinger, passed through the mouth into the pharynx, covered the point of the saAV and kept it from striking against the sep- tum of the nose. The second incision Avas then carried down to the bone and into the orbit, and the soft parts divided in the angle TO GAIN ACCESS TO THE PHARYNX. 173 between the frontal and zygomatic processes of the malar bone. The second cut with the saAV Avas then made from beloAV upAvards through the zygomatic process of the temporal and the frontal process of the malar bone to the spheno-maxillary fissure, and thence across the floor of the orbit to the lach- rymal bone. m The resected portion Avas thus left attached only to the nasal bone and the nasal process of the frontal by its OAvn uninjured nasal process. The hard palate and alveolar pro- cess had not been touched. He then passed an elevator under the malar bone and turned the piece sloAvly upAvards upon its connections as upon a hinge until the malar bone had nearly reached the median line of the face, and the spheno-maxillary and nasal fossae Avere completely accessible. The bleeding was severe, but.stopped spontaneously, the arteria spheno-palatina alone Avas tied at its entrance into the foramen spheno-palatinum. The bone Avas replaced and nicely adjusted, its tendency to rise being restrained by pressure until the metallic sutures had been set in the skin. OTHER METHODS OF GAINING ACCESS TO THE PHARYNX THROUGH THE NOSE. These may be described in this connection, although, pro- perly speaking, they are not resections of the superior maxilla. Boeckel makes tAvo transverse cuts across the nose, and unites their extremities by a third along its side. The cuts are carried to the bone, and the quadrilateral osteocutane- ous flap thus formed turned back upon the cheek, the other nasal process Avhich forms its base having first been broken with padded forceps, one blade of Avhich is passed into the nostril. Oilier turns the Avhole nose doAvmvard. He begins his incision at the edge of the bone close behind the ala of the nose, carries it upAvards along its side to the highest part of the depression between the eyes, then across and doAvn to the 15* 174 EXCISION OF JOINTS AND BONES. corresponding point on the other side (Fig. 85, A). The bone is sawn through in the line of the incision, the necessary liberating incisions made in the septum or the sides, and the nose turned doAvn. Ollier's operation for removal of a naso-pharyngeal pjlyp. B. Modification for a very large polyp. The septum is pressed aside, the polyp extracted, its base of implantation scraped, and the nose replaced. A modification, which is sometimes desirable on account of the size of the polyp or the distance of its implantation, is indicated in Fig. 85, B. The incision runs more ob- liquely backward, and a transverse one is made from each end to the ala of the nose. The bone is divided in the direction of the cutaneous incisions, in the vertical one as before described, in the horizontal one by passing a fine saAV across the nostrils through holes made betAveen the bone and cartilages, and saAving backAvards. This line of section must be high enough to avoid the roots of the teeth. In some cases it is sufficient to mobilize the lower end of the nose by an incision under the lip in the gingivo-labial fold, and then by carrying it and the lip upAvard very free access to the nasal fossae is obtained. EXCISION OF THE INFERIOR MAXILLA. This may be total or partial ; and partial excision may involve the removal of any part of the body of the bone or EXCISION OF THE INFERIOR MAXILLA. 175 of the ascending ramus. Partial excision of the body may sometimes be accomplished through the mouth Avithout the aid of a cutaneous incision, or by an incision along the loAver border of the bone Avith or without another at right angles to it extending toAvards or even through the lip, or by two vertical incisions doAvmvards from the angles of the mouth when only the upper part of the body of the bone is to be removed. When the ascending ramus also is to be resected the in- cision should pass along the loAver border of the bone to the angle of the jaAv, and then upAvards along the posterior border of the ramus to the level of the lobule of the ear. If the incision is carried higher the facial nerve is neces- sarily divided Avith consequent paralysis of the muscles sup- plied by it, a complication Avhich should be avoided, not- withstanding the assertion of some authors that the paralysis may disappear after a time. The horizontal portion of the incision should be a little below the border of the bone in order that the cicatrix may be less conspicuous. Syme removed the entire ramus Avith the condyle, Avithout open- ing into the cavity of the mouth, by an incision slightly convex backAvards extending from the zygoma to, and a little beyond, the angle of the jaw. The principal danger is of injury to the internal maxillary artery, Avhich lies almost in contact Avith the inner side of the neck of the condyle. The lingual nerve also is in close relation Avith the inner side of the ramus, lying be- tAveen it and the internal pterygoid muscle. Maisonneuve introduced a modification of the method of operating Avhich has rendered it almost easy and has diminished the above- mentioned danger. It consists in separating the attach- ments of the condyle by twisting and tearing out the bone after all the connections have been divided. If this modifi- cation, Avhich sounds, perhaps, rougher and less surgical than it really is, is not adopted, the joint must be ap- proached from in front so as to avoid the external carotid, Avhich lies close behind the bone in the substance of the parotid. It is sometimes allowable to divide the neck of the condyle, or even the ramus beloAV the sigmoid notch, Avith cutting pliers, and leave the upper fragment in place. Another danger is in the division of the attachments of 176 EXCISION OF JOINTS AND BONES. genio-hyo-glossus muscles to the bone. The tongue, de- prived of its support, falls back upon and closes the glottis. As a preliminary, therefore, to any operation in Avhich these attachments are divided, a stout ligature should be passed through the tip of the tongue and held by an assistant. After the operation it should be fastened to a hare-lip pin in the external incision, or to the skin of the face by a strip of adhesive plaster, and retained for a couple of days, at the end of which time the muscles Avill usually have formed neAV attachments. The bone should be saAvn through Avith a chain or com- mon saAV, according to circumstances, or merely nicked with the saAV, and its division completed Avith cutting-pliers. The tooth occupying the proposed line of section should first be drawn. Ligature of one or both carotids has been proposed and performed as a preliminary operation to prevent excessive hemorrhage, but it has proved to be not only unnecessary but ineffectual. In Mott's case the main operation had to be adjourned to allow the patient to recover from the shock of the preliminary one. In another case in which both carotids had been tied, the main operation had to be aban- doned on account of hemorrhage.1 Syme says the pre- liminary ligation is unnecessary, because the only arteries that need to be divided are the facial and the. transverse branches of the temporal, bleeding from Avhich can be easily controlled, and, furthermore, all the advantages offered by ligation of the carotids can be obtained by their temporary compression during the operation. The attempt should be made, Avhen possible, to get pri- mary union of the intra-buccal wound and to drain through the external one. This makes it easier to keep the Avound SAveet, diminishes the danger of purulent infection, and avoids the risks incident to the swalloAving of the decom- posing discharges. The results of the operation are usually very good, and the deformity less than might be expected. Subperiosteal excision has been folloAved by reproduction of the entire 1 Mentioned by Syme in Contributions to the Pathology and Prac- tice of Surgery, Edinb., 1848, p. 19. EXCISION OF THE INFERIOR MAXILLA. 177 bone with condyles and diarthrodial cartilages, and eA'en Avhen the periosteum is not preserved the cicatrix becomes very firm and fibrous, and able to support a plate Avith arti- ficial teeth. Resection of the Anterior Portion of the Body.—This may be done by means of a vertical incision in the median line, or of a horizontal one below the free border of the bone, or from Avithin the mouth Avithout any cutaneous in- cision. If one of the incisions is made, the external and internal surfaces of the bone are cleared through it, a tooth draAvn at each of the proposed points of section, and the bone saAvn through. If no external incision is made, the external surface of the bone is cleared, beginning at the edge of the gum or in the gingivo-labial fold, according as the periosteum is or is not to be preserved, and the lip draAvn doAvn under the chin so that the bone protrudes through the mouth. It can then be easily saAvn through and freed from its attachments on the inner side. Resection of the Lateml Portion of the Body.—The in- cision extends along the loAver border of the jaw from its angle nearly to the symphysis, and then is carried vertically upAvards to the base of, but not through, the lip. The flap is dissected up, the elevator being used of course if the periosteum is to be preserved, the inner surface of the bone cleared near the symphysis for the passage of a chain-saAv, and the section made if possible at a short distance from the median line, so as not to disturb the insertion of the genio-hyo-glossus. This section may be made Avith a nar- roAv saAV from before backAvards if preferred. The bone is then draAvn doAvmvards and outAvards, its inner surface cleared, and the saAV applied behind the last molar tooth or at any suitable point. Resection of the Ramus and Half of the Body. (Fig. 86.)—An incision is begun close to the posterior border of the ramus on a level Avith the lobule of the ear, carried doAvn to the angle of the jaAV, and thence along its lower 178 EXCISION OF JOINTS AND BONES. border to the symphysis, where it is met, if necessary, by a vertical one, beginning beloAV the free border of the lip a little to that side of the median line on Avhich the bone is to be removed. The flap thus marked out is dissected up from the bone as far as can be done without open- ing into the buccal cavity, and the divided facial artery tied. The inner surface of the bone is then cleared in the same manner, an incisor tooth drawn, and the bone saAvn through. The jaw is then drawn doAvnwards and fonvards, the denudation of its inner surface completed by di- viding the attachment of the mucous membrane and of the internal pterygoid, and the inferior dental nerve cut squarely across at the point Avhere it en- ters the bone. The insertion of the temporal muscle, upon the coronoid process is divided with curved scissors while the jaAV is forcibly depressed, or the process itself is cut through if it is so long that its ex- tremity cannot be reached. The remaining soft parts are carefully detached upAvards toAvards the condyle, the knife, or better the elevator or the handle of the scalpel, being kept close to the bone, and the separation completed by tAvisting the jaAV out. Excision of the whole of the Inferior Maxilla.—The in- cision is made from the lobule of one ear doAvn to the angle of the jaAV, along the loAver border of the bone to the other angle, and then up to the lobule of the other ear. The outer and inner surfaces of the jaAV are denuded, the bone Excision of inferior maxilla. ANCHYLOSIS OF THE JAAV. 179 saAvn through in the median line, and each half removed as before described. In the subperiosteal method the incisions are the same, except that the vertical incision may be in the median line, since the genio-hyo-glossus and genio-hyoid muscles remain attached to the periosteum. The attachment of the tem- poral muscle is not cut but is freed Avith the elevator, as is also that of the external pterygoid to the condyle. ANCHYLOSIS OF THE JAAV. The most common cause of anchylosis of the jaw is found in cicatricial retraction or adhesions left behind by intra-buccal ulceration. Rizzoli (1858) Avas the first to point out that the proper aim of an operation intended to relieve this infirmity should be the establishment of a pseud- arthrosis in front of the adhesions or cicatricial bands Avhen the cause itself could not be removed. His operation con- sisted in the division of the inferior maxilla behind the last molar tooth by means of a specially constructed osteotome introduced through the mouth. Bony union of the fracture Avas then to be prevented by motion. Esmarch (1859) proposed the removal of a Avedge-shaped piece of the bone. By some surgeons the base of the Avedge is taken from the alveolar process, by others from the loAver border of the jaAV. Dieffenbach proposed to divide the ascending ramus horizontally from before backAvards by means of a chisel passed through the mouth to the anterior border of the ramus. Operation (removal of Avedge-shaped piece).—An inci- sion is begun at the angle of the jaAV and carried tAvo inches fonvard along the lower border. A narrow strip of bone is then cleared on both sides up to the edge of the gum, a tooth draAvn if necessary, the chain-saAV passed around the bone through the incision, and the section made. The an- terior fragment is then depressed and protruded through the Avound, and a Avedge-shaped piece from one-third to one-half of an inch in Avidth at its Avidest part cut off Avith cutting forceps. 180 EXCISION OF JOINTS AND BONES. RESECTION OF THE STERNUM. Oilier1 reports the folloAving case. Vertical incision four inches long; detachment of periosteum, and removal of a " red vascular sequestrum one and one-quarter inches square, adherent to the rest of the bone only by medullary granulations." The adjoining rarefied bone Avas gouged aAvay, portions of the internal plate being left at a few points. The projecting and denuded ends of tAvo costal cartilages, the fourth and fifth, were cut off. Three years aftenvards the patient died of phthisis, and the autopsy showed reproduction of all the parts removed. RESECTION OF THE RIBS. This can be performed only in those regions Avhere the bone is covered by a thin muscular layer. In this part of their course the intercostal arteries lie in a groove on the inner side of the loAver border of the ribs. The incision should correspond in length and direction with the portion of bone to be removed, and should be crossed at each end by a short transverse one. The flaps are then dissected up, the periosteum separated as far as possible, a chain-saw passed at the limits of the diseased portion, and the piece removed. Instead of the saw, cut- ting pliers may be used. EXCISION OF THE CLAVICLE. On account of the proximity of the large vessels of the neck this has been considered the most dangerous of all the excisions. The danger, hoAvever, varies greatly Avith the nature and extent of the disease Avhich renders the opera- tion necessary. Thus, Avhen there is osteitis Avith thicken- ing and loosening of the periosteum, the operator can easily keep close to the bone, and the danger of injury to the 1 Traite de la Regeneration des Os. vol. ii. p. 53. EXCISION OF THE CLAVICLE. 181 vessels, as well as of exciting diffuse inflammation below the deep fascia, is reduced to the minimum. On the other hand, Avhen caries has existed for a long time, the soft parts have become infiltrated and bound doAvn, and the bone thickened and roughened, the difficulties are immensely increased ; and Avhen the bone is the seat of a malignant tumor, extending in all directions, its removal may tax the powers of the most skilful. Valentine Mott spoke of his case as the most difficult and tedious operation he had ever witnessed or performed; it lasted four hours, and more than forty ligatures Avere applied, including tAvo upon the internal jugular vein. As only the inner half of the bone is in close relation Avith the vessels, and the danger is especially great at the sterno-clavicular joint, it is advisable to first raise the outer end of the bone from its place by opening its articulation Avith the acromion or by dividing it a little to the inner side of that joint, and then, after clearing the posterior surface from Avithout imvards, to divide the attachments of the inner end while tAvisting the bone upAvards about its long axis, and keeping the edge of the knife against it. When this is impracticable the periosteum must be carefully sepa- rated near the middle, and the bone saAvn through with the usual precautions against injury to the underlying parts. Each half is then raised in turn and dissected out. For the removal of a tumor no fixed rules can be given, the different steps of the operation must be determined by the surgeon himself. In other cases the directions are as folloAvs:— Operation.—The subperiosteal method must be employed throughout. The incision is made along the anterior sur- face of the bone, and corresponds in length with the portion to be removed. A short transverse incision is then made at each end of the first, the flaps dissected up, and the denudation carried as far as possible around the bone above and beloAV. The bone is then freed at its acromial end, or divided in the middle, and the separation completed as above described. 16 182 EXCISION OF JOINTS AND BONES. EXCISION OF THE SCAPULA. It is impossible to lay doAvn fixed rules for making the incisions when the operation is rendered necessary by a tumor of the bone. They will be determined by the cir- cumstances of the case and especially by the extent of the disease, for Avhile in some cases the acromial end of the clavicle must also be removed, in others the acromion and neck of the scapula may be left behind. Mr. Holmes1 says: " The surgeon turns doAvn appro- priate skin-flaps. . . . When the Avhole tumor is thus exposed, the muscles inserted into the vertebral border of the bone should be rapidly divided, as also those which are attached to the spine of the scapula. The tumor should be lifted well up, and freed from its other attachments, com- mencing from its loAver angle. The subscapular artery is divided near the end of the operation and can be held till the tumor is removed, or can be at once tied. The liga- ments of the shoulder are then easily divided and the mass removed." Gross2 made a vertical incision sixteen inches long doAvn- wards from the superior angle of the scapula, and circum- scribed an oval portion by a second curved incision, begin- ning five inches beloAV the upper end of the first and ending about the same distance above its lower end, and removed the bone after sawing through the acromion and neck of the scapula. Velpeau3 recommends three incisions : one along the spine of the scapula, the others starting from the anterior ex- tremity of the first and running, one toAvards the root of the neck, the other toAvards the axilla behind. Syme made tAvo incisions crossing each other near the centre of the tumor. Other surgeons have made triangular or semilunar flaps. In January, 1878, Dr. George A. Peters removed, at the New York Hospital,the entire scapula for malignant disease, leaving the arm. He made an incision along the spine of 1 A Syst, of Surgery, vol. v. p. G69. 2 (Jross's Syst. of Surgery, vol. ii. p. 1078. 3 Medecine Operatoire, vol. ii. p. 659. EXCISION OF THE SCAPULA. 183 the scapula, divided the fibres of the deltoid and trapezius, and exposed the tumor, Avhich involved only the acromion and adjoining portion of the spine. He then made a ver- tical incision across the centre of the first, beginning tAvo inches above it and extending to the inferior angle of the scapula, reflected the flaps, dissected out the under surface of the bone from behind fonvards, separated the acromion from the clavicle and humerus, and then, raising the lower angle of the scapula toAvards the head, approached the coracoid process from below, and found no difficulty in separating it from its attachments. Only tAvo vessels re- quired ligation, the supra-scapular and a large branch of the subscapular. The operation was performed under the spray, and the Avound treated antiseptically. The result was very good; six weeks afterwards the wound had closed, and the patient possessed a certain degree of control over the humerus. Subperiosteal Excision of the Scapula (Oilier). Fig. 87. 1. Incision of the Skin and Muscular Interstices.— An incision is made along the Avhole length of the spine Fig. 87- of the scapula, and from its posterior extremity two others are made, one folloAv- ing the posterior border doAvn to the inferior angle, the other running obliquely fonvards and upAvards for about an inch. A short transverse incision may also be needed at the anterior end of the first. 2. Denudation of the Bone.—The attachments of the deltoid and trapezius to the acromion and spine are separated, the periosteum of the posterior border of the SCapula divided in the in- Excision of the scapula. 184 EXCISION OF JOINTS AND BONES. terstice between the rhomboideus and infra-spinatus, and the infra-spinous fossa carefully denuded. The periosteum is very thin in its loAver third. The lower angle is freed by detaching the teres major and serratus magnus, the bone raised, and the subscapularis detached from below upAvards. If the marginal cartilage is not completely ossified and united with the bone, it should be separated and left adherent to the periosteum. The supra-spinous fossa is then cleared, care being taken not to injure the supra-scapular nerve in the supra-scapular notch, but to raise it up Avith the periosteum and its fibrous sheath. The posterior part of the bone is then carried up- wards and fonvards, and the denudation of its under surface and anterior border completed. If the extent of the disease permits, the denudation should stop at the neck of the scapula, Avhich is then divided with a chain-saAV or cutting forceps. 3. Opening of the Scapido-humeral Joint. Detachment of the Articular Capsule and Denudation of the Coracoid Process.—The acromion is next separated from the clavicle, the scapula turned upAvards, the joint opened from beloAV, and as the bone is pressed steadily upAvards everything that holds is detached Avith an elevator. After the coracoid process has been thus separated from most of its muscular and ligamentary attachments the feAV that remain can be broken by twisting the bone aAvay. In suitable cases the coracoid process may be divided at its base, and left in place, and thus the most difficult and laborious part of the operation done aAvay Avith. The partial excisions of the scapnda do not require detailed description. The acromion, spine, and posterior border are reached by straight or slightly curved incisions along the portion to be removed. A crucial or H incision is required at the angles. RESECTION OF THE HUMERUS. The position of the musculo-spiral nerve is the most im- portant element in this operation. In its passage around the posterior aspect of the humerus the nerve lies close to the bone Avithin the sheath of the triceps muscle, and leaves EXCISION OF THE ULNA. 185 the latter on the outer side of the arm to enter that of the supinator longus at its origin. In approaching the bone, therefore, on the outer side near the junction of the middle and loAver thirds, the operator should lay bare the outer border of the brachialis anticus and folloAV doAvn within its sheath to the bone. Upper Portion.—Same incision as in Ollier's method of excision of the shoulder carried further down along the outer edge of the biceps. The cephalic vein must be sought for and draAvn aside. Periosteum and capsule divided, bone denuded and removed as in excision of the shoulder-joint (?• *';)• Middle Portion.—Incision along the posterior border of the deltoid and outer edge of the biceps. Outer border of the brachialis anticus laid bare and folloAved doAvn to the bone. Division of the periosteum and denudation of the bone-Avith especial care for the safety of the musculo-spiral nerve. Oilier prefers to seek the nerve and, having found it, to draAv it aside. He also recommends that AvheneA^er it is possible to leave a portion of the shaft connecting the ex- tremities it should be clone, as a precaution against shorten- ing, and the formation of a pseudarthrosis. If this is not possible the chain-saAV is passed at tAvo points, and the in- termediate piece removed. Lower Portion.—Incision on outer side of the posterior aspect of the arm, between the triceps and supinator longus, as in Ollier's excision of the elboAV (q. v.). Total Excision.-—Combination of incisions for upper and loAver portions. After the ends have been denuded of peri- osteum the middle portion can be cleared by pushing one end out through its incision and peeling the periosteum back like the finger of a glove until the middle is reached. The bone is then saAvn off, and the other half removed in a simi- lar manner through the other incision. EXCISION OF THE ULNA. Longitudinal incision along the posterior aspect of the bone, joined at its upper end by a short one running ob- 16* 186 EXCISION OF JOINTS AND BONES. liquely upAvards and outAvards betAveen the triceps and anconaeus. The triceps is draAvn to the inner side, and the olecranon freed. After separation of the periosteum the bone is saAvn through in the middle, and each piece is dis- sected out in turn. EXCISION OF THE RADIUS (OLLIER). An incision invohing the skin only is made from the styloid process of the radius along the outer border of the forearm to the radio-humeral articulation. The fascia is divided and the posterior border of the supinator longus found. By folloAving it toAvard the wrist the knife can be kept betAveen it and the extensor tendons of the thumb, which can then be drawn backward and saved from injury. By folloAving it upward the interstice betAveen it and the exten- sores carpi radiales is found, through Avhich the operator penetrates to the radius now covered only by the supinator brevis. The latter muscle is then divided longitudinally and the periosteal sheath opened. The periosteum is detached laterally, the bone sawn through at its middle, and each fragment removed sepa- rately. Partial Excisions of the Ulna and Radius.—The incisions and methods are the same as those above described. EXCISION OF THE METACARPAL BONES AND PHALANGES. The metacarpal bones should be exposed by a longitudinal incision along the dorsum. As the extensor tendons cross the bones obliquely this incision should involve only the skin at first, the tendon is then draAvn aside, and the incision carried doAvn to and through the periosteum, which must be retained Avhen possible. It is advisable that the joints, especially the metacarpo-phalangeal, should not be opened. The bone is then divided in the middle Avith cutting for- ceps and each end dissected out, or the gouge alone may be used. EXCISION OF THE COCCYX. 187 The after-treatment is important. Extension must be made upon the corresponding finger for a long time to keep it from being draAvn up into the hand. In the case of the metacarpal bone of the thumb lateral pressure must also be made. For resection, of a phalanx the incision should be made on the side of the finger near the dorsum. For the ter- minal phalanx the incision should be U-shaped, the arms passing along the sides of the phalanx, the curve around its end. Resection of the different portions of the thumb, even if not subperiosteal, is to be preferred to amputation, but the contrary is true of the phalanges of the other fingers. Lateral pressure, by means of splints or an India-rubber glovefinger, and extension by Aveight must be made to insure the necessary length and proper shape of the member. RESECTION OF THE BONES OF THE PELVIS. Oilier1 reports a case in Avhich he removed the ascending ramus of the ischium and most of the pubis for suppurative osteo-arthritis of these bones and the pubic synchondrosis. The incision Avas about four inches long and extended from a fistula in the genito-crural fold up toAvards the pubis. The periosteum Avas detached, the ascending ramus of the ischium removed, and then the ascending ramus, body, and part of the horizontal ramus of the pubis. The bone that was removed Avas eroded and rarefied, but not necrotic. EXCISION OF THE COCCYX (OLLIER). This may be required on account of disease of the coccyx, or as a preliminary to operations upon the rectum. Oilier has removed it for osteitis, Simpson and jNott for the relief of coccygodynia, and Verneuil in cases of imperforate anus, and to facilitate the removal of cancers of the rectum. 1 De la Regeneration des Os, vol. ii. p. 180. 188 EXCISION OF JOINTS AND BONES. The limits of the bone are determined by the finger in the rectum, and a longitudinal incision made through the skin and fibrous covering of the bone, from a quarter of an inch above its upper to the same distance beloAV its loAver end, and a transverse incision made at the upper end of the first. The posterior surface of the bone is then denuded. The sacro-coccygeal articulation having been opened by this denudation, its fibro-cartilage is divided, and the cornua cleared on both sides. An elevator is then passed through the joint and used as a lever to force out the coccyx, peel- ing off at the same the fibrous covering of its anterior sur- face. If the sacrum is also diseased, and the gouge is used upon it, it must be remembered that the sacral canal extends to its very end, and is there formed posteriorly not of bone, but of fibrous tissue. RESECTION OF THE SHAFT OF THE FEMUR. A longitudinal incision is made on the outer side in the groove betAveen the vastus externus and biceps, Avith a trans- verse liberating incision at each end. Denudation is carried as far around as possible, the chain-saAV passed at each end of the diseased portion, and the denudation completed as the piece is raised from its bed. In the case of a child extension should be made, and the limb kept of the same length as the other; in the case of an adult the fragments should be brought nearer together as the patient is older, and his power of regeneration less; and, in many cases, it is better to bring the fragments into contact. Shortening is less of an infirmity than pseudar- throsis. RESECTION OF THE SHAFT OF THE TIBIA (OLLIER). (Fig. 88.) A longitudinal incision is made along the inner surface of the tibia near its posterior border. The perios- teum is incised, and the bone denuded. For the latter pur- pose it is necessary to use a Avell-curved elevator, because RESECTION OF THE SHAFT OF THE TIBIA. 189 the sharpness of the angles of the bones makes it very difficult to get around them Avithout perforating the perios- teal sheath. After the denudation is completed at one point, the curved elevator is passed behind the bone, and then the Fig. 88. Resection of the tibia. Method of placing the curved elevator so as to protect the periosteal sheath. chain-saw along its grooAre. The bone is divided, the ele- vator AvithdraAvn, and each fragment raised in turn and cleared along its posterior surface and borders. If the periosteum is loosely adherent, it may be stripped off by passing the elevator up and doAvn in the sheath behind the bone. In resection of only a portion of the diaphysis it is better to saAV through the bone at each end of the portion that is to be removed. The bone is necessarily denuded for some distance be- yond the proposed line of section, but this distance may be diminished by a transverse incision through the periosteum at that point. Moreover, necrosis of the denuded part rarely folloAvs. 190 EXCISION OF JOINTS AND BONES. RESECTION OF THE FIBULA. The loAver portion of the fibula is subcutaneous, its upper portion is covered by the peroneal muscles. The biceps is attached to its head, and the external popliteal or peroneal nerve after following the posterior border of the tendon of that muscle winds around the outer side of the neck of the fibula, and divides into the anterior tibial and musculo- cutaneous, the latter of Avhich soon becomes superficial. Sometimes this division, and even the subsequent ones, take place as high up as the head of the fibula, and then there is danger of dividing some.of the branches during resection of the upper extremity of the bone, unless the method indi- cated by Oilier is strictly carried out. The earlier authors considered the division of this nerve unavoidable. As the upper tibio-fibular articulation communicates in a large proportion of cases Avith that of the knee, it should not be opened, except Avhen it shares in the disease. The head of the fibula should be divided or gouged out in such a way as to leave this articulation covered by a thin but complete plate of bone. Resection of the Upper Extremity of the Fibula (Oilier).1 —A longitudinal incision is begun an inch above the head of the fibula at the posterior border of the tendon of the biceps, and carried doAvn a little behind the bone along the interstice betAveen the soleus and the peroneal muscles. The incision should involve only the skin and fascia. The nerve is then sought for Avhere it passes around the neck of the fibula, and protected by two blunt hooks placed about an inch apart. While thus protected, it is freed from the cellular tissue, Avhich binds it to the bone, and then draAvn fonvard so as to permit the division of the periosteum. This division is made on the posterior border of the bone, and carried doAvmvards as far as is necessary in the interstice betAveen the soleus and peroneal muscles. The periosteum is then detached and the bone removed, either by dividing it at tAvo points Avith a chain-saAV and 1 Traite de la Regeneration des Os, p. 2G7. EXCISION OF THE BONES OF THE FOOT. 191 removing the intermediate portion, or by dividing it at the loAver limit of the disease, and tAvisting out the upper frag- ment, or by modifying the latter method to the extent of dividing the head of the bone Avith a sharp chisel in such a manner as to leave the tibio-fibular joint unopened. Resection of the Loiver Portion of the Fibula.—Longi- tudinal incision along the antero-external aspect of the bone. Denudation and removal of the bone in the usual manner. For other details, see excision of the ankle-joint. EXCISION OF THE AVHOLE FIBULA. As the incisions for the resection of the upper and loAver portions lie on opposite sides of the peroneal muscles, they cannot be made continuous with each other. Each half of the bone must be removed separately. EXCISION OF THE BONES OF THE FOOT. Calcaneum.—Disease of the tarsal bones is apt to origi- nate in the calcaneo-astragaloid articulation and then in- volve the calcaneum mainly, the astragalus being only superficially affected. The disease in the former is usually central, leaving a sequestrum inclosed in a shell of rarefied vascular bone, or a cavity is formed Avithin a similar shell by ulceration and discharge through one or more fistulae. The removal of the entire thickness of the bone gives better results than simple gouging out of the diseased portions, evidement de Vos, but the anterior portion should if pos- sible be left, as it favors reproduction of the bone. The English surgeons do not usually employ the sub- periosteal method, claiming1 that the results obtained by the ordinary method are so good that they are disinclined to make any change. So far as can be judged from the published descriptions, these results, although satisfactory so far as the restoration of function is concerned, are infe- rior to those obtained by the subperiosteal method. The 1 Holmes, System of Surgery, vol. v. p. 720. 192 EXCISION OF JOINTS AND BONES. Fig. 89. absence of the calcaneum destroys the plantar arch and the sightliness if not the usefulness of the foot, Avhereas in some of Ollier's subperiosteal cases the neAV heel Avas as promi- nent and firm as that of the other foot. A. Holmes's Method.—An incision is commenced at the inner edge of the tendo Achillis, and draAvn horizontally forward along the outer side of the foot to a point some- what in front of the calcaneo-cuboid articulation. This incision should go doAvn at once upon the bone, so that the tendon should be felt to snap as the incision is commenced. It should be on a level Avith the upper border of the os calcis. Another incision is then made vertically across the sole, commencing near the anterior end of the former inci- sion and ending at the outer border of the internal surface of the os calcis. The bone being now denuded by throwing back the flaps, the calcaneo-cuboid and calcaneo-astragaloid joints are sought for and laid open. The calcaneum having been separated thus from its bony connections by the free use of the knife, aided, if ne- cessary, by the lever, lion-for- ceps, etc., the soft parts are next to be cleaned off' its inner side Avith care, in order to avoid the vessels, and the bone will then come away. B. Subperiosteal Method (Oi- lier). Fig. 89, A.—An inci- sion involving only the skin is begun at the outer border of the tendo Achillis about an inch higher than the tip of the ex- ternal malleolus, carried doAvn beloAV the outer tuberosity of the calcaneum and then fonvard and slightly upAvard to the up- per part of the base of the fifth metatarsal. The edge of the tendo Achillis and the upper border of the plantar muscles being recognized, the incision is carried down to the bone, care being taken not to cut the peroneal tendons. A. Excision of the calcaneum. B Excision of the astragalus. EXCISION OF THE BONES OF THE FOOT. 193 The posterior half of the bone is then denuded Avith an elevator, and the tendo Achillis detached and pressed to the inner side. The under surface and posterior third of the inner surface are next cleared, the peroneal tendons draAvn aside with blunt hooks, the external lateral ligament de- tached, the anterior portion of the outer surface denuded, and the calcaneo-cuboid joint opened. The interosseous ligament is divided Avith a narroAv bis- toury, the bone grasped Avith lion-forceps and turned doAvn- Avard so as to open the calcaneo-astragaloid joints and give access to the calcaneo-scaphoid and internal lateral liga- ments and to the inner surface of the bone. It is difficult, if not impossible, to avoid opening some of the tendinous sheaths during the operation, but the damage is very much less than that inflicted by the former method. Resection of the posterior portion alone can be accom- plished much more expeditiously. The portion to be re- moved is denuded and then sawn off, either directly or by perforating the bone and saAving it from above doAvmvards Avith a chain-saAV. Astragalus.—Excision of the astragalus may be rendered necessary by dislocation, comminuted fracture, or caries. Oilier considers this operation, under normal circumstances, the most difficult of all excisions. He employs the folloAV- ing method on the cadaver. Operation (Oilier). Fig. 89, B.—Curved incision across the dorsum of the foot, with convexity directed fonvards, beginning on the inner side at the point Avhere the tendon of the tibialis anticus crosses the tibio-tarsal articulation, running forwards and outwards to the middle of the scaphoid, and then backAvards to a point a little beloAV the tip of the external malleolus. This incision must expose but not in- volve the tendons. The extensor tendons are lifted out of their sheaths and drawn aside, the extensor brevis cut across or detached at its origin, and the neck and outer non-articular surface of the astragalus cleared. The capsular and ligamentary attachments of the bone to the scaphoid and tibia are sepa- rated, the interosseous ligament divided, and the foot being turned imvards the insertion of the strong internal tibio- 17 194 EXCISION OF JOINTS AND BONES. astragaloid ligament is detached. The remaining connec- tions are then ruptured by grasping the bone with strong forceps and twisting it out. Verneuil thinks the operation is made easier by saAving through the neck of the bone and first removing the head. Holmes makes a curved incision from one malleolus to the other across the instep, dividing all the soft parts and laying open the joint freely. He then divides the ligaments connecting the astragalus with the scaphoid, forces up the end of the bone, and feels for and cuts the interosseous ligament. The posterior portion is then cleaned carefully to avoid injury to the tendons and vessels Avhich lie near it. When dislocated the astragalus may be easily removed by a straight, curved, or crucial incision made over the most prominent part, and avoiding vessels, nerves, and tendons. When badly shattered, as in gunshot injury, the fragments may be removed through a longitudinal incision betAveen the extensor tendons of the first and second toes. Metatarsal Bones and Phalanges.—A metatarsal bone should be exposed by an incision along the dorsum involv- ing only the skin; the tendon is then draAvn aside, the periosteum divided, the bone denuded, saAvn through, and removed. Whenever possible, the upper extremity of the bone should be left. For the first and fifth metatarsals it is better to make the incision more upon the side than upon the dorsum. If the corresponding toe is to be preserved, extension must be made upon it for a long time, in the manner and for the reasons mentioned under excision of the metacarpal bones. The phalanges and their articulations are best excised by lateral incisions. TREPHINING. Trephining of the Cranium maybe undertaken for the evacuation of an intra-cranial abscess or hemorrhagic effu- sion, or for the removal of a suspected tumor of the bone TREPHINING. 195 or meninges, or for the cure of epilepsy, or after fracture to raise depressed portions of the bone. In all except the latter case the advisability of the operation is greatly diminished by the difficulty of determining the point at which the trephine should be applied. Among the more or less reliable indications, according to which the surgeon must make his selections of this point, may be mentioned: the history of an injury more or less recent,1 with or Avithout pain and inflammation of the soft parts (Pott's puffy tumor) at the point Avhere the injury Avas received, or at one dia- metrically opposite ; constant, Avell-localized pain at any one point; injury over the course of one of the larger arteries with rapidly supervening symptoms of compression, func- tional disturbance of certain"groups of motor nerves. The results obtained by certain physiologists in their efforts to determine the location of motor centres in the cor- tex of the brain have inspired the hope that the injured or compressed portion of the brain might be localized exactly in any given case by consideration of the muscles or groups of muscles paralyzed. Unhappily, this hope has not yet been realized, and the weight of authority is decidedly against any interference based solely upon such theoretical considerations. The impropriety of such interference, as viewed from the surgical stand-point, Avas shoAvn by Professor (rosselin in his masterly report upon the papers of MM. Lucas-Champonni&re and Proust ;2 and, still more recently, Professor BroAvn-Sequard3 has denied the accuracy of the physiological experiments and deductions upon Avhich the whole question turns, and protested against any surgical interference directed thereby.4 As the motor centres which Broca, Ferrier, Hitzig, and other physiologists claim to have localized lie under the anterior half of the parietal bone and along or near the fissure of Rolando, and as these are the ones Avhich it has been proposed to seek, it is perhaps desirable that direc- tions should be given for finding this fissure. 1 In Dupmtren's case there was no sign of the abscess until ten years after the receipt of the injury. 2 Bulletin de 1'Academic de Meilecine, Seance du 3 Avril, 1877. 3 The Lancet, 21st July, 1877, p. 107. 4 Sec also discussion in Bull, de la Soc. de Chir., Jan. 7, 1878. 196 EXCISION OF JOINTS AND BONES. According to Lucas-Champonniere1 the fissure of Rolando corresponds to a line draAvn from a point on the sagittal suture five and a half centimetres posterior to the bregma (junction of the sagittal and coronal sutures), fonvard and outAvard to a point seven centimetres behind and three cen- timetres above the external angular process of the frontal bone. According to Pozzi2 the starting-point of this line should be only four and three-quarters centimetres behind the bregma. The line may be more simply described as the hypothe- nuse of a right-angled triangle Avhose base is the upper half of a line drawn from the bregma to the meatus auditorius externus, and Avhose perpendicular extends two inches back- wards from the bregma along the median line. The bregma is situated at the point Avhere a vertical plane passing through both external auditory canals intersects the sagittal suture when the head is held exactly upright. Whenever it can be avoided, the trephine should not be applied over a sinus or the middle meningeal artery near the anterior inferior angle of the parietal bone. Bleeding from a sinus may be arrested by plugging it Avith Avax, but a fatal result is likely to folloAV. The middle meningeal artery lies enveloped in the thickness of the dura mater, adhering to it so closely that, Avhen cut, its Avails cannot re- tract sufficiently to arrest hemorrhage. For the same reason it is very difficult to apply a ligature to this vessel, and, as the actual cautery cannot be safely used, the best means of stopping the Aoav of blood is that proposed by Tillaux, of seizing the Vessel and dura mater with spring forceps, and keeping it thus compressed for tAventy-four or forty-eight hours. The instruments used in trephining are a stout knife, periosteum elevator, trephine, and a screav-pointed elevator which is intended to be screAved into the hole made by the centre-pin of the trephine, and used to lift out the circular piece of bone after it has been saAvn through. Ojieration,.—A crucial, V or T-shaped incision, one and a half to two inches long, is made through the soft parts 1 Bulletin de la Socie'e de Chirurgie, 1877, p. 121. 2 Archives (>6n. de Med., Avril, 1877, p. 4oO. TREPHINING. 197 Fig. 90. Trephine. doAvn to the bone, and the flaps, including the pericranium, raised by means of the periosteum elevator. Tae proba- bility of a reproduction of the bone is increased by preserving the connection of the pericranium Avith the soft parts. The centre-pin of the trephine hav- ing been protruded one-sixteenth of an inch, and fastened in its place by the binding screAV on the side, it is forced by to-and-fro rotary movements upon its point into the bone at the place selected, and these movements con- tinued until the circular edge of the trephine has cut a groove sufficiently deep to insure its steadiness without the aid of the pin, Avhich must then be AvithdraAvn so as to avoid injury by it to the dura mater. The hole made by the pin is then enlarged, and made to fit the point of the screw-pointed elevator so that this insfcru- Fig. 91. ment can be applied after- Avards without making too much pressure upon the loose disk of bone. The rotary movements are repeated very cautiously, and all parts of the groove fre- quently examined, as its Hey's saw. depth increases,Avith a probe, pen, or quill toothpick, so as to have timely notice of com- plete perforation. The teeth of the trephine must be freed from the bone dust from time to time by means of a brush or by dipping the instrument into water. If, as is 'usually the case, perforation takes place upon one side of the groove before it does upon the other, the trephine must be slightly inclined so as to act only upon the unsaAvn portion, or the elevator may be used to lift out the disk, breaking the thin shell Avhich remains. If the removal of a much larger piece of bone is desired the trephine should be applied successively at two, three, or 17* 198 EXCISION OF JOINTS AND BONES. more points, and the intervening portions saAvn through with a Hey's saAV (Fig. 91). In a case of depressed fracture the trephine must be applied to the sound bone in such a manner as to overlap the edge of the fracture. The depressed portion is after- wards raised by means of an elevator passed through the opening left at the edge of the sound bone by the removal of the incomplete disk. In puncturing for a deep-seated abscess a grooved knife or a trocar is to be preferred to the ordinary flat blade. Frontal Sinus.—As the Avails of the frontal sinus are not parallel to each other, Larrey has proposed to use two tre- phines of different diameters, the larger for the outer, the smaller for the inner table. Antrum.—A very small trephine should be used, and, in order to avoid a scar, it should be applied through the mouth after dividing the gingivo-labial fold, and dissecting up the soft parts as far as to the infra-orbital foramen, just beloAV and to the outer side of Avhich the opening into the antrum should be made. The antrum may also be opened by draAving the first or second molar tooth, and enlarging its socket Avith a drill. No additional directions are needed for trephining the flat bones or the epiphyses of the long ones. » PART V. NEUROTOMY AND TENOTOMY. DIVISION AND RESECTION OF NERVES. Division of a nerve of sensation, or even of a mixed nerve in extreme cases, may be required for the relief of neuralgic pain. It is seldom that simple division is more than temporarily sufficient. At least half an inch of the trunk of the nerve should be excised, and, as additional security against reunion, the end of the distal segment may be bent back.upon itself. Prof. Weir Mitchel1 has seen severe constant pain folloAV the bending back of the end of the proximal segment. SUPRA-ORBITAL NERVE. The frontal nerve, main branch of the first division of the trigeminus, divides just behind the upper margin of the orbit into the supra-orbited and supra-trochlear nerves; both branches are distributed to the forehead, the former emerging from the orbit through the supra-orbital notch or foramen, the latter a little nearer the nose. The former is much the larger and more important of the two, the latter supplying only a narroAV strip of integument near the me- dian line. The supra-orbital notch or foramen is found at the junction of the inner and middle thirds of the supra- orbital arch, or a little to the inner side of the junction. When it is a notch it can be readily felt through the skin, and is then an important guide in the operation. The nerve may be divided subcutaneously after its emer- gence from the notch, or it may be exposed by a transverse incision above or beloAV the eyebrow. 1 Oral communication. 200 NEUROTOMY AND TENOTOMY. Subcutaneous Division.—A tenotomy knife is entered betAveen the eyebroAvs midAvay betAveen the nerve and the median line, and passed horizontally beneath the skin until its point has passed beyond the nerve. Its edge is then turned backwards and pressed against the bone, and the nerve, lying between it and the bone, divided by with- draAving the knife. Or the knife may be entered at the same point, but passed close to the bone instead of just under the skin, its edge turned dowmvards towards the margin of the orbit, and the nerve divided by SAveeping the knife doAvmvards across the mouth of the supra-orbital foramen. Excision of a Portion of the Nerve.—A. Above the Eye- brow. (Fig. 92, A.)—An incision one to one and a half inches long is made just above and parallel to the eyebroAV, its centre cor- responding to the posi- tion of the nerve. This incision is carried doAvn to the bone, the distal end of the nerve recog- nized, seized with for- ceps, dissected out, and cut off. B. Below the Eye- brow. (Fig. 92, B.j— The eyebroAV being draAvn up and the eyelid doAvn, the surgeon makes an incision one to one and a half inches in length along the edge of the supra-orbital arch, dividing succes- sively the skin, orbicular muscle, and tarsal ligament. He then seeks the nerve in the notch, traces it back as far as necessary, and cuts out a portion Avith curved scissors. A, B. Resection of supra-orbital nerve. C. Resection of superior maxillary nerve. SUPERIOR MAXILLARY NERVE. 201 SUPERIOR MAXILLARY NERVE. After leaving the cavity of the cranium by the foramen rotundum, the superior maxillary nerve crosses the spheno- maxillary fossa, traverses the infra-orbital canal, and ap- pears upon the face at the infra-orbital foramen, Avhere it at once divides up into numerous branches distributed over the cheek, nose, lip, and loAver eyelid. Within the infra- orbital canal it gives off the anterior dental branch, and posterior to this canal it gives off the posterior dental, and, through branches to the spheno-palatine ganglion, the pala- tine nerves distributed to the palate and nasal fossa. The point at Avhich the nerve should be divided Avill vary accord- ing to the region affected, but in this, as in other cases, simple division has usually proved insufficient, and it has been found necessary to excise all that portion of the trunk Avhich lies in the canal. Sometimes the nerve has been cut above the branches going to the ganglion, and the latter torn out forcibly. The roof of the infra-orbital canal is composed in its pos- terior half of fibrous tissue, in its anterior half of thin bone which becomes thicker as it approaches the margin of the orbit. The infra-orbital foramen lies directly above the second bicuspid tooth and from one-quarter to one-half an inch beloAV the margin of the orbit. The nerve is accom- panied on its passage through the canal by the infra-orbital artery. A. Division of the Nerve on the Face.—This may be done: (1) subcutaneously; (2) through the mouth; (3) by an external incision* 1. Subcutetneously.—A tenotomy knife is entered about an inch to the outer side of the foramen, carried beloAV it into the canine fossa, hugging the bone, and then SAvept upwards along the surface of the bone so as to divide the nerve close to the foramen, the lip being draAvn doAvmvards and forwards to make the tissues tense. 2. Through the Mouth.—An incision is made in the gingivo-labial fold and the soft parts dissected aAvay from 202 NEUROTOMY AND TENOTOMY. the bone until the nerve is reached and divided. Gue*rin advises that a small portion of the distal end be excised. 3. By External Incision.—The incision may be trans- verse, oblique, or curved; it is only necessary that its centre should correspond to the foramen. The tissues are divided successively until the bone is reached and the nerve found either by folloAving up one of its branches or by seeking it at its point of emergence. B. Resection of the Infra-orbital Portion (Tillaux1). Fig. 92, C.—A vertical incision is made along the side of the nose from the lachrymal tubercle or the bony ridge of the nasal process of the superior maxilla, Avhich is con- tinuous Avith the loAver edge of the orbit, doAvn to the ala of the nose. A second horizontal one is then begun at the upper portion of the first and carried outAvards along the lower margin of the orbit beyond its centre. These inci- sions should involve all the soft parts doAvn to the bone. The loAver flap is dissected up, the nerve found, and a silk ligature thrown around it close to the foramen. The upper flap is then raised, together Avith the loAver eyelid and eyeball, exposing the floor of the orbit as far back as possible, upon which the infra-orbital canal can be recognized as a grayish line running obliquely backAvards and inwards. The canal is opened with a knife or chisel, the nerve isolated from the artery, raised from its bed Avith a small hook, and dissected out as far back as may be considered necessary. It is then divided Avith curved scissors, and the distal portion draAvn out by means of the ligature applied to it in the beginning. The length of the portion removed by Tillaux Avas six centimetres. * Dolbeau2 divided the nerve with curved scissors on the central side of the branches going to the spheno-palatine ganglion, and tore out the ganglion by draAving upon the nerve. Malgaigne's Method.—Pass a stout tenotome along the 1 Traite d'Anat. Topographique, p. 310, and Bull, de la Socie'e de Chirurgie, 1877, p. 413. 2 Oral communication. INFERIOR DENTAL NERVE. 203 floor of the orbit for nearly an inch in the direction of the nerve ; cut transversely with its point through the floor of the orbit, the bone being thin will offer no resistance. This divides both canal and nerve. Expose the nerve at the infra-orbital foramen by a simple transverse incision, seize it Avith forceps and tear it out of the canal. INFERIOR DENTAL NERVE. This nerve may be divided (A) after its exit from the dental canal, (B) in the canal, (C) before its entrance into the canal. The nerve enters the canal by the inferior dental foramen on the inner side of the ascending ramus of the loAver jaAV at the level of the croAvns of the loAver teeth ; the canal runs obliquely doAvmvards and fonvards just below the alveoli, and the nerve emerges through the mental fora- men Avhich lies midAvay betAveen the alveolar process and the loAver margin of the jaw below the second bicuspid tooth. A. At the Mental Foramen.—An incision is made in the gingivo-labial fold above the foramen, and the soft parts dissected off until the nerve is reached, usually about one- third of an inch below the bottom of the fold. B. Within the Canal.—An incision is made through the skin down to the bone along the course of the nerve, the periosteum raised, and a trephine applied. After removal of the outer table of the bone the nerve is easily found in the canal and diAuded. Or the trephine may be applied at two points and the intermediate portion of the nerve excised. C. Before its Entry into the Canal.—The mouth being held Avidely open and the commissure of the lips drawn backAvards and outAvards, an incision extending from the last upper to the last loAver molar tooth is made one-third of an inch on the inner side of the sharp anterior border of the coronoid process, and carried through the mucous membrane to the tendon of the temporal muscle. 201 NEUROTOMY AND TENOTOMY. The surgeon passes his finger into the incision and along the inner surface of the bone, betAveen it and the internal pterygoid muscle, until he touches the bony point Avhich marks the orifice of the canal. Passing a blunt hook along the finger, he raises the nerve upon it, isolating it, if possi- ble, from the accompanying artery, and divides it Avith blunt- pointed scissors or knife. It has been proposed to expose the nerve at this point by making an incision through the cheek, and applying a tre- phine, but this method has been justly rejected in favor of the more simple one just described. BUCCAL NERVE. The buccal nerve, a branch of the inferior maxillary, is not infrequently the seat of painful and persistent neuralgia. It is best approached through the mouth by the folloAving method:— The surgeon places his finger-nail upon the outer lip of the anterior border of the ascending ramus of the lower jaw at its centre, and divides in front of this border the mucous membrane and the fibres of the buccinator verti- cally. He then seeks for the nerve, separating the tissues with a director, and divides it. LINGUAL NERVE. Division of this nerve may be required for the relief of pain in cases of carcinoma of the tongue. When the mouth is opened Avidely the pterygo-maxillary ligament can be readily seen and felt as a prominent fold behind the last loAver molar, and the lingual nerve can be felt just beloAV the attachment of the ligament on the inner side of the loAver jaAV, close to the bone beloAV the last molar tooth. The tongue should be draAvn aside by an assistant, the mucous membrane divided for about an inch parallel to the margin of the alveolar process, beginning at the last molar tooth over the position of the nerve, or, according to Chau- TENOTOMY. 205 vel,1 one-fifth of an inch from the attachment of the mucous membrane to the side of the tongue. The nerve is then readily found in the submucous tissue, raised upon a hook and divided, or a portion excised. Moore's Method.—Mr. Moore has employed the folloAving method successfully in five cases. He cuts the nerve about half an inch from the last molar tooth, at a point Avhere it crosses an imaginary line draAvn from that tooth to the angle of the jaw. He enters the point of the knife nearly three- quarters of an inch behind and below the tooth, presses it down to the bone and cuts toAvards the tooth. This neces- sarily divides the nerve. The projection of the alveolar ridge might protect the nerve from a straight bistoury, and therefore a curved one should be used. TENOTOMY. Professor Sayre2 in answering the question, Hoav are Ave to determine whether, in any given case, Ave shall be com- pelled to resort to tenotomy ? lays down the following rule as of universal application:— " Place the part contracted as nearly as possible in its normal position, by means of manual tension gradually ap- plied, and then carefully retain it in that position ; Avhile the parts are thus placed upon the stretch, make additional point-pressure Avith the end of the finger upon the parts thus rendered tense, and if such additional pressure pro- duces reflex contractions, that tendon, fascia, or muscle must be divided, and the point at Avhich the reflex spasm is excited (the point at which the pressure is applied) is the point Avhere the operation should be performed." According to Prof. Sayre, the blade of a tenotomy knife should be one inch long, its shank one and three-quarters, its handle strong and marked in such a Avay that the sur- geon can see at a glance in Avhich direction the edge of the 1 Prex'is d'Operations de Chirurgie, p. 435. 2 Orthopedic Surgery and Diseases of the Joints, N. Y., 187G, p. 27. 18 206 NEUROTOMY AND TENOTOMY. blade is turned. The blade may be straight or curved, it should be thick at the heel, very narroAV, and the point should be somewhat rounded and sharpened from side to side like a Avedge or chisel. A fold of skin should be pinched up at the side of the tendon, and the knife entered at its base, so that a continu- ous track Avill not be left on its withdrawal. A preliminary puncture may be made Avith a sharp-pointed knife or lancet \ to facilitate the entry of the tenotome. The knife must be entered " on the flat" and passed either under the tendon or betAveen it and the skin ; its edge is then turned toAvards the tendon and the division effected Avith gentle saAving movements, the thumb being pressed firmly against the tendon if the knife has been passed under it. During the entry of the knife and the division of the tendon, the latter must be kept firmly upon the stretch, and as soon as the division is complete the knife must be turned upon its side and AvithdraAvn, Avhile the surgeon folloAvs its point Avith his thumb or finger so as to force out any blood that may be in its track and to prevent the entrance of air. Seal the Avound Avith plaster or collodion, and then bring the member into the desired position. Tendo Achillis.—The knife should be entered on the inner side of the tendon near its border, about one inch above the upper surface of the calcaneum. In this Avay the posterior tibial artery, Avhich lies betAveen the tendon and the inner malleolus and beloAV the deep fascia, is secured from injury. The heel must be depressed as much as pos- sible, so as to make the tendon more prominent, and give additional security to the artery. Tibialis Posticus.—The tendon of this muscle may be divided (A) above the malleolus, or (B) on the side of the foot just behind its insertion into the scaphoid. A. Above the Malleolus.—The muscle is made tense by everting the foot; the knife is entered at the inner side of the tendon and passed behind it. B. On the Side of the Foot.—Same position given to the foot. The knife should be directed from abovre doAvmvards, TENOTOMY. 207 and pass under the upper border of the tendon at a point half an inch beloAV and in front of the tip of the malleolus. Bell1 prefers to cut toAvards the bone. Tibialis Anticus.—Can be easily made prominent and isolated. Peronei.—May be divided at the posterior face of the loAver end of the fibula, or on the side of the foot below and in front of the tip of the outer malleolus. Flexor Tendons at the K>iees.—It must be remembered that the external popliteal nerve accompanies the tendon of the biceps closely, lying upon its inner side. Sterno-cleido-mastoid.—The danger to be avoided in this operation is that of injury to the external jugular vein at the outer border of the muscle, or to the anterior jugular vein at its inner border. The first can usually be seen under the skin and avoided, the other leaves the muscle about three-quarter of an inch above the sternum and passes backAvard. The muscle should be divided about half an inch above the top of the sternum, and most authorities agree in preferring to divide from before backAvards. The knife should be entered at the outer border of the muscle. Levator Palpebral.—In a case of paralysis of the orbi- cularis palpebrarum folloAved by retraction of the levator palpebrae with inability to close the eve, and subsetpient ulceration of the cornea, Professor Detmold divided the latter muscle at its attachment to the upper edge of the tar- sal cartilage. The result Avas very good. 1 Manual of Surgical Operations, 3d edition, p. 288. PART VI. PLASTIC OPERATIONS ON THE FACE. Plastic operations are required for the relief of congeni- tal defects, or for the restoration of parts lost by disease or injury. The methods most commonly employed are of tAvo kinds:— 1. By Approximation of the Edges.—This is applicable to cases in Avhich the loss of tissue is not great, and the ad- joining parts are supple. The edges of the gap are simply pared and brought together. It is sometimes necessary to make "liberating incisions" on one or both sides for the relief of tension. 2. By Transfer of a Flap.—A flap of suitable shape and size is dissected up and transferred, by turning it about its base, to the place Avhere it is needed, its vitality being insured by the preservation of its base or pedicle. This method admits of a great variety of modifications in its de- tails, from a simple sliding of a skin-flap, Avhich differs but slightly from the method by approximation, to the transfer of skin, muscle, and bone, or the taking of the flap from an- other limb or individual. The names Indian, Italian, French, and German methods have been given to the different varieties, but Verneuil1 has pointed out the impropriety of continuing to employ them, especially since at least two of them, the French and Ger- man, have their origin in an over-sensitive patriotism, not mindful enough of the actual facts. The Indian and Italian methods Avere first employed for the restoration of the nose; in the former, a flap Avas taken from the forehead and brought doAvn by tAvisting the pedicle Avhich occupied the space be- tAveen the eyebroAvs. The term is noAV applied to any ope- ration in which the flap is made Avith a long pedicle situated at some distance from the space Avhich the flap is to cover, 1 Menioires de Chirurgie, vol. i. Chirurgie Ke.parutrice, p. 401. plastic operations on the face. 209 and in Avhich also the flap is brought into place by rotation over a greater or less arc described about the base of the pedicle as a centre (see Fig. 119). In the Italian method the flap is taken from a distant part of the body, as in restoration of the nose by a flap taken from the arm (Fig. 121). Tagliacozzi, of Bologna, the originator of this method, alloAved the flap to suppurate for a feAV days, so as to increase its thickness, before fas- tening it in its neAv situation. Graefe sought for primary union, and gave, rather pompously, the name German method to this modification, ignorant of the fact that it had been sug- gested more than a century before by Reneaulme de la Garanne, and unmindful of the other fact that it contained no neAV principle, and must have been entertained by Tag- liacozzi, and only rejected for the sake of another adArantage incompatible with it. In the so-called French method, the principles of Avhich are found in Celsus, the flap has a broad base, and is brought into place, not by rotation, but by traction in the direction of its axis (Figs. 102 and 114). The variations and com- binations of these methods are uoav so numerous, that the names no longer have much descriptive value. General Principles.—The edges of the flaps must be brought together Avithout tension, and united very accurately by means of fine silk or silver sutures; and it is Avell to cut the edges obliquely so as to have a broader surface of con- tact. All hemorrhage must cease before the flaps are brought into place. The presence of a clot of blood under a trans- ferred flap is one of the most common causes of failure. Flaps must be taken from healthy non-cicatricial skin, and Avhenever the skin is thin and not very vascular, the subcutaneous layer should be taken Avith it to insure its vitality. The base of a flap should occupy the quarter from Avhich the main supply of blood is received, and the direction and shape of the flap should be such that it can be brought into place Avith the least amount of tAvisting of the base. The flap should be made considerably larger than the space it is to fill, and, to insure accuracy, it is well to cut 18* 210 PLASTIC OPERATIONS ON THE FACE. it according to a pattern previously made of paper or oiled silk. It is Avell also to mark the angles by fine pins planted erect in the skin. The raAv surface left by the dissection of a flap may be partly covered by draAving its edges together Avith sutures ; the remainder must be left to granulate. Dr. Gurdon Buck1 recommends a dressing for it Avhich he calls the " collodion crust;" it is made by covering the surface Avith dry scraped lint, and then with an additional layer of lint saturated with collodion. CHEILOPLASTY. A. Lower Lip.—-Restoration of the loAver lip is usually undertaken to make good the loss of substance occasioned by the removal of an epi- thelial tumor. The choice of a method depends upon the extent of the disease. 1. \-Incision (Fig. 93). —When the tumor is small, involving not more than one- quarter or one-third of the lip, it may be removed by a V-incision, and the sides of the gap brought together Avith one or two points of twisted suture. The mu- cous membrane on the in- side of the lip should be excised to the same extent as the skin, although it is not usually involved in the disease. If not removed it forms a disagreeable fold or pucker in the lip. The hare-lip pins must be deeply placed, passing close to the mucous membrane on the inside. This insures confron- tation of the raAv surfaces throughout their entire breadth, Cheiloplasty, V-incision. 1 Reparative Surgerv, 1876, p. 13. CHEILOPLASTY. 211 and the pressure of the twisted sutures prevents hemorrhage from the coronary arteries. 2. Oval Horizontal Incision (Fig. 94).—When the tumor covers a considerable extent of surface, but does not pene- Fig. 94. Oval horizontal incision. trate deeply, it may be safely excised by cutting under it with curved scissors. The mucous membrane and skin may then be stitched together, or the Avound allowed to heal by granulation. 3. Method of Celsus or Serres (Figs. 95 and 96).—The V-incision is supplemented by a horizontal one on each side Fig- 95. Fig. 96. Cheiloplasty, Celsus's incisions. Cheilopiasiy, Celsus's flaps in pli carried outwards from the angle of the mouth for about two inches, and comprising the Avhole thickness of the cheek for the first two-thirds of its length, but dividing the mucous membrane at a someAvhat higher level than the skin. The 212 PLASTIC OPERATIONS ON THE FACE. lower gingivo-labial fold is divided close to the gum on both sides, and the dissection carried downwards close to the periosteum, and backwards toAvards the angle of the jaw until the edges of the gap in the lip can be brought together without tension. The sides of the V are then brought to- gether, and the lip formed from the loAver parts of the hori- zontal incisions (Fig. 96). The mucous membrane and skin are stitched together along the edge of the neAV lip, and the remaining portion of Fig. 97. the loAver flap on each side (that Avhich remains external to the neAV angle of the mouth) is re-united to the upper flap. The mucous membrane at the outer end of the horizontal incision is stitched to the skin and covers the angle. 4. Dieffenbach (Fig. 97) adds a vertical incision at the Cheiloplasty, Dieffenbach's method. end of each horizontal one, thus marking out two quadri- lateral flaps Avhich are brought together in the median line. The gaps left in the cheek by the transfer are allowed to close by granulation. 5. Syme-Buchanan (Figs. 98 and 99). — The method Fig. 98. Fig. 99. Syme-Buchanan incisions. Syme-Buchanan flaps in place. by latero-inferior flaps is ascribed by some to Syme, by others to Buchanan, of Glasgow. After the tumor has been removed by the usual V-incision, CHEILOPLASTY. 213 the incisions are prolonged doAvmvards and outAvards for nearly an inch, and then curved upAvards and outAvards. These flaps are dissected off the bone and brought together in the median line. The mucous membrane and skin are stitched together along the upper edge, the gaps left below by the shifting of the flaps draAvn together as much as possible, and the remainder left to heal by granulation. Fis. 100. Restoration of lower lip. Buck's incisions. 6. Buck's Method (Figs. 100 and 101). —Buck pre- ferred to make two operations. He first removed the tumor Fig. 101. Restoration of lower lip. Buck's flaps in place. by the V-incision, brought the sides of the gap together, and allowed them to unite. After the union had become 214 PLASTIC OPERATIONS ON THE FACE. complete he restored the angle of the mouth and lengthened the loAver lip Avith material taken from the upper one by the folloAving method.1 In Fig. 100, B B represent two pins inserted a finger's breadth below the under lip border, one on either side of the chin, a little to the outside of the angle of the mouth, and equidistant from the median line ; D D are also tAvo pins inserted, one on either side, into the upper lip at the margin of the vermilion border, equidistant from the median line, and at such distance apart as to include betAveen them sufficient length of lip border for a new upper lip. The steps of the operation are then the folloAving: With the forefinger of the left hand placed on the inside of the mouth, the left cheek is to be kept moderately on the stretch while it is transfixed Avith a sharp knife at the point B. An in- cision is then carried through the entire thickness of the cheek, upAvard and a little outAvard, a distance of one inch and a half to a point E, near the middle of the cheek. The corresponding side of the upper lip should next be trans- fixed at the point D, and the incision carried through the lip and cheek outward and a little upward to join the first incision at E. The next step is to transfer the triangular patch, thus marked out, from the cheek to the side of the chin. For this purpose an incision should be made on the side of the chin from B vertically dowmvards to the edge of the jaAV and to the depth of the periosteum. The edges of this in- cision retracting Avide apart, afford a V-shaped space for the lodgment of the triangular patch, which is noAV brought around edgeAvise, and adjusted by sutures in its new posi- tion (see Fig. 101). The gap left in the cheek is closed by bringing its edges together and securing them in contact by sutures. By this adjustment a neAV and naturally-shaped angle is formed for the mouth at the point D. The incisions should be made with the utmost precision, and special care should be taken that the lining mucous membrane is divided exactly to the same extent as the skin. The same procedure may be applied to the other side of the mouth, and executed at the same operation. 1 Reparative Surgery, 1876, p. 22 et seq. CHEILOPLASTY. 215 7. Square Lateral Flaps, Malgaigne (Fig. 102).—The tumor is circumscribed by tAvo vertical incisions carried dowmvards from the edge of the lip, and a third horizontal one uniting the lower ends of the first tAvo. To fill the Fig. 102. Cheiloplasty, Malgaigne. square gap thus created, tAvo horizontal incisions are made on each side, one from the angle of the mouth, the other from the loAver corner of the gap. The flaps circumscribed by these incisions are brought forward and united in the median line, and the mucous membrane stitched to the skin along the edge of the lip and at the commissures. (See also 3. Method of Celsus, p. 211, and Stomatoplasty, p. Fig. 103. Cheiloplasty, SJdillot. 8. Square Vertical Flaps (Fig. 103).—Selillot made the flap at right angles to the line of the mouth. The in- 216 PLASTIC OPERATIONS ON THE FACE. cisions are shoAvn in Fig. 103. Each flap is swung around to meet the other in the median line, its inner vertical bor- der becoming the edge of the lip. B. Angle of the Mouth (Stomatoplasty).—An attempt to restore a large portion of either lip by means of material taken from the other, or to close a gap by simple approxi- mation not infrequently leaves the mouth small, rounded, and pouting, Avith obliteration of one or both angles. This defect can be overcome by the operation described on page 213, as Buck's method of restoration of the loAver lip, or by extending the mouth laterally by a horizontal incision involving both skin and mucous membrane, and then pre- venting reunion by stitching the skin and mucous membrane together on both sides and at the angle of the incision. Se"dillot considers it indispensable to excise a portion of the skin so as to have a comparative excess of mucous mem- brane which Avhen stitched to the skin will roll outwards and form a vermilion bor- Fig. 104. Lengthening of the mouth, Buck. the mucous membrane. A der. This simple method has been modified by Dr. Buck as follows :— Buck's Operation1 for Enlargement of the Mouth and Restoration of its Angle. (Fig. 104.)—An incision is made with great exactness along the line of the vermilion border cir- cumscribing the circular half of the mouth, and ex- tending to an equal dis- tance on the upper and loAver lips (a to b). This incision should only divide the skin, without involving sharp-pointed, double-edged knife should then be inserted at the middle of this curved incision, and directed flatAvise tOAvard the cheek, between 1 Reparative Surgery, p. 28 et seq. CHEILOPLASTY. 217 the skin and mucous membrane, so as to separate them from each other as far as the new angle of the mouth re- quires to be extended. The skin alone is next divided from the commissure of the mouth outward toward the cheek. The underlying mucous membrane is then divided in the same line, but not so far outward. The angles at the outer ends of the tAvo incisions are then accurately united by a single thread suture. The fresh-cut edges of skin and mucous membrane above and beloAV, that are to form the new lip borders, are shaped by paring first the skin and then the mucous membrane in such a manner that the latter shall overlap the former, after they have been secured together by fine thread sutures inserted at short intervals. C. Upper Lip.—The V incision and the oval horizontal incision (p. 211) may be used when the loss of tissue will be small. Also the square lateral flaps (p. 215) Avhen the gap to be filled is in the centre of the lip and rather large. 1. Vertical Flaps (Figs. 105 and 106).—These may be Fig- 105. Fig. 106. tenoplasty of upper lip. Sedillot. Sedillot. Flaps in place. made Avith the base directed upAvard (Sedillot), or down- Avard (Chauvel). Chauvel claims that the latter method is to l>e preferred because the retraction of the cicatrix in the former tends to draAv the new lip upAvards and expose the teeth. 19 218 PLASTIC OPERATIONS ON THE FACE. The flaps comprise the entire thickness of the cheek, are turned inward at right angles to their former position and united in the median line. The gaps left in the clieek by their removal are brought together Avith sutures or left to granulate. 2. Infero-lateral Flap (Buck). Fig. 107.—For loss of the right half of the upper lip Dr. Buck employed the fol- loAving method, enlarging Fig- 107. the mouth aftenvards and re-establishing the angle by the method described above (p. 216). The extremity of the under lip, Avhere it joined the right cheek, Avas di- vided through its entire thickness at right angles to its border, and the di- vision carried to the ex- tent of one inch from the border (a to b, Fig. 107). A second incision Avas made from the terminus of the first parallel to the lip border for a distance of one inch and a half tOAvard the chin, b to c. The quadrilateral flap thus formed from the under lip Avas folded edgewise upon itself, and made to meet the remain- ing half of the upper lip, and be adjusted to it by its free extremity. In order, hoAvever, to make this fold, the under lip had first to be divided obliquely half across its base, c to-d. The left half of the upper lip Avas prepared for the neAV adjustment by dividing the buccal mucous membrane close to the jaAV and detaching the parts above tOAvard the orbit from the underlying periosteum, and secondly by paring a strip of vermilion border from the extremity of the half-lip of sufficient length to permit the end of the half-lip to be matched to the free extremity of the under-lip flap. The parts concerned having been thus prepared, the under-lip Repair of upper lip by infero-lateral flap. Buck. HARELIP. 219 flap Avas doubled edgeAvise upon itself, and its free extre- mity adjusted to the half of the upper lip, and the two secured to each other in a vertical line below the columna nasi by sutures. The space betAveen the newly-adjusted half of the mouth and the neighboring cheek was closed by approximating the opposite parts and securing them to each other by sutures after their edges had been carefully matched. (Fig. 104 sIioavs the result of this operation.) HARELIP. If the patient is a young child its arms should be securely bound to its sides Avith a tOAvel, and its head firmly held by an assistant. After anaesthesia has been obtained it can be easily kept up by applying to the nostrils from time to time sponges saturated with ether. Single Harelip, Simple.—The simplest method of ope- rating is to pare the sides of the cleft and bring the raw surfaces together by a few sutures. The objection to the method is that the retraction of the scar produces a more or less considerable depression in the free border of the lip. It has therefore been generally aban- doned for one of the folloAving. 1. Double Flaps (Fig. 108). —In order to hold the parts upon the stretch and insure precision in making the cuts, a stout liga- ture should be passed through the lip at each angle of the cleft, or each angle should be seized with artery forceps. The lip being drawn fonvard and doAvmvard by means of the ligature or forceps, the mucous membrane is divided close to the gum and the dissec- tion carried upAvard and backAvard as far as may be necessary to alloAV the sides of the cleft to be brought together Avithout tension. Simple single harelip, double flaps. A. Incisions. B. Flaps turned down. C. Ligature for holding lip tense. D. Incisions to shorteu and adjust flaps. E. Thread passed through the ends of the flaps. 220 PLASTIC OPERATIONS ON THE FACE. Fip;. 109. Then making one side of the cleft tense, by draAving upon its ligature, the lip is transfixed near the angle, and the incision carried upward along the border of the cleft to its top, or, if necessary, into the nostril, thus cutting out a narroAV flap Avhich remains attached at its loAver extremity to the lip (Fig. 108, A). A similar flap is then made upon the other side, the two are turned doAvn, so that their raw surfaces face each other, and a thread passed through their free ends (Fig. 108, E). The freshened edges of the cleft are then confronted, a harelip pin placed near the vermilion border and another near the nostril, and tAvo or three fine silk or silver sutures inserted betAveen them. The ends of the de- pendent flaps are then cut off ob- liquely, enough being left to form a distinct projection on the lip after they have been united with fine su- tures. By this means the formation of a notch by the retraction of the cicatrix is avoided. 2. When the cleft Avas shalloAV, Nedaton left the flaps attached to each other at the apex, turned them doAvn, and brought the raAv surfaces together as above described (Fig. 109). 3. Single Flap (Fig. 110).—A flap is made upon one side only, usually the shorter portion of the lip. The oppo- Harelip, N<51aton's method. A. Incision. B. Flap turned down. Fig. 110. ^L Harelip. Single flap. site side of the cleft, and a portion of the free border of the lip adjoining it, are freshened by the removal of a strip of skin and mucous membrane. The sides of the cleft are approximated, and the flap applied to the free border of the lip. HARELIP. 221 4. Giraldes's Method (Fig. 111).—This is applicable only when the cleft extends into the nostril. The flap on Fig. ill. Harelip. Giraldes's method. the short side is made, as before described, Avith its base below; that on the long side is reversed, being left attached at its upper end. A third, horizontal, incision is carried outAvard from the edge of the nostril, at the point of the first flap, to make that portion of the lip more movable. The second flap is then turned upAvard across the nostril, the first brought doAvn to take its place, and the two raAv surfaces thus brought into contact united by sutures. Double Harelip, simple (Fig. 112).—Flaps are made upon the lateral portions, A and B, as before described (p. Fig. 112. Double harelip. 219, 1), and the sides of the central portion, C, are pared. The flaps are then brought together, as shoAvn in the figure, after mobilizing the lip by free division of the gingivo-labial fold and carrying the dissection Avell upward and outward, pins passed to include the sides and the central portion at the base and apex of the latter, the flaps trimmed (p. 220), and united Avith fine sutures. 19* 222 PLASTIC OPERATIONS ON THE FACE. If the parts are too scanty to permit the use of this method, liberating incisions must be made around the aloe nasi, or flaps obtained from the cheek. (See Upper Lip, p. 218, et seq.) Complicated Harelip.—Harelip may be complicated by fissure of the palate and alveolar process. When the fissure is single the bone on the long side of the lip projects beyond its proper line. In very young children, it may sometimes be forced back into place by making pressure upon it Avith the thumb, but it is easier to fracture it first Avith Butcher's pliers; the bent blade of this instrument being applied upon the anterior surface near the further nostril. The tAvo por- tions of the alveolar arch soon unite after they have been brought into contact, especially if the opposing surfaces have been pared. Sutures are not needed. When there is double fissure, the intermediate portion of bone containing the incisor teeth projects so far that it seems to be an appendage of the nose rather than of the mouth. In order to restore it to its place, it is necessary to divide the vomer with strong scissors, or, better, to cut a triangular piece out of the septum of the nose. It is not necessary to fasten the bones together Avith sutures. The portion of skin covering the projecting bone must be dis- sected off, and used to lengthen the columna nasi or fill out the lip. In extreme cases it may be pro- per to cut aAvay the projection en- tirely ; but Avhenever it can be saved and brought into line, it renders valu- able service by giving the upper jaAV its proper length, and furnishing a space into Avhich artificial teeth can be fitted. The three or four teeth Avhich are found in this piece are ahvays so defective and irregularly cheek compressor. placed that they have to be draAvn. It is sometimes desirable to take the strain off the sutures by means of a cheek compressor, similar to that represented in Fig. 113. For uranoplasty, etc., see Operations upon the Mouth. RHINOPLASTY. 223 RHINOPLASTY. The different kinds of rhinoplastic operations may be classified according to the nature and extent of the loss which they are designed to repair: 1st. A superficial loss not involving the bones or septum. 2d. Loss of the septum and nasal bones, the skin remaining entire. 3d. Loss of more or less of the surface and septum. As the loss of tissue is ahvays the result of injury or dis- ease, it presents so many variations in form and extent, that it is difficult in practice to determine the exact boundaries between the classes, and this classification is chosen for con- venience of description, and not Avith the intention of limit- ing the choice of an operation in any given case to those described in the class to Avhich the lesion might belong. For the same reason, a description of an operation as actually performed will sometimes be more serviceable than any general rules that might be laid down. As may be readily understood, the existence or non- existence of the septum and nasal bones affects materially, not only the method of operating, but also the result. If unsupported centrally, the neAV member tends constantly to shrink and flatten, and the surgeon has the mortification of seeing that he has merely substituted one deformity for an- other. Oilier tried to meet this Avant by including the peri- osteum in the flap taken from the forehead by the Indian method. There Avas, hoAvever, no new formation of bone, and the operation in that respect was a failure. On another occasion he took a strip of healthy periosteum from one of the limbs, and tried to graft it under the skin of the fore- head, hoping thereby to procure a lamella of bone, Avhich could be used to give solidity to the neAV nose. Thinking the graft had failed, he AvithdreAv the strip of periosteum after a feAV days, and then discovered that it had united nicely at one point. There is reason, therefore, to think that a more patient repetition of the experiment might be successful. On a third occasion, he included the periosteum of the forehead in a flap transferred by a modification of the French method, and by folding it together longitudinally 224 PLASTIC OPERATIONS ON THE FACE. Fig. 114. Rhinoplasty. Lateral flaps. along the centre he got reproduction of bone Avhere the two layers faced each other. 1. Superficial Defect not Involving the Bones or Septum. —If the loss of tissue is confined to the integument, that is, if the cartilage is spared, as it usually is in cases of epithelioma, no plastic ope- ration should be undertaken. The tumor must be carefully dissected off, and the Avound left to granulate. The slight mobility of the integument of the region prevents de- formity by cicatricial retrac- tion, and the wound heals over, leaving a scar Avhich does not contrast offensively with the neighboring skin. If, on the other hand, there is a gap to be filled, one that is small and does not involve the free border of the ala, square lateral flaps may be made by horizontal incisions (Fig. 114), and draAvn to- gether after they have been rendered freely movable by dis i section from the underlying parts. If the gap is larger, or if one of the alae is lost, suitable oblique or vertical flaps may be taken from the nose or cheek and transferred by rotation. Three of the many variations of this method are shoAvn in Figs. 115 and 116. Fig. 115, A represents a vertical flap taken from the cheek beside and beloAV the nose, and left adherent at its upper end. The flap should be cut long enough to alloAV a natural appearance to be given to the free border of the ala by turning it in upon itself. This device will also pre- vent excessive cicatricial contraction of the border and con- sequent narroAving of the nostril. Denonvilliers's Method (Fig. 116) sometimes makes it possible to secure this object more certainly by supplying a border that is already cicatrized. Supposing the loAver portion of an ala to be lost, a triangular flap, left adherent RHINOPLASTY. 225 to the lobe of the nose, is marked out by an incision Avhich, starting from a point near the lobe on the unaffected side of the median line, is carried directly upward nearly to the root of the nose, and thence obliquely doAvmvard to the Rhinoplasty. A. Single lateral flap. Rhinoplasty. Denonvilliers's method. B. Langenbeck's method. upper outer corner of the affected ala. The flap is mobi- lized by careful dissection off the bone and cartilage, and transferred doAvmvard. The gap left by the transfer heals by granulation. For the sake of giving more stiffness to the border, Denonvilliers sometimes included a strip of cartilage in it. Von Langenbeck1 restored an ala by taking a triangular flap from the opposite side of the nose (Fig. 115, B). The flap Avas left adherent at the apex of the triangle, which lay near the inner angle of the eye of the affected side, Avhile its base occupied the opposite ala. It was dis- sected up carefully so as not to include the cartilage, trans- ferred to the other side, and fastened to the freshened edges of the gap. The Avound left by the removal of the flap healed by granulation, and so perfectly that it was difficult to recognize there had been any loss of tissue at that point. Michon restored the ala by taking a triangular flap from 1 Essais de Chirurgie Flastique d'aprfes les Pr6ceptes du Prof. B. von Langenbeck, Bruxelles, 1856, quoted by Verneuil. 226 PLASTIC OPERATIONS ON THE FACE. the septum. The base of the flap was placed anteriorly parallel to the ridge of the nose, and the apex lay near the junction of the septum with the floor of the nasal fossa. The flap Avas dissected up and attached to the loss of sub- stance, its mucous surface directed outAvards, its apex made fast to the cheek. The columna, Avith or Avithout the tip of the nose, can be restored from the upper lip. Dupuytren and Dieffen- bach cut a vertical cutaneous flap, adherent at its upper end, immediately below the columna, turned it upAvard, twisting it upon its pedicle so that its cutaneous surface remained external, and secured it in place. As the tAvist- ing of the pedicle created considerable deformity, Sedillot and Blandin made the flap of the entire thickness and length of the lip, pared off" its cutaneous surface, and turned it directly upAvard Avithout twisting the pedicle, the mucous membrane thus forming the outer surface. The gap left in the lip was then closed Avith sutures. In Blan- din's case the result was excellent, and the mucous mem- brane gradually assumed the characteristics of ordinary skin; but in Se'lillot's case, in Avhich the tip of the nose had also to be restored, the membrane remained red and covered Avith thick epidermic scales, and the end of the nose looked much like a cherry.1 In all his rhinoplastic ope- rations Liston made the columna separately by this method, and found that the mucous membrane soon took on the ap- pearance of ordinary integument. 2. Loss of the Septum and Nasal Bones, the Skin re- maining entire.—Baron Larrey, about 1820, operated upon a soldier the bridge of Avhose nose had been shattered and depressed by the explosion of a gun. He removed the deformity by dissecting up the adherent portions of skin and replacing them in their original position. The details of the operation are lacking. Dieffenbach published in 1829 the description of an ope- ration by Avhich he overcame the great deformity resulting from the loss of the septum and bones of the nose by scro- fulous disease. As the case is a classical one, quoted, and 1 Se-dillot, Me-decine Ope-ratoire, 2d ed., vol. ii. p. 233. RHINOPLASTY. 227 often very incorrectly,1 in the text-books, and is an indica- tion of what may sometimes be accomplished in extreme cases, the following description of it is given.2 The patient Avas a girl, twelve years of age. She had lost the ossa nasi, nasal processes of the ethmoid, vomer, and cartilages, and instead of a prominent nose there was a deep pit Avith a ridge at the bottom. The plan of ope- Dieffenbach's operation. B. The result. C. The flaps. ration was to divide the remains of the old sunken member into portions, raise them up, and secure them in the proper position. Dieffenbach passed a narroAV-bladed knife first into one nostril and then into the other, and cut out, making tAvo incisions, one on each side of the sunken ridge (Fig. 1 The description in Holmes's System of Surgery, vol. v. p. 570, is almost unrecognizable. It is taken from Malgaigne's incorrect account, and also contains at least one gross error in translation. 2 As the original Avork could not be obtained, this description is made up from an English translation of the book, published in 1833, a French translation of the case in the Gazette Medieale, vol. i. p. G5, 1830, and a brief description with plates, in a collection of Dief- fenbach's Plastic Operations, published by two of his pupils in 1846. 228 PLASTIC OPERATIONS ON THE FACE. 117, C.). The strip of skin betAveen these incisions Avas three times as broad at its loAver end, Avhere it was connected Avith the upper lip by the shortened columna, as at its upper part Avhere it joined the forehead. The cheeks Avere next cut through down to the bones on each side by insert- ing the knife a fe\v lines beloAV the upper end of the first incision and carrying it obliquely downwards, parallel and a little external to the side of the nose, and then around into the nostril, thus separating the lateral attachments of the alae nasi. The columna, being too short, Avas then elongated by tAvo slight incisions in the upper lip, and the cheeks rendered more movable by dhiding their attach- ments to the bone through the lateral incisions. The flaps were then raised, the sides of the incisions pared obliquely in a manner to which Dieffenbach attaches an importance that seems undeserved, reunited, and fixed with harelip pins and sutures, and the whole retained in place by draw- ing the cheeks toward the median line and fastening them there Avith two long pins passed under the nose and through the detached edges of the cheeks. This compression was aided by tAvo splints of leather through which the pins passed. A quill covered with oiled lint Avas introduced into each nostril. Osteoplastic Method.—Oilier treated successfully a some- what similar case by making a triangular flap, its base constituted by the loAver portion of the nose and the ad- joining cheeks, its apex situated one and a half inches above the eyebroAvs. The frontal portion of the flap in- cluded the underlying periosteum. The left nasal bone and vomer having been destroyed by the disease, central support could be obtained for the ne\v nose only by aid of the right nasal bone, Avhich Avas accordingly loosened Avith a chisel and forced downward. The flap Avas then trans- ferred doAvmvard, pinched in laterally to increase its height at the bridge, and supported there by draAving the cheeks, previously loosened from their underlying attachments, tOAvard the nose and fastening them there with long pins.1 1 For further details of this operation the reader is referred to the original account in the Bulletin de la Socieie de Chirurgie, 1862, p. 62, or to its reproduction in Verneuil's Chirurgie Reparatrice, p. 428, and in the Gazette Hebdomadaire, 1862, p. 98, and also to a similar operation described more fully on page 231 of this manual. RHINOPLASTY. 229 Double Layer, or Superficial Flaps (Fig. 118).— Verneuil1 employed successfully a method suggested to him by Oilier, in Avhich permanent elevation of the bridge of the nose Avas secured by superposing t\vo flaps and thereby doubling the thickness. The patient had discharged a pistol into his mouth, causing the destruction of a portion of the hard palate and septum, the nasal bones, part of the Fig. 118. Rhinoplasty, sunken nose. Double layer, or superposed flaps. Verneuil. nasal processes of the superior maxillary, the spine of the frontal, and the anterior Avail of the frontal sinuses. The alae and lobe were uninjured but much flattened; above them Avas a broad deep groove extending to the middle third of the forehead. The two principal indications Avere to bring the lateral portions nearer the median line and to reconstitute the bridge of the nose. The latter could be accomplished permanently only by filling in the great cavity Avhich Avould be left by raising the sunken parts. Aerneuil made an incision along the median line of the depression and a transverse one at each end of the first, and dissected up the tAvo lateral flaps thus marked out. He then raised an oblong flap from the middle of the forehead, its base remaining adherent betAveen the eyebroAvs, and turned it directly doAvmvard so that its raAv surface Avas 1 Chirurgie Reparatrice, p. 428, and Bull, de la Soc. de Chirurgie 18G2, p. 70. 20 230 PLASTIC OPERATIONS ON THE FACE. directed outward, its tegumentary surface tOAvard the nasal fossae. The two lateral flaps Avere then placed upon it and united in the median line. The raAv surfaces united Avith each other, and the result was a nose eleArated one-third of an inch above the adjoining surface. Subcutaneous Method.—Prof. Pancoast1 operated upon a similar case in the Avinter of 1842-3 by subcutaneous division of the adhesions. The ossa nasi and septum had been entirely destroyed by disease, and the nose Avas sunken far beloAV the level of the face. " A narrow long- bladed tenotomy knife Avas introduced on either side by puncture through the skin over the edge of the nasal pro- cess of the upper maxillary bone. The knife Avas pushed up under the skin to the top of the nasal cavity, and then brought down, shaving the inside of the bony Avail, so as to detach the adherent and inverted nose upon either side. The point of the nose could now be draAvn out. . . . The nose still remained adherent to the top of the nasal chasm. The knife Avas a third time introduced under the skin in a direction corresponding nearly Avith the long diameter of the orbits of the eyes and the adhesions separated from the nasal spine and internal angular processes of the os frontis." The soft parts on the cheek Avere loosened by SAveeping the knife outward along the surface of the bone so far as to divide the infra-orbital nerve and artery on each side, draAvn tOAvard the median line, and held together Avith quilled sutures passed through the cavity of the nose. In two weeks the root of the neAV nose had sunk to the level of the face, but the patient Avas Avell satisfied, and refused any further operation, beyond the removal of an elliptical piece of skin to raise this portion again. The ultimate result is not knoAvn. Dubrueil2 quotes a similar operation by Malgaigne, but Avithout giving the date. As it is not mentioned in the lat- ter's Medecine 0} eratoire, edition of 1837, it is probable that Prof. Pancoast's operation antedates it. 3. Loss of mire or less of the Surface and the Septum. A. Indian Method.—This method was introduced into 1 Operative Surgery, Phila., 1852, p. 858. 2 Medecine Operatoire, p. 451. RHINOPLASTY. 231 Europe in 1814, by Carpue, an English surgeon, and the stimulus given by it to this class of operations Avas so great during the succeeding tAventy-five or thirty years, that this period has been called that of the renaissance of rhinoplas- tic surgery. The ultimate results, hoAvever, Avere not very favorable, and the method has fallen into comparative neglect. It Avas found that the noses, although sufficiently full, or even excessive at the time of the operation, under- Avent gradual atrophy, and, Avhen central support was lack- ing, sank to the level of the cheeks. The nostrils, too, closed sometimes to such an extent, that they Avould hardly admit a probe; and, finally, the Avhole flap had a tendency to slide doAvmvard, and collect in a lump at the end of the nose after dhdsion or excision of the pedicle. The scar left upon the forehead Avas a serious disfigurement, and the attempt to diminish it by draAving the sides of the gap to- gether gave rise to complications, Avhich endangered the patient's life. The operation itself Avas not Avithout danger. Dieffenbach lost tAvo out of six patients upon Avhom he ope- rated in Paris. Fig. 119. Rhinoplasty. Indian method unmodified. The operation Avas originally performed as follows (Fig. 119) : A flap, the size and shape of Avhich Avere determined by a pattern previously made of paper or card, Avas marked out upon the forehead immediately above the nose. Care 232 PLASTIC OPERATIONS ON THE FACE. Avas taken to make it at least a quarter of an inch broader and half an inch longer than the space it was to fill. Its base Avas situated betAveen the eyebnnvs, and Avas half an inch broad. At the upper end of the flap Avas a projecting tab intended to form the columna. The flap, including all the tissues doAvn to, but not through, the periosteum, Avas then dissected up, brought doAvn by twisting the pedicle, placed in its neAV position Avith its raAv surface imvard, and attached by sutures to the freshened edges of the gap it Avas to fill. Prominence Avas given to the ridge by# stuffing the nostrils Avith oiled plugs of lint, or draAving the cheeks tOAvard the median line by means of long pins passed transversely through the edges and under the nose. The gap in the forehead Avas left to heal by granulation. After the flap had united, the pedicle Avas divided, and returned to its ori- ginal position. Modifications.1—Larrey (1820) pointed out the desira- bility of saving even the smallest fragments of the original nose, especially if they belonged to the free border of the ala. Prof. Bouisson2 formulated this principle, and extended it to the other methods, as folloAvs: 1st. Save as much as possible of the septum. 2d. Give lateral support to the flaps by means of the healthy portions of the cartilage of the alae. 3d. Insure the regularity of the outline of the nostril by giving the loAver border of the flap cartilaginous support. Dupuytren and Dieffenbach opposed the retraction and closure of the nostrils by folding back upon itself that por- tion of the edge of the flap, Avhich Avas to form the free border. The torsion of the pedicle involves more or less danger of gangrene by obstructing the return of the venous blood. Lisfranc (1826) Avas the first to attempt to diminish this defect. By lengthening the incision on one side, the base or attachment of the pedicle Avas made oblique instead of transverse, and the torsion correspondingly diminished at that point. Of course, the total amount of torsion remained the same, but, by being spread along the pedicle, it Avas 1 The dates of these modifications, and the award of credit for their suggestion are mainly taken from Verneuil's Chirurgie Reparatrice, to which the reader is referred for further details and documentary proof. 2 Rhinoplastie laterale. RHINOPLASTY. 233 made more spiral and less abrupt. Von Langenbeck (be- fore 1856) Avent a step further, and put the base upon the side of the nose close to the eye, the upper incision ending at the eyebroAV, the loAver just below the tendo oculi. Lab- bat did about the same thing in 1827. Auvert, a Russian surgeon (date unknown, but long be- fore 185(1), made the flap oblique instead of vertical, still keeping the base between the eyebroAvs. Alquie, of Mont- pellier (1850), proposed to make the flap horizontal, the loAver incision being hidden by the eyebroAV ; and Landreau even curved it someAvhat upAvard at the end, so that the base of the pedicle Avas hardly twisted at all in bringing doAvn the flap. Ward (1854) made a flap AAThich was directed ob- liquely upAvards, and Follin (1856) made a transverse one; in each case the base of the pedicle was upon or near the median line of the forehead, a little above the eyebrows. Both cases did well. The objection to a transverse flap is that the retraction of the cicatrix upon the forehead draws the corresponding eyebroAV upAvard. The advantages are that the torsion is less, and the scar someAvhat disguised by the natural lines. Various means have been employed to prevent the descent of the flap. Dieffenbach made a longitudinal incision on the side of the nose, and engaged the pedicle in it. paring off its prominences aftenvards. Blandin excised the portion of skin intermediate between the base of the pedicle and the loss of substance, and thus obtained a raAv surface to Avhich the whole length of the pedicle Avas then united. Instead of excising this intermediate piece of skin, Buck left it attached by its upper end, and used it to cover part of the gap left upon the forehead. Velpeau divided the pedicle close to its base, trimmed it to a point, and engaged it in a vertical incision made in the underlying skin. B. Ollier's Osteoplastic Method1 (Fig. 120).—A lupus had destroyed the alas, columna, lobe, cartilages, and part of the septum. The nasal bones Avere uninjured, but had suffered an arrest of development, and Avere bounded in- feriorly by a strip of cartilage. The nose Avas not more than an inch long. The skin of the cheeks and lips had also 1 Traite de la Regeneration des Os, vol. ii. p. 469. 20* 234 PLASTIC OPERATIONS ON THE FACE. Fiir. 120. been involved by the lupus, and, therefore, could not be used for the restoration. Starting from a point in the median line of the forehead two inches above the eyebroAvs, Oilier made two incisions diverg- ing dowmvards, each of which ended a quarter of an inch to the outer side of the loAver border of the nasal orifice. In dissecting up the long triangular flap thus marked out, he included the perios- teum from above doAvmvards as far as to the upper end of the nasal bones; he then con- tinued the dissection along the right nasal bone, leaving the periosteum adherent to it, and on reaching the loAver end of the bone he separated from it the cartilaginous strip above mentioned, leaving it adherent to the flap. On the left side he divided, with a chisel, the bony con- nections of the left nasal bone, leaving the bone attached to the flap by its anterior surface; this Avas accomplished by introducing the chisel, first betAveen the two nasal bones, then between the left nasal bone and the frontal, and finally between the left nasal bone and the nasal process of the superior maxillary. Drawing the flap doAvmvard, he then divided the cartilaginous septum from before backAvards and downwards Avith scissors, so as to have an antero-posterior flap of cartilage attached by its base to the cutaneous one, and able to furnish central support for the new nose by rest- ing its free border upon the floor of the nasal fossa, or rather upon the remains of the loAver portion of the original septum. He next dreAV the whole flap dowmvard until the upper border of the left nasal bone came into line Avith the loAver border of the right nasal bone, and then fastened the tAvo bones together Avith a metallic suture. The sides of the flap Avere then united to the cheeks, and those of the frontal incisions drawn together above the apex of the flap. Rhinoplasty. Ollier's osteoplastic method. RHINOPLASTY. 235 The parts united, the space left by the removal of the left nasal bone Avas filled Avith bone produced by the perios- teum brought doAvn from the forehead, and the result Avas satisfactory. C. Alquie* used a flap of similar shape in a case in which the alae and septum Avere lost, but the columna remained. The apex of the triangle was placed in the space Fig. 121. betAveen the eyebrows, and the incisions diverged doAvmvard and outward. With a narroAV tenotome passed along the incisions he separated the skin en- tirely from the nasal bones and Avas then able to de- press it far enough to at- tach it to the freshened end of the columna. D. Italian Method (Fig. 121). —Tagliacozzi made tAvo nearly parallel in- cisions along the anterior surface of the biceps, their length and the distance betAveen them varying ac- cording to the size of the gap the flap Avas to fill. The apex of the flap Avas directed tOAvard the should- er. The intermediate strip of skin Avas dissected up, but left adherent at both ends, and a piece of oiled lint passed under it and kept there until suppuration Avas established. The strip Avas then cut free at its upper end, and dressed carefully for about a fortnight, or until its under surface Avas nearly cicatrized. It Avas then considered fit to be applied, having undergone the necessary shrinking and thickening. Its edges and those of the nasal aperture Avere pared and fastened together Avith sutures, and the arm bound fast to the-head. When union had taken place Rhinoplasty. Italian method. 236 PLASTIC OPERATIONS ON THE FACE. between the two, the loAver end of the flap Avas cut loose from the arm and its edges trimmed to the proper shape. Graefe did not let the flap suppurate, but tried to get primary union. PLASTIC OPERATIONS UPON THE EYELIDS. In these operations it is important to save as much as possible of the original tissues, especially the free border of the lid, the conjunctiva, and the orbicular muscle. As the skin is thin and delicate, the flaps must have broad bases to insure their vitality ; they must also be so placed that their natural retraction will not tend to re-establish the previous defect. Blepliaroraphy.—Suture of the eyelids has proved it- self a very valuable adjunct of many of the plastic opera- tions upon the eyelids, and has even taken the place of some of them, for experience has shoAvn that a loss of sub- stance in either eyelid may be safely alloAved to fill and heal by granulation if the borders of the lids are kept fast- ened together. The eye must be kept closed in this Avay for six months or a year, after Avhich time the scar, in most cases, shoAvs no tendency to retract. When the time comes to separate the lids, this should, at first, be done for only half an inch in the centre, and the opening subsequently enlarged at long intervals of time, any indication of cica- trical retraction being meanwhile Avatched for. The prolonged occlusion does no harm to the eye ; on the contrary, it may be sufficient in itself to cure a com- mencing keratitis occasioned by ectropion. Operation.—A narroAV strip of conjunctiva is excised from the border of each lid on the conjunctival side of the lashes, beginning and ending a short distance from the com- missures, so as to leave a space for the flow of the tears. The tAvo raAv surfaces are then brought together accurately with silver sutures. To separate the lids aftenvards a director should be en- tered at the opening left at one of the angles, its point PLASTIC OPERATIONS UPON THE EYELIDS. 237 Fig. 122. pressed against the centre of the line of union, and cut doAvn upon between the tAvo toavs of lashes. Canthoplasty.—Enlargement of the palpebral opening (Fig. 122). The external angle of the eye is divided hori- zontally with scissors, and the skin and conjunctiva united along the sides of the incision by three points of sutures, one of them being placed at the angle. Richet's modification1 (Fig. 122, B). Richet marks out a small flap by tAvo incisions through the skin, beginning at opposite points on the upper and loAver lids near the outer angle and meeting at a point external to that angle. The flap, including every- thing except the conjunc- tiva, is then excised, the conjunctiva split horizon- tally, and its tAvo portions trimmed and fastened to the edge of the cutaneous _ ,. , , "'"„. . ,.. . . . . ~ Canthoplasty. A. Straight incision. mClSlOnS. Richet's modification. Blepharoplasty, to prevent or remedy— 1. Ectropion.—The descriptions will be given for the loAver lid only, that being the more frequent seat of the de- formity. Blepharoraphy (q.v.) is often sufficient in itself to prevent ectropion, and is ahvays a useful adjunct of a plastic operation. The lids should be kept united during the process of cicatrization of the Avound left by the loss of substance, and for several months thereafter. Wharton Jones (Fig. 123).—Wharton Jones included the contracted cicatrix in a triangular flap one inch high, its base occupying nearly the Avhole length of the lid border. 1 Anatomic M6dico-Chirurgicale, 4th edition, p. 88. 238 PLASTIC OPERATIONS ON THE FACE. By dividing the bands of cellular tissue, but without dis- secting up the flap, he restored the lid to its normal position, Fig. 123. Ectropion. Wharton Jones. and held it there by uniting the edges of the incision below it, Avhich thus assumed the form of a Y • Alphonse Guerin1 (Fig. 124) makes two incisions form- ing an inverted V, the point of Avhich lies just beloAV the Fig. 124. centre of the free border of the lid. From the loAver ex- tremities of these incisions he makes a third and fourth parallel to the border of the lid. The tAvo triangular flaps bounded by the 1st and 3d, and the 2d and 4th incisions are then dissected up, the lid raised to its normal position, and held there by uniting the adjoining sides of these tAvo flaps in such manner that their apices and that of the in- verted V meet at a common point. The gaps left by the Chirurgie Operatoire, 4th edition, p. 318 PLASTIC OPERATIONS UPON THE EYELIDS. 239 removal of the two flaps are alloAvcd to granulate. For greater security Guerin also unites the borders of the lids (blepharoraphy). Von Graefe (Fig. 125, A).—Make an incision along the border of the lid just outside of the lashes from the lach- Ectropion. A. \*on Graefe's method. B. Knapp's method. rymal point to the external commissure. From each ex- tremity of this make a vertical incision doAvmvard from one- half to three-quarters of an inch in length. These incisions should involve only the skin. Cut off the upper inner cor- ner of this flap, not by a straight incision, but by one form- ing an angle, as shoAvn in the figure, and fasten this angle by a suture to that formed by the border of the lid and the inner vertical incision. Reunite the edges of the transverse incision, cuttim>' the ends of the sutures Ions; enough to reach to the forehead, and then fastening them there Avith adhesive plaster. The excision of the inner angle of the flap raises the eyelid by shortening its border. Dieffenbach, Adams, and Amnion have proposed other methods of shortening the lid. They are indicated in Fig. 126, Avhere the shaded spaces represent the portions of skin to be removed, and the threads the manner in Avhich the edges are afterwards brought together. Adams's excision included the Avhole thickness of the lid. Richet (Fig. 127).—Richet makes an incision parallel to the border of the lid, half an inch beloAV it, and extend- ing nearly from one angle of the eye to the other. The lid, having been freed by this incision, is then united to the other (blepharoraphy). 240 PLASTIC OPERATIONS ON THE FACE. He next makes a second incision parallel to the first and one-third of an inch beloAV it, divides the intermediate strip of skin vertically in the middle and dissects up its tAvo halves. Immediately below the loAver end of this vertical Ectropion. A. Dieffenbach. B. Adams. C. Ammon. The shaded spaces indi- cate the portions of skin removed ; the threads show how their edges are brought together. incision he removes from the lower border of the second incision a V-snaPe(l naP °f skin, its point directed doAvn- Avard. He then raises the two halves of the middle flap, brings them again into contact with the border of the lid, Ectropion. Richet. excises their superfluous length, and unites them. The sides of the v are then brought together and the edges of the incisions re-united. Knapp (Fig. 125, B).—Knapp employed the folloAV- ing method to remove an epithelioma occupying the inner portion of the loAver eyelid, the free border of Avhich was involved. He circumscribed the tumor by tAvo vertical and tAvo horizontal incisions and excised it. The horizontal in- PLASTIC OPERATIONS UPON THE EYELIDS. 241 cisions Avere then prolonged on both sides, the loAver external one being inclined doAvmvard so as to make the base of the flap broader, the tAvo flaps dissected up, draAvn together and united by their vertical edges. Buroiv (Fig. 128).—The loss of substance is made triangular in shape, the apex directed doAvmvard; the base is then prolonged horizontally outAvard, and an equal and similar triangle marked out upon the upper side of the pro- Fig. 128. Ectropion. Burow. longation. The skin contained Avithin the second triangle is then excised, and the irregular flap bounded by the outer sides of the two triangles and the prolongation of the hori- zontal incision dissected outAvards and doAvnwards, and then moved toward the median line until it covers both the open spaces. It is not necessary that the tAvo triangular spaces should touch at one corner; they may be an inch, or even more, apart; but they must of course be connected by the hori- zontal incision. Dieffenbach (Fig. 129).—When the cicatrix or tumor Avas large Dieffenbach gave the loss of substance a trian- gular shape, the apex directed doAvmvard. He prolonged outAvard the horizontal incision forming the base of the triangle, and carried another incision doAvmvard and imvard from its outer extremity. The quadrilateral flap thus marked out Avas dissected up and carried imvard to cover the loss of substance. The gap left by its removal Avas 21 242 PLASTIC OPERATIONS ON THE FACE. then drawn partly together with sutures, and the remainder left to granulate. Ectropion. Dieffenbach. Indian Method.—Sedillot refers the first blepharoplasty by the Indian method to Von Graefe in 1809. As this Avas previous to the introduction of rhinoplasty by the same method, the idea Avas probably entirely original Avith Von Graefe. The case is mentioned in his Rhinoplastik, 1818, but without details. The flap can be taken from the fore- head or cheek ; it should be very large and should include the subcutaneous cellular tissue. Fricke, of Hamburg, took a vertical flap from the temporal region to restore the upper eyelid. Fig. 130. Ectropion. A. Modified Indian Method. B. Richet. One of the modifications of this method, intended to ob- viate the necessity of dividing the pedicle, is shown in Y\v. 130, A. PLASTIC OPERATIONS UPON THE EYELIDS. 243 Richet (Fig. 130, B).—The lids are freed by two in- cisions inclosing all the cicatricial tissue, and then united (blepharoraphy), the sutures being cut long and their ends fastened upon the forehead. Tavo flaps are then marked out as shoAvn in the figure, the external one, 0, raised and used to cover the original loss of substance, and the inner one, D, used to fill the gap occasioned by the removal of C. Hasner d'Art ha (Fig. 131) employed the following method in a case Avhere a tumor occupied the commissure Ectropion. Hasner d'Artha's method. and inner portion of each eyelid. He made a curved in- cision, a, beginning at the border of the upper eyelid beyond the limit of the tumor, crossing the eyebroAV to the forehead, and then crossing downward to terminate near the root of the nose. A second curved incision, c, began at the same point as the first and Avas carried along the upper and inner edge of the tumor to the point marked /. A third curved incision, e, began on the border of the loAver lid beyond the limit of the tumor and was carried along the loAver margin of the latter to the point/. A fourth curved incision, g, parallel to the border of the loAver lid, was car- ried from the point/ outAvard to the cheek. The tumor and the portion of the lids circumscribed by the incisions c and e Avere then removed, and each of the flaps d and h dissected up to its base. The former Avas loAvered, the latter raised, and the excess of each cut off. The upper border of the flap h formed the free border of 244 PLASTIC OPERATIONS ON THE FACE. the loAver lid, and the loAver border of the flap d formed the free border of the upper lid, and the commissure corre- sponded to the apex of the flap h. The skin of the fore- head and cheeks Avas mobilized and reunited to the flaps. (Dubrueil.) Denonvilliers's method "by exchange" (Fig. 132). In a case of ectropion of the loAver lid, Avith deviation of the Ectropion. Denonvilliers's method "by exchange." outer angle of the eye doAvmvards, Denonvilliers used the folloAving method. By making three incisions to meet in the form of a Z, he marked out tAvo adjoining triangular flaps ; one of them included the outer angle of the eye, the apex of the other Avas situated upon the forehead just above the eyebroAV. He then dissected up the flaps, restored the angle of the eye to its proper position, brought the upper flap doAvn into the gap made by the loAver incision, and the loAver flap up into that made by the upper incision. Ectropion due to excess of the conjunctiva may be treated by cauterization of the conjunctiAra, or by excision of a portion. The latter operation is simple ; a fold is pinched up Avith forceps and excised Avith knife or scissors. The edges of the gap may then be brought together by sutures or left to granulate. 2. Entropion.— Canthoplasty (q. v.) may be employed to remedy moderate entropion, especially if it be due to spasm of the orbicularis. Ligature (Fig. 133), proposed by Gaillard to remedy trichiasis, is equally applicable to the cure of entropion. PLASTIC OPERATIONS UPON THE EVELIDS. 245 A transverse fold is pinched up, and a needle carrying a stout ligature passed through its base, shaving the anterior surface of the cartilage. The ligature is tied and alloAved to cut through the skin. The resulting linear cicatrix main- tains the lid in the position Entropion; ligature. given it by the ligature. Rau has modified this by placing several ligatures in- stead of only one. Exci.sion or cauterization of a fold of the skin is appli- cable to cases of entropion due to laxity of the skin of the eyelid. A transverse or a vertical fold is pinched up quite near to the margin of the lid and excised; the borders of the Avound are united by sutures. Instead of excision, cau- terization of the strip, preferably with sulphuric acid, is sometimes used. Von Graefe ( Fig. 134) treated a case of spasmodic entropion by removal of a triangular piece of skin. He made a cutaneous incision parallel to the free border of the lid, and about a line from it, and excised a triangular cuta- neous flap, the base of Avhich occupied the median portion of the first incision. The sides of the Avound left by the excision of the triangular piece Avere then draAvn together with sutures. Fig. 134. Fig. 13f>. Entropion—lower lid. Von Graefe. Entropion—upper lid. \ron Graefe. 21* 216 PLASTIC OPERATIONS ON THE FACE. For spasmodic entropion of the upper lid, Avith retraction of the tarsal cartilage, Von Graefe modified the operation as follows (Fig. 135) : After excision of the triangular cutaneous flap, he dreAv the sides of the wound apart, divided the orbicular muscle horizontally near the edge of the lid, and dreAv it upwards, exposing the cartilage. He then excised a triangular piece of the cartilage, the apex being at its lower border, taking care not to include the conjunctiva in the dissection. The sides of the cutaneous Avound were then drawn together with three sutures, the middle one of which included also the sides of the gap left in the cartilage. Excision of a Portion of the Orbicularis.—Key cured a case of spasmodic entropion by excising a feAv fibres of the orbicular muscle. He made an incision through the skin parallel to and near the free border of the lid, exposed the muscle, and removed a bundle of fibres from its central margin. It is Avell to combine this Avith removal of a hori- zontal strip of skin. Division or Resection of the Tarsal Cartilage.—When the entropion is caused or maintained by shortening or in- curvation of the tarsal cartilage, the operation must be directed to the removal of this cause. Vertical division at one or tAvo points of the entire thick- ness of the lid has been employed. After having been divided, the border of the lid is held in its proper position by ligatures passed through it and fastened to the forehead (upper lid) or cheek (loAver lid) while the Avound fills and heals by granulation. A horizontal incision through the conjunctiva from one vertical incision to the other makes it easier to turn the lid out and hold it in place. Longitudinal Tarsotomy (Amnion).—The eyelid having been turned out, a knife is passed through it from the con- junctival side, quarter of an inch from the border, and on a line Avith the lachrymal point, and an incision made parallel with the border nearly to the outer angle. A longitudinal strip of skin is then excised, and the edges of the gap left by the excision drawn together. By this means the free border of the lid is drawn aAvay from the surface of the eye, turning upon the longitudinal incision as upon a hinge. PLASTIC OPERATIONS UPON THE EYELIDS. 247 Excision of part of the Cartilage (Streatfeild), Fig. 137. —The eyelid is fixed with Pope's forceps (Fig. 136), the flat blade against the conjunctiva, and an incision made Entropion. Streatfeild's method. parallel to the border of the lid at the distance of one line from it, and carried to a depth sufficient to expose the bulbs of the eye- lashes. The surgeon, raising the edge of the skin, passes around the bulbs to the tarsal cartilage, and then makes a second incision Pope-s forceps. at a greater distance from the border of the lid than the first one Avas, meeting the first at its two extremities and inclos- ing with it an OAral strip of skin. These two incisions are carried into the cartilage, circumscribing a longitudinal wedge-shaped strip, the apex of which reaches nearly to the conjunctival side of the cartilage. The Avound is left to heal by granulation, Avith the expectation that the con- traction of the cicatrix will overcome the entropion. 3. Symblepharon.—When the adhesion betAveen the tAvo layers of the conjunctiva is incomplete, that is, when it does not extend to the bottom of the sulcus betAveen the lid and eyeball, it is sufficient to throAv a ligature lightly around it. After the ligature has cut through, the tabs are succes- sively excised, and the borders of each Avound draAvn to- gether or left to heal by granulation. To avoid reunion of 248 PLASTIC OPERATIONS ON THE FACE. the surfaces, the second tab should not be removed until after the wound left by the removal of the first has healed. When the adhesion is complete, but not broad, a thread or silver wire may be passed through its base and tied loosely around it. After the hole made by the wire has cicatrized the adhesion is divided. The narroAV line of cica- trix left at the bottom of the fold by the wire favors the separate healing of the two sides of the incision. Arlt's Method.—A thread is passed through the fold close to the cornea, and the symblepharon dissected aAvay from the eyeball. Each end of the thread is then attached to a needle and passed through the lid from Avithin outAvards at the bottom of the Avound. By draAving upon the thread and tying it outside the lid the symblepharon is folded upon itself and its point fixed at the bottom of the sulcus. The edges of the wound on the eyeball are then draAvn together Avith sutures, the conjunctiva being loosened by dissection, if necessary. Fig. 138. Symblepharon. Teale"% Method (Figs. 138, 139, 140).—The symble- pharon is separated from the ball of the eye by an incision along the line of its union Avith FlS- 14°- the cornea and dissected doAvn to the bottom of the fold as in Arlt's operation, its apex, hoAV- ever, being left upon the cornea. Tavo long, narroAV conjunctival flaps, B and C, are then dis- sected up on opposite sides of the eyeball, their bases directed toAvards the symblepharon, their Fig. 139. PLASTIC OPERATIONS UPON THE EYELIDS. 249 borders parallel to that of the cornea. These flaps should not include the subconjunctival tissue. The inner flap B is brought doAvn and fastened to the denuded surface of the eyelid, the outer flap C covers that of the eyeball. They are fastened in place by means of fine sutures, and the edges of the gaps left by their removal brought together in the same manner. Ledentus Operation. — Where one lid Avas adherent throughout its entire length, Ledentu divided the adhesion to a depth equal to that of the normal fold, dissected a long conjunctival flap from the other half of the eye, leaving it adherent at both ends, brought it doAvn across the cornea, and applied it to the raw surface left on the eyeball by the division of the adhesion. This flap should be at least one- third of an inch broad. 4. Pterygion. Excision.—-The pterygion is pinched up with forceps, a knife passed flatwise under it close to the Pterygion ; ligature. cornea, and the portion of the groAvth Avhich corresponds to the latter shaved off. The edges of the conjunctival Avound are then draAvn together Avith sutures. 250 PLASTIC OPERATIONS ON THE FACE. Scissors may be used instead of the knife; in that case the incision must begin at the point of the groAvth. Ligature, Szokalski (Fig. 141).—A thread is passed under the pterygion by means of two small curved needles, as shown in Fig. 141. The thread is cut close to the nee- dies, and thus made to furnish three ligatures, one at each end, encircling the groAvth at right angles to its long axis, and one in the middle, encircling its implantation upon the sclerotic. The ligatures are tied tightly, and the inclosed portion falls in a feAv days. 5. Trichiasis.—Temporary removal of the deviated lashes is seldom effectual. Permanent removal by destruc- tion of their bulbs, or excision of the border of the lid, is now considered unjustifiable. The direction of the lashes may be changed by operation upon the lid. The retraction folloAving excision of an oval strip of skin, or the use of ligatures as in entropion, is sometimes sufficient, but it may be necessary to act more directly upon the lashes. Von Graefe's Method.—An incision is made along the free border of the lid on the conjunctival side of the devi- ated lashes. From each end of this a vertical incision is next made through the free border and the skin. The flap thus circumscribed and containing the lashes is dissected up a short distance. It is then easy to fasten it with sutures in such a position that the lashes can no longer touch the eyeball. Anagnostakis made a cutaneous incision parallel to the border of the upper lid and one-eighth of an inch from it, exposed the orbicular muscle by draAving the skin up, and excised that portion of it which corresponded to the upper part of the tarsal cartilage. The loAver edge of the cuta- neous incision Avas then draAvn up and fixed to the fibro- cellular layer covering the cartilage by means of three or four sutures, Avhich Avere then alloAved to cut themselves out. PART VII. SPECIAL OPERATIONS. CHAPTER I. OPERATIONS UPON THE EYE AND ITS APPENDAGES. In most operations upon the eye the lids should be held back by an eye-speculum (Fig. 142), and the eyeball Fig. 142. Eye speculam. fixed by pinching up a fold of the conjunctiva with toothed forceps. THE CORNEA. Removal of a Foreign Body.—When the foreign body has penetrated to only a slight depth, it may be easily removed Avith the point of a knife or fine forceps; but, if it lies so near the posterior surface of the cornea that there is danger of forcing it through into the anterior chamber by the efforts made for its extraction, a lance-shaped knife must be entered very obliquely and passed behind it, betAveen the layers of 252 OPERATIONS UPON THE EYE. Fio-. 143. Stop n probe fo ring the edle and r punctu- cornea. the cornea if there is sufficient space, other- wise Avithin the anterior chamber. If the foreign body falls into the anterior chamber, notwithstanding these efforts to prevent it, the surgeon must wait until the aqueous humor has reaccumulated, and then make an incision three or four millimetres in length at the lower portion of the periphery of the cornea, in the hope that the foreign body will be Avashed out during the flow of the liquid. Puncture of the Cornea.—This may be made with broad needle or a well-AVorn Beer's knife. It is advisable to employ anaesthesia, and to steady the eyeball Avith fixation forceps. The surgeon stands behind the patient, raises the upper lid, and fixes it against the margin of the orbit Avith two fingers of his left hand, Avhich also rest against the inner side of the eyeball and prevent it from rotating imvards. The nee- dle or knife is then entered a little in front of the edge of the cornea at the outer side. Its direction must be sufficiently oblique to avoid injury to the iris, and not so much so that the instrument will remain between the layers of the cornea and fail to penetrate to the anterior chamber. By partly Avith- draAving the instrument and tAvisting it slightly, the incision is made to gape and alloAV the escape of the liquid; or a fine blunt probe may be passed into the incision after entire AvithdraAval of the needle. Sub- sequent tappings are effected by reopening the original Avound with the probe. Figure 143 represents a combined needle and probe. The needle is provided Avith a shoulder to prevent its introduction to too great a depth. Removal of a Staphyloma, a. Critchctt's Method (Figures 144 and 145).—Pass four THE CORNEA. 253 or five curved needles behind the projection and leave them fast in the sclera. '• Then make an opening in the sclerotic Fig. 144 Critchett's operation for staphyloma. The dotted line represents the incision. about tAvo lines in extent, just anterior to the tendinous in- sertion of the external rectus muscle, Avith a Beer's knife (Fig. 146). Into this opening insert a pair of small probe- pointed scissors and cut out an elliptic piece just Avithin the Fig. 145. Critchett's operation for staphyloma. After re.no val. points Avhere the needles have entered and emerged."1 After removal of the lens and some of the Adtreous humor, 1 Ophthalmic Hospital Reports, vol. iv. Part I. page 7. ■ /■> 254 OPERATIONS UPON THE EYE. the needles are drawn through and the sutures tied, leaving a horizontal linear cicatrix. Knapp has modified this by passing the sutures through the conjunctiva only, hoping thereby to diminish the risk of the occurrence of sympathetic ophthalmia. b. Carter's Method.1 (Resection of the anterior portion of the globe.) Divide the conjunctiva all round, close to the margin of the staphyloma, and dissect it from the sclerotic nearly to the equator; then detach the four recti muscles and cut off the front portion of the eyeball well behind the cil- iary region. The superior and inferior recti should then be united in front of the Avound by a catgut suture, and the internal and external recti in front of them; and the edges of the conjunctival incision should be brought together in a horizontal line by silk sutures. THE IRIS. Iridotomy.—Incision of the iris may be performed for the purpose of establishing an artificial pupil. As its success depends upon the retraction of the divided fibres, it should be undertaken only when their contractility is not interfered Avith by too extensive adhesions, or has not been de- stroyed by disease. The more common lesions to Avhich the operation is applicable are central opacity of the cornea, occlusion of the pupil, and excessive prolapse of the iris after removal of a cataract; but the danger of injury to the lens is so great that the operation is practically restricted to the class of cases last mentioned. 1 Holmes's Surgery, its Principles and Practice, p. 709. Fie. 146. THE IRIS. 255 The best place for an artificial pupil is in the loAver inner quarter of the iris, the second best in the loAver outer quar- ter. As the portion of the cornea traversed by the knife or needle is likely to become more or less opaque in conse- quence, the incision in it should be made as far as possible from the point Avhere the pupil is to be created. Simple Incision.—Cheselden, who Avas the first to per- form this operation, entered a narroAV-bladed knife through the sclerotic just anterior to the insertion of the external rectus, the point directed towards the centre of the globe of the eye. After the point had penetrated to the depth of one-eighth of an inch it Avas directed fonvard, passed through the iris to the anterior chamber and transversely across the latter, its edge looking backAvard. By pressing the edge against the iris and AvithdraAving it a horizontal incision Avas made in that membrane. BoAvman punctured the cornea midway betAveen its centre and external border, passed a narrow blunt-pointed knife through the puncture into the anterior chamber, and thence through the pupil to the posterior surface of the inner half of the iris, Avhich he then divided by cutting forwards. The danger of injury to the cornea during the last step of the operation is very great. Bell1 uses a double-edged needle Avhich is "• introduced through the cornea near its margin ; on arriving at the place Avhere the pupil ought to be, one edge is draAvn against the iris and divides it transversely, if possible, Avith- out injuring the lens." A^eckcr proposes simple iridotomy and double iridotomy; the former in cases of central opacity of the cornea or lens, the latter Avhen the pupil has become obliterated after re- moval of a cataract. He uses a small lance-shaped knife with a shoulder, straight or bent upon the flat, and a pair of forceps-scissors. Simple Iridotomy (Wecker).—The knife is entered mid- Avay between the centre and border of the cornea on the side opposite to that on which the pupil is to be made. As soon as the cornea has been perforated the knife is Avith- 1 Manual of Surgical Operations, 3d ed. p. 162. 256 OPERATIONS UPON THE EYE. draAvn and the forceps-scissors passed through the Avound to the further border of the pupil, where they are opened and one of the blades passed behind, the other in front, of the iris. By closing them sharply the circular fibres are divided from the margin of the pupil toAvards the periphery of the iris. The scissors are then AvithdraAvn, the iris re- placed if it engages in the Avound, a few drops of a solution of atropine placed between the eyelids, and a compress applied. Double Iridotomy (Wecker).—The knife is passed per- pendicularly through the cornea and iris one millimetre from the edge of the conjunctiva, on the side toAvards Avhich the obliterated pupil has been retracted ; its point is then made to pass along the posterior surface of the iris until arrested by its shoulder, when it is AvithdraAvn sloAvly. The forceps-scissors are next introduced through the incision, and one blade passed behind and the other in front of the iris for a distance of one-quarter of an inch or a little less. Tavo successive sections of the iris are then made, inclosing a triangular flap, the apex of Avhich is directed towards the incision in the cornea. The pupil is formed by the retrac- tion of this flap. Iridectomy.—Excision of a portion of the iris may be employed for the purpose of creating an artificial pupil (optical iridectomy), or for the relief of tension in glaucoma or iridochoroiditis (antiphlogistic iridectomy), or as a pre- liminary to the removal of a cataract.1 The size of the portion excised is determined by the length and position of the line of the incision on the posterior surface of the cornea; the nearer this is to the margin of the cornea the larger will be the portion of the iris removed. In antiphlo- gistic iridectomy, therefore, Avhen the entire breadth of the iris from the pupil to its outer margin should be removed, the knife must be entered one millimetre outside of the clear portion of the cornea; in optical iridectomy, on the other hand, the excised portion should be small and the knife should be entered Avithin the margin of the cornea. 1 For a complete list of the indications for iridectomy the reader is referred to Stellwag on Diseases of the Eye, p. 197. New York, Wm. Wood & Co., 1868. THE IRIS. 257 In antiphlogistic iridectomy at least one-fourth of the iris should be removed, the piece being taken from the upper segment in order that the loss may be hidden by the upper eyelid. In optical iridectomy the pupil should be made on the inner side of the loAver segment unless corneal opacities are in the Avay. Operation for Antiphlogistic Iridectomy.—The instru- ments required are a lance-shaped knife, straight (Fig. 147) or bent (Fig. 148), iridectomy forceps (Figs. 149 and 150), and scissors curved upon the flat (Fig. 151). Fig. 147. Fig. 148. The patient having been anaesthetized and placed in a recumbent posture, the surgeon takes such a position in front of or behind him as will facilitate the making of the first incision. The eye speculum and fixation forceps hav- ing been applied, the latter immediately opposite the point of puncture, the knife is introduced perpendicularly to the surface of the sclerotic one millimetre outside of the margin of the cornea and passed steadily in until its point has entered the anterior chamber at its very rim; its direction is then changed and it is carried along the anterior sur- face of the iris until its point reaches the centre of the 258 OPERATIONS UPON THE EYE. Fig. 149. Fig. 150. Fig. 151. Fie 152. Iridectomy Incision of cornea. pupil, or until the length of the incision is considered sufficient (Fig. 152). By inclining the point of the knife to each side, the length of the incision in the poste- rior surface of the cornea may be made equal to that on the anterior surface. THE IRIS. 259 The knife is then AvithdraAvn and the aqueous humor alloAved to run off* very sloAvly in order that the relief of intra-ocular pressure may not be so sudden as to lead to congestion and hemorrhage. If the iris does not noAV present in the Avound the iridec- tomy forceps must be introduced closed as far as to the margin of the pupil, Avhich is then seized and draAvn out gently through the incision. An assistant then cuts off with the curved scissors all the protruding portion of the iris close to the lips of the Avound (Fig. 153). Or the fixation forceps may be con- F'g- lr>3- tided to the assistant before the introduction of the iri- Fio-. 154. Tyrrell's hook. dectomy forceps, and the surgeon left free to use the scissors himself. Instead of the iridectomy forceps Tyr- rell's hook (Fig. 154) may be used to draAv the iris out through the incision. It must be introduced upon its side, hooked around the margin of the pupil, and then its point must be turned toAvards the cornea and aAvay from the centre of the eyeball so that it will not catch upon the posterior edge of the in- cision during its AvithdraAval. yVJ j--_ If any hemorrhage takes place into the ante- rior chamber the escape of the blood before co- agulation should be favored by separating the lips of the incision Avith a curette, and making gentle pressure upon the eyeball. Optical Iridectomy.—As only a small central portion of the iris is to be removed, the incision should be made in the cornea Avith a narroAV knife or a broad needle (Fig. 155). If the margin of the pupil is adherent, the adhesions may be broken up with a blunt hook ( Corelysis, Iridectomy. Excision of the iris. 260 OPERATIONS UPON THE EYE. q. v.), or a portion of the iris, not including the margin of the pupil may be pinched up and removed {Iridorhexis, q. v.). Iridorhexis.—A modification of optical iridectomy intro- duced by Desmarres for cases in Avhich the existence of adhe- sions at the margin of the pupil, or the friability of the iris, renders it impossible to draw out the latter through the inci- sion in the cornea. After the incision has been made in the cornea as for optical iridectomy, the iris is seized near the pupil Avith iri- Fig. 156. Canula forceps. dectomy or canula forceps (Fig. 156), drawn up into the incision, and a portion excised or torn off. Iridesis, or displacement of the pupil by ligature. Crit- chett, the inventor of this operation, claims1 that by it the size, form, and direction of the pupil can be regulated to a nicety, and its mobility preserved. It is applicable to nu- merous groups of cases in Avhich the natural pupil, or even a part thereof, is movable, and has a free edge; but the simplest class is that of central opacity of the cornea in which it is only required that the natural pupil should be moved slightly to one side, so as to bring it opposite the transparent part of the cornea. It has also been used in cases of conical cornea, to change the shape of the pupil to that of a slit; and in a case Avhere the pupil had been ren- dered very small and narroAV by broad synechiae, Critchett made it large and almost circular by draAving its sides apart at nearly opposite points. 1 02)hthalmic Hospital Reports, vol. i. p. 220. THE IRIS. 261 The operation is performed as folloAvs:— An opening is made with a broad needle through the margin of the cornea close to the sclerotic, and just large enough to admit the canula forceps. A small portion of the iris near but not close to its ciliary attachment is seized and draAvn out to the extent considered sufficient for the pro- posed enlargement of the pupil; a piece of fine floss silk, previously tied in a small loop round the canula forceps, is slipped doAvn, and carefully tightened around the portion of iris made to prolapse, so as to include and strangulate it (Fig. 157). This manoeuvre is best accomplished by hold- Iridosis. ing each end of the silk Avith a pair of small broad-bladed forceps, bringing them exactly to the spot Avhere the knot is to be tied, and then draAving it moderately tight. The small portion of the iris included in the ligature speedily shrinks, leaving the little loop of silk, Avhich may be removed on the second day. If it is desired to make the pupil extend to the periphery of the iris, the margin of the pupil must be seized Avith the forceps, and draAvn out through the incision. In this case Soelberg Wells prefers a blunt hook to the canula forceps. Corelysis, or rupture of adhesions uniting the margin of the pupil and the lens. The operation Avas first performed by Streatfeild, as folloAvs:1 He punctured the cornea Avith a broad needle on the outer side near its margin, passed his 1 Ophthalmic Hospital Reports, vol. i. p. 6. 262 OPERATIONS UPON THE EYE. spatula (Fig. 158) along the anterior surface of the iris to the pupil, engaged the adhesions in the notch on the edge of the spatula, and tore them. When the entire margin of the pupil was adherent, he passed the needle along the Fig. 158. Streatfeild's spatula hook. surface of the iris, across the pupil to its opposite margin, and cut the adhesions at that point. Then withdraAving the knife, he passed the spatula through the hole thus made, and easily broke up the remaining adhesions. When the adhe- sions were too strong to be broken Avith the spatula, he used the canula scissors. A few drops of the solution of atro- pine should be applied to the eye, both before and after the operation. OPERATIONS UNDERTAKEN FOR THE RELIEF OF CATARACT. A cataract is an opacity of the crystalline lens, or of its capsule, or of both; the former being much the most common variety. It may be hard, soft, or semiliquid, and its con- dition, in this respect, has an important bearing upon the choice of a method of operation. The lens is composed of a solid nucleus and a soft cortex ; the Avhole lying free Avithin the capsule which is itself attached to the vitreous humor. In consequence of the absence of adhesions between the lens and the capsule, moderate pressure is sufficient to force out the former after the latter has been divided. In operating upon a cataract, the patient should be re- cumbent ; anaesthesia, though desirable, is not indispensable, except A\dth young children or unruly patients; the other eye should be covered Avith a bandage, unless its sight is entirely lost; and an eye speculum may be used to keep the lids apart, if the services of a trained assistant cannot be had. The objection to a speculum is that it is somewhat in the way of the knife, cannot be removed promptly enough, and is apt to make dangerous pressure upon the eye. If used, the screw of the instrument should be loosened as soon OPERATIONS FOR THE RELIEF OF CATARACT. 263 Fig. 159. N, as the incision has been made. A feAV drops of a solution of atropine should be placed under the lids a short time before the operation. The methods of operation may be classified as:— Depression or couching; Division, discission, or solution; Extraction; Operation for secondary cataract. Depression or couching, Avhich was the original and, for many years, the only method of removing cataract, is noAV universally abandoned, on account of the danger that the displaced lens may set up inflammation of the eye by con- tact Avith the other parts, especially the iris and ciliary pro- cesses, and thus cause total loss of sight. Soelberg Wells states that about fifty per cent, of the eyes thus operated upon have been lost by chronic irido-choroiditis. The opera- tion Avill be described, however, for the sake of reference. If the puncture is made in the sclerotic, the operation is called scleroticonyxis; if in the cornea keratonyxis. Scleroticonyxis.—A curved couching needle (Fig. 159), its convexity turned upwards, is passed through the sclerotic on the temporal side about four milli- metres from the margin of the cornea, and three millimetres below the horizon- tal diameter of the eye. Its convexity is then turned fonvard, and the needle carried behind and parallel to the iris, across to the upper and inner margin of the pupil (Fig. 160), Avhen the handle is lightly tilted upwards, and the lens sloAvly depressed by the concave surface of the needle. After holding it in place for a moment, the needle is slightly rotated to disentangle its point, and AvithdraAvn. Some authors recommend that the anterior capsule should rfh Couching needle. 264 OPERATIONS UPON THE EYE. be formally divided horizontally or vertically before the lens is depressed. Keratonyxis.—The needle is passed through the cornea a little below its horizontal diameter, and midway betAveen Fig. 160. Depressing cataract. its centre and margin, and carried backAvards and inwards, through the pupil to the lens, Avhich is then depressed as before. In the Arariety of depression called reclination, the upper edge of the lens is rotated backward about its transverse axis at the same time that it is depressed, so that its ante- rior becomes its superior surface. Division, Discission, or Solution.—The object of this operation is to tear open the anterior capsule Avith a fine needle, and by thus bringing the aqueous humor into con- tact -with the lens to promote the gradual softening and absorption of the latter. The selection of the term discis- sion Avas made in consequence of an erroneous impression, that the more completely the lens Avas broken up at first, the more rapidly Avould the work of absorption go on, and the surgeons, therefore, tried to cut the Avhole lens into fragments. Experience has since shown that in most cases the absorption must be gradual, and the operation frequently repeated, only a small amount of the substance of the lens being alloAved to come into contact Avith the aqueous humor on each occasion. If the lens is all broken up at once, the numerous fragments SAvell, and act as foreign bodies in the aqueous humor, and set up inflammation in the iris and OPERATIONS FOR THE RELIEF OF CATARACT. 265 cornea to the immediate arrest of the process of absorption. This operation is more especially indicated in the cortical cataract of children, and of young persons up to the age of twenty or twenty-five years, also in those forms of lamellar cataract in which the opacity is too extensive to alloAV of much benefit being derived from an artificial pupil. After Fig. 161. Fig. 162. d* Bowman's fine stop needle. the age of thirty-five or forty, absorption is much sloAver, and the iris much more irritable. There are tAvo methods of performing the operation; in one the needle is passed through the cornea, in the other through the sclerotic. Division through the Cornea.—The pupil is widely dilated with atropine, the eyelids drawn apart by an assistant, or fixed with the eye speculum, and a fold of conjunctiva on the inner side of the eye seized with the fixation forceps. A fine spear-shaped needle with a shoulder (Fig. 161) is passed through the outer lower quadrant of the cornea, almost perpendicularly to its sur- face at a point Avell Avithin the dilated pupil, so that the iris shall not be touched by the needle. One or more incisions, according to the effect desired, are then made in the anterior capsule of the lens, the needle Avith- draAvn, and a compressive bandage applied. The operation Hays's knife needle. 266 OPERATIONS UPON THE EYE. may be repeated as soon as all redness and irritability of the eye have disappeared. Division through the Sclerotic (Hays1).—The patient having been prepared as before, the knife-needle (Fig. 162), Avith its cutting edge upAvards, is passed through the sclerotic at a point on its transverse diameter three or four millimetres from the temporal margin of the cornea, and perpendicularly to the surface of the eyeball. Its direction is then changed and its point carried betAveen the iris and lens to the opposite margin of the pupil. If it encounters and penetrates the lens on the Avay, it will probably dislo- cate it, in Avhich case extraction should be at once performed; if the needle is pushed into the lens Avithout dislocating it, the instrument should be AvithdraAvn until its point is free, and then pushed on again in a better direction. This being accomplished, the edge of the knife is turned back against the centre of the lens, and a free incision made by AvithdraAving it a short distance, Avhile pressing its edge firmly against the cataract. In order to expedite the cure, Wells thinks it is a good plan to combine division Avith extraction, and remove the Avhole cataract by a linear incision, after it has been softened by contact Avith the aqueous humor. In children this may be done Avithin a Aveek after the division. The same pro- ceeding may be employed in cases of partial cataract, the transparent portion of the lens being made opaque and softened by the introduction of the needle. Extraction.—The methods of extraction may be classified as— The flap ; Yon Graefe's; The linear; The scoop ; Extraction by suction; and Removal of the lens in its capsule. Flap Extraction.—The common flap operation is cer- tainly the best Avhen it is successful. It is nearly painless, does not affect the appearance of the eye, and leaves a 1 American Journal of Medical Sciences, July, 1855, p. 81. OPERATIONS FOR THE RELIEF OF CATARACT. 267 natural movable pupil. These advantages, however, are offset by serious disadvantages; the great size of the flap involves the risk of partial or diffuse suppuration of the cornea, accompanied possibly by suppurative iritis or irido- Fiji. 163. Fig. 164. Sichel's knife. choroiditis. Prolapse of the iris is a not un- frequent complication, and the after-treatment requires much more care and attention. Many surgeons are umvilling to use chloroform in the operation, because the Avound is so large that a fit of vomiting may force out the vitreous humor, or even the retina and choroid. The instruments required are a Beer's (Fig. 146) or Sichel's (Fig. 163) knife, fixation forceps, (Iraefe's cystotome and curette (Fig. 164), and a small blunt-pointed knife or pair of scissors for enlarging the Avound, if neces- sary. The section may be made in the upper or loAver half of the cornea; the former is rather the more advantageous, the latter the easier of execution. Operation.—(Right eye, upper section).—- First Stage.—Patient recumbent, the operator seated behind him. The eyelids are separated by an assistant standing at the patient's left side, and draAving the lids gently apart Avith the fore- finger of each hand, Avithout making any pres- sure upon the eye. The surgeon steadies the eyeball by pinching up a fold of conjunctiva, with fixation forceps, either just below the cornea, as in Fig. 165, or better, perhaps, just below its prolonged horizontal diameter on the inner side, and draAVS the eyeball gently doAvn. He then enters the point of the knife at the outer side of the cornea half a millimetre Aron Graefe's cystotome and curette. 268 OPERATIONS UPON THE EYE. within its margin, and just on its transverse diameter, and carries it steadily across the anterior chamber, taking care Flap extraction of cataract. Mode of fixing the eye and making the incision. to keep the side of the blade parallel to the iris, and to press slightly doAvmwards Avith its back so that it may ahvays fill the incision completely and prevent the escape of the aque- ous humor. The counter puncture is made, by the steady advance of the knife, at a point immediately opposite that of entry, the fixation forceps removed, and the knife pushed on in the same direction until the section is all but finished; Avhen only a small bridge of cornea remains undivided at its upper border, the edge of the knife is inclined slightly fonvards, and the section completed by withdrawing the knife. Close the eyelids for a moment before beginning the second stage. Second Stage.—The anterior capsule is next divided by introducing the cystotome through the incision Avhile the patient looks doAvnward, and draAving its point gently across that membrane. Care must be taken not to displace the lens by pressing the point too forcibly against it. Close the eyelids again for a moment. Third Stage.—The patient is again directed to look down- Avard, and steady gentle pressure is made upon the eye with the forefinger or curette placed upon the loAver lid (Fig. 166). This pressure should first be directed back- OPERATIONS FOR THE RELIEF OF CATARACT. 260 Fig. 166. Flap extraction of cataract. Removal of the lens by pressure. Avards so as to tip the upper edge of the lens forward, and then upAvards and backAvards so as to force the lens through the dilated pupil into the anterior chamber and out through the incision. It should be gentle and very steady so as to avoid rupture of the posterior capsule and escape of the vitreous humor. Any portions of the cortical substance of the lens Avhich may have been left behind in the capsule, or stripped off during the passage of the lens through the pupil and the incision, must then be removed, and the eye closed. Such Avas the operation employed for extraction of the ordinary, hard, senile cataract. The objections to it, as before mentioned, Avere the great size of the flap, the pos- sible prolapse of the iris during the after treatment, and the risk of iritis excited by the bruising of the iris during the passage of the lens through the pupil. Von Graefe Avas the first to suggest that this last risk would be dimin- ished by the excision of a portion of the ins, iridectomy, and on putting the suggestion into practice he found that it also enabled him to remove the cataract safely through a much smaller incision. According to Mr. Carter,1 Von Graefe Avorked very sedulously during several years at the endeavor to exclude, one by one, the chief sources of the dangers by Avhich extraction Avas beset, and he arrived at 1 Holmes's Surgerv, its Principles and Practice, p. 724. 23* 270 OPERATIONS UPON THE EVE. Fiji. 167. Fig. 168. M \'on Graefe's cataract knife. Iridectomy forceps. last at the point of losing only four eyes out of one hundred opera- tions. A feAV improvements in detail have been added since his death, but so far as principles and broad outlines are concerned he had covered the ground. In view of the shortness of the incision, Avhich occupies not more than one- quarter of the periphery of the cornea, the operation is generally spoken of as a " modified linear extraction;" but the curved outline of the incision, and the fact that the lens is removed entire, cer- tainly bring it Avithin the class of flap extractions. Von Graefe's Method. Modi- fied Linear, or Modified Flap Extraction.—The instruments re- quired, besides the eye speculum and fixation forceps, are a long, thin, narrow knife (Fig. 167), the blade of Avhich is thirty milli- metres long and tAvo millimetres wide, iridectomy forceps (Fig. 168), scissors, a cystotome (Fig. 164), and a small hard rubber or tortoise shell curette. The patient is etherized and recumbent; the surgeon stands or sits behind him, holding the knife in his right hand for the right eye, in the left hand for the left eye. The eyeball is secured Avith the fixation forceps, and the point of the knife is entered in the sclerotic Avith its edge up- Avard, one millimetre from the upper and outer margin of the cornea, and two millimetres below OPERATIONS FOR THE RELIEF OF CATARACT. 271 Fig. 169. &. Diagram to illustrate the me- thod of making Von Graefe's incision. a tangent to its circle drawn at the upper end of its vertical diameter (Fig. 169, A). The point of the knife is at first directed toAvards the centre of the eyeball, but as soon as it has pene- trated to the anterior chamber it is turned so as to pass parallel to and along the anterior surface of the iris dowmvards and inwards about seven millimetres to a point corre- sponding to B in Fig. 169. The handle is then depressed, turning on the back of the blade in the incision, until the point is raised to the horizontal line of the punc- ture, Avhen the handle must be inclined someAvhat backAvards, and the point pushed sharply through the sclerotic and con- junctiva at C, Fig. 169. Great care must be taken not to make the counter-puncture too far back in the sclerotic, a mistake Avhich may easily happen if the blade is carried too far doAvmvard and inward before it is turned up to make the counter-puncture. The edge is then directed forward, and the incision com- pleted by steady advance and withdraAval of the knife. The incision is represented by the upper, un- dotted line in Fig. 170; its centre should lie at the junction of the cornea and sclerotic. The little bridge of conjunctiva which remains at the centre of the incision is then divided in such manner as to leave a conjunctival flap tAvo or three millimetres long adherent by its base to the cornea. If the cataract is large and hard, cision. it may be adAlsable to use a broader knife, and make the points of puncture and counter-puncture one milli- metre loAver, so that it Avill not be necessary to use a scoop or make much pressure on the eye to effect the removal of the lens. Many surgeons prefer to make the incision Avholly in the cornea and close to its edge, on the ground that the Avound Avill heal more promptly and kindly, and be accompanied by less risk of loss of the vitreous or of prolapse of the iris. The object of the iridectomy, which is the next step in Fig. 170. Line of Von Graefe's in- 272 OPERATIONS UPON THE EYE. the operation, is the neutralization of the circular fibres rather than the removal of a large portion of the iris, although some surgeons counsel the latter on account of the greater security it gives against subsequent inflammation. The iridectomy forceps are introduced closed, and opened slightly when the point reaches the margin of the pupil. The margin rises between the branches, is seized, Avith- draAvn gently, and cut off with scissors close to the forceps. If this is properly done the angles formed by the edges of the incision and the margin of the pupil will appear in the anterior chamber as at A and B in Fig. 171. The portion Fig. 171. Diagram of the correct and faulty sections of the iris. of iris removed should extend quite to its ciliary insertion so that there may be none to engage in the external incision and prevent its primary union. The capsule is next freely divided by two successive lacerations made Avith the cystotome. Each should begin at the loAver edge of the pupil and extend upAvards, one along the inner, the other along the outer side, to the upper border of the lens, where it has been exposed by the iridec- tomy. This upper border should also be torn to an extent corresponding to the external incision. This manoeuvre must be executed Avith great delicacy and lightness of touch in order that the lens may not be displaced into the vitreous humor. The escape of the lens is aided by pressure upon the cor- nea with the curette. The fixation forceps are applied at the inner or outer side, and the curette placed upon the loAver edge of the cornea and pressed slightly backAvards and upAvards so as to cause the upper edge of the lens to present in the section ; the pressure must then be made directly backAvards, in order that the lens may be rotated around its transverse axis and tilted Avell fonvard into the OPERATIONS FOR THE RELIEF OF CATARACT. 273 incision. The curette is then pushed slowly upAvards over the surface of the cornea so as to folloAV step by step the delivery of the lens. Any fragments scraped off during the passage may be removed by passing the curette again over the surface of the cornea. If the vitreous humor happens to be liquid it may escape as soon as the first incision is made. In such a case it is best to excise a portion of the iris and remove the lens in its capsule by passing a scoop behind it into the vitreous humor and lifting it out. Linear Extraction. — Mr. Dixon suggests1 rectilinear extraction as a more suitable name, because the incision in the cornea is a straight one, in contradistinction to that of a flap extraction Avhich also forms a line, but a curved one. This operation is a modification of one invented by Gibson in 1811, Avhich had fallen into entire disuse before its rein- troduction by Von Graefe in 1855. It is designed for the removal of soft cataracts through a small corneal incision, especially the cortical cataract of individuals betAveen ten and thirty years of age. It is also often employed with advantage as supplementary to the needle operation. It is performed as folloAvs:— A straight vertical incision, from four to six millimetres long, is made on the outer side of the cornea, about two millimetres Avithin its margin, Avith a straight lance-shaped iridectomy knife, Avhich is passed into the anterior chamber parallel to the surface of the iris. The capsule is then freely lacerated Avith the cystotome, and the escape of the soft lens facilitated by the introduction of a curette into the Avound, and by making gentle pressure on the inner side of the eye Avith the finger. If portions of the cortex remain behind the iris they can be brought into the anterior chamber by closing the lids and making gentle pressure in circular lines upon them. If the iris protrudes, it must be gently replaced, or, if much bruised, excised. Scoop Extraction.—This is a modification of linear ex- traction, devised by Waldau to obviate the dangers and dif- ficulties occasioned by the presence in the lens of a hard nucleus of greater or less size. As the principal danger 1 Holmes's System of Surgery, vol. iii. p. 199. 274 OPERATIONS UPON THE EYE. lies in the bruising of the iris, Von Graefe met it by iridec- tomy, which afterwards suggested to Waldau the idea_ of introducing a scoop and removing the lens Avithout making any pressure upon the eyeball. The instruments required are a bent lance-shaped iridec- tomy knife (Fig. 148), iridectomy forceps and scissors, and a thin, flat, slightly concave scoop. Waldau's scoop resem- Fig. 172. Fig. 173. Fig. 174. \ 0 1 Critchett's scoop. Bowman's scoops. bled a small spoon. Three different kinds are shown in Figs. 172, 173, 174. The eye speculum and fixation forceps having been applied, an incision, eight or nine millimetres long, is made at the upper border of the cornea Avhere it joins the sclerotic. The corresponding portion of the iris is removed, and the capsule freely torn Avith the cystotome, as before described. The scoop, Avith its convexity baclovards, is then intro- duced, and carried carefully doAvn behind the lens, until its extremity has passed the lower margin of the latter, and engaged it in its hook-like end. It is then AvithdraAvn, care being taken not to press the lens against the iris and cornea. If a little of the vitreous humor escapes at the same time, it must be snipped off and a compress applied. It is better to remove any fragments of the lens that may be left behind by gently rubbing the eyeball, rather than reintroducing the scoop. Removed by Suction.—Tangier suggested, in 1847, the removal of soft cataracts by aspiration through a holloAV needle. Blanchet modified the method by substituting a small canula for the needle, and introducing it through an incision in the cornea, but the operation Avas not favorably received until after it had been again modified by T. Pridgin Teale, Jr., in 1863, Avho recommended it as a substitute OPERATIONS FOR THE RELIEF OF CATARACT. 275 for pressure in the removal of the harder portions of the cata- ract by linear extraction, and as supplementary to discission. The instruments required are a broad needle and a suction curette. The latter (Fig. 175) is described by Mr. Teale1 as consisting of three parts, a curette, handle, and suction tube. "The curette is of the size of the ordinary curette, but differs from it in being roofed in to Avithin one line of its extremity, thus forming a tube flattened on its upper sur- face, and terminating, as it Ave re, in a small cup." The anterior capsule is first ruptured Avith a fine needle passed through the cornea, and then an opening is made Avith a broad needle in the cornea through which the cu- rette is passed to the centre of the pupil. The soft matter is then AvithdraAvn by suction. Soelberg Wells2 says this operation has been employed at the Royal London Ophthal- mic Hospital Avith great suc- cess, and that it is especially indicated in cases cf soft cor- tical cataract. If the cataract is somewhat harder, it is Avell to break it up Avith the needle a feAV days before attempting to remove it. 1 Ophthalmic Hospital Reports, vol. iv., part 2, p. 197. 2 On the Diseases of the Fve, p. 280. Phila. : H. 0. Lea. Fig. 175. urette and mouthpiece for removal of cataract by suction. 276 OPERATIONS UPON THE EYE. Removal of the Lens in its Capsule.—This operation is indicated Avhen the capsule is opaque, and Avhenever the eye is exceptionally irritable, or has been chronically inflamed, so that the accidental retention of any fragments of the lens Avould be a source of serious danger. When successful, this method gives very fine results, but its risks and dangers are so great that it is seldom employed. Originally intro- duced by Richter and Beer, it Avas revived by Sperino, Pagenstecher, and Wecker. The former employed the ordinary flap operation Avithout laceration of the capsule. Pagenstecher made a large flap in the sclerotic together with iridectomy. Wecker's method Avas nearly identical, the incision being made at the sclero-corneal junction. Pagenstecher's Method.—The patient having been thor- oughly anaesthetized, a large flap is made, usually down- Avards, Avith a Beer's knife, a small bridge of conjunctiva being left temporarily at its apex. Iridectomy is then per- formed in the outer loAver quadrant, and the conjunctival bridge divided Avith blunt^pointed scissors. Any posterior synechiae that may exist are torn through with a fine silver hook, and then the lens removed in its capsule by slight pressure upon the eyeball. If the hyaloid membrane should be ruptured and the Aatreous escape, the lens must be re- moved with the aid of a small scoop passed in behind its lower edge. Secondary Cataract.—Secondary cataracts vary much in thickness and opacity. They may be produced by portions of the lens left behind and becoming entangled in the cap- sule, by the deposit of lymph upon the latter, or by the proliferation of the intracapsular cells. No operation for secondary cataract should be performed until, at least, three or four months after the removal of the primary cata ract; and if the pupil has become contracted, or if very extensive posterior synechiae have formed, a preliminary iridectomy should be made. Formerly the plan Avas to remove the opaque and thickened membrane entirely from the eye, but it has proved very much.safer and equally efficacious to make a small opening in the membrane Avith a needle. Anaesthesia is hardly necessary. The eye speculum OPERATION TO CORRECT STRABISMUS. 277 and fixation forceps having been applied, BoAvman's fine needle (Fig. 161) is passed through the cornea near its margin, and an effort made to tear a hole Avith it in the centre of the membrane or at the part Avhich is thinnest and least opaque. If the membrane yields before the needle, or if it is too tough to be torn, Mr. BoAvman's device of a second needle must be employed. This is to be passed through the cornea on the side opposite to that occupied by the first needle, and then the operator, transfixing and steadying the mem- brane with one needle, tears it Avith the other. If any portion of the iris should happen to be bruised or torn, it must be excised through a linear incision. Dr. AgneAV passes a needle through the centre of the membrane, thus steadying both it and the eye. He then makes a linear incision on the temporal side of the cornea through Avhich he passes a small sharp-pointed hook, the point of Avhich is passed into the same opening in the mem- brane as the needle. He next tears the membrane, rolls it up about the hook, and either draws it out altogether or, if this cannot be done, tears it widely open. OPERATION TO CORRECT STRABISMUS—STRABOTOMY. The tendon of the internal rectus is attached to the sclerotic at a distance of five millimetres from the border of the cornea, that of the external rectus at a distance of seven millimetres. Each tendon is seven or eight milli- metres broad and is contained in a firm sheath resemblino; a glove finger, a prolongation or depression of the capsule of Tenon at the point Avhere it is traversed by the tendon about midAvay betAveen the anterior margin of the orbit and the posterior pole of the eyeball. The capsule of Tenon is a reflection of the periosteum of the orbit from the anterior margin of the latter to the transverse meridian of the eye- ball and thence baclcAvard to and along the optic nerve, thus constituting a diaphragm Avhich divides the orbit into an anterior and a posterior loge, the former of Avhich contains the eyeball (received into a cup-like depression of the diaphragm), the latter the muscles and optic nerve. The 24 278 OPERATIONS UPON THE EYE. capsule sends a prolongation, not only anteriorly along the tendons, but also posteriorly along the muscles, and the union between the muscle and sheath is so firm that even after division of the tendon the muscle can move the eye- ball by acting through the attachments of the capsule. If the body of the muscle itself is divided in the posterior loge, its influence upon the movements of the eyeball is entirely lost. This is the chief point to be borne in mind in per- forming strabotomy, the tendon must be divided, not the muscle, and the amount of deviation of the eye to be over- come is the measure of the extent to Avhich the adjoining tissues must be divided. The Operation for Division of the Interned Rectus will alone be described, that being the one commonly required. The special instruments required are : fine-toothed forceps (Fig. 176), blunt hook (Fig. 177), and blunt-pointed scis- sors, straight or curved on the flat. Fig. 176. A small but deep fold of conjunctiva and subconjunctival tissue is seized Avith the toothed forceps just above the loAver extremity of the line of insertion of the tendon of the internal rectus, that is, tAvo millimetres below a point on the equator of the eyeball five millimetres beyond the inner margin of the cornea, and divided with the scissors just below the forceps ; additional snips are made Avith the scis- sors within this opening until the tendon or the sclerotic is exposed. The surgeon then passes the point of the stra- botomy hook, which should be somewhat bulbous, through OPERATION TO CORRECT STRABISMUS. 279 the opening to the loAver border of the tendon, and, keeping the point and side of the hook constantly upon the sclerotic, SAveeps it at first backAvard, and then upward and forward around the insertion. When this manoeuvre is properly executed, the point of the hook can be seen under the con- junctiva above the upper border of the tendon, Avhile its course is hidden by the latter and prevented from being draAvn fonvard to the margin of the cornea. If the Avhole of the hook can be seen under the conjunctiva, it is not under the tendon, and the SAveep must be repeated-. When the tendon has been secured, the conjunctiva may be pressed back over its point, and the tendon divided Avith scissors close to its insertion, beginning at its upper border; or, the con- junctiva being left in place, the scissors may be passed along the hook as a guide, one blade beloAV the tendon, the other betAveen it and the conjunctiva, and the tendon divided Avith repeated snips. After the tendon has been completely cut through, the hook should be swept upwards and doAvmvards to ascertain if the lateral expansions of the tendon have been divided, for the persistence of even a feAV of them might be sufficient to prevent the success of the operation. If it is feared that too great an effect has been produced, a deep suture may be passed through the tendon and the conjunctiva on the side towards the cornea so as to limit the amount of retraction. The accommodative movements of the eye should be tested immediately after the operation, and if there is the slightest tendency to divergence Avhen the object is six or eight inches distant from the eye a suture should be inserted. In the subco)ijunclival method the incision in the con- junctiva is made beloAV the insertion of the tendon on a line with the loAver border of the cornea, and the conjunctiva is not pressed aAvay from the anterior surface of the tendon after the hook has been passed under the latter. If the squint exceeds five or six millimetres, as estimated by the method shown in Fig. 178, both eyes should be ope- rated upon, the insertion of the internal rectus being set back in each case. Thus, if the degree of squint repre- sented in Fig. 179 Avere corrected by setting back the tendon of the internal rectus from C to D, the muscle 280 OPERATIONS UPON THE EYE. could only Avork at a great disadvantage as compared Avith the internal rectus of the other side, and the result Avould be the appearance of divergent squint Avhenever the attempt was made to look at an object near the eye, because the Method of estimating the degree of Double operation for strabismus. squint. muscle could not turn the eye far enough inward. The condition must therefore be divided between the two eyes, the internal rectus on one side being set back to E, on the other side to E'. Secondary Strabismus following Tenotomy of the oppo- nent is treated by advancing the insertion of the opposing tendon (Prorraphy). Thus, supposing divergent squint to have folloAved division of the internal rectus, an incision half an inch long is made in the conjunctiva in the line of the horizontal diameter of the cornea, and the conjunctiva and subconjunctiA'al tissue dissected up as far back as to the caruncle. A hook is then passed around the insertion of the internal rectus, and the tendon divided as before; a suture is passed through it, and it is draAvn toAvards, and fastened to, the strip of conjunctiva adjoining the inner border of the cornea. The tendon of the external rectus must then be divided according to the rules laid down for division of the internal rectus, remembering that its attach- ENUCLEATION OF THE EYEBALL. 281 ment to the sclerotic is distant seven millimetres from the edge of the cornea. ENUCLEATION OF THE EYEBALL. As the globe of the eye lies someAvhat nearer the inner than the outer side of the orbit, it will be found easier to approach it from the latter quarter. Tillaux1 divides the conjunctiva and subconjunctival fascia with curved scissors along the attachment of the external rectus, divides the tendon of that muscle, carries the scissors baclovard through the incision, their concavity turned toAvards the globe, and cuts the optic nerve close to the eyeball. He then seizes the posterior pole of the globe Avith pronged forceps, draAvs it out through the conjunctival incision, and divides the re- maining conjunctival attachments and tendons close to the sclerotic. Other surgeons prefer to seek and divide each tendon in turn before cutting the optic nerve. Extirpation of the Entire Contents of the Orbit.—In order to gain additional room, it is Avell to first divide the external commissure of the lids. A bistoury is then entered at the inner angle, carried Avell back toAvards the apex of the orbit, and SAvept along the floor to the outer angle, then reintroduced at the inner angle, and carried along the roof of the orbit to the outer angle. The muscles and optic nerve, Avhich still remain attached to the eye and apex of the orbit, are finally divided Avith curved scissors introduced from the outer side. Hemorrhage should be arrested by filling the cavity Avith lint. OPERATIONS UPON THE LACHRYMAL APPARATUS. Extirpation of the Lachrymal Gland (Fig. 180).—The principal portion of the lachrymal gland lies just behind the 1 Anatomic Topographique, p. 190. 24* OPERATIONS UPON THE EYE. junction of the upper and outer margins of the orbit, envel- oped in a fibrous capsule formed by a reflection of the peri- osteum or capsule of Tenon. The "accessory" portion, to- gether with the ducts, occu- pies the adjoining eyelid, and is composed of isolated granu- lations of glandular tissue, Avhich, if left behind after re- moval of the main portion, may continue to secrete tears and discharge them into the wound, thus causing abscesses and fistulae. Tillaux1 has pointed out that the existence of the fi- brous capsule renders it pos- sible to enucleate the gland Avithout opening the posterior loge of the orbit, a defect in the older methods Avhich in- cluded division of the external commissure. Make an inci- sion one inch in length along the upper and outer portion of the bony margin of the orbit. Carry this incision through all the soft parts, including the periosteum, doAvn to the bone; separate the periosteum from the bone at the under side of the incision, and depress it. The gland can then be distinctly seen through the thin layer of periosteum, Avhich separates it from the roof of the orbit, and can be removed with great ease after the latter has been torn through. Extirpation of the lachrymal gland. S. Skin. P. Periosteum. B. Frontal bone. G. Lachrymal glaud. T. Cap- sule of Tenon. R. Reflected perios- teum forming the capsule of the gland. E. Eyeball. C. Conjunctiva. L. Eye- lid. 7. Incision. Lachrymal Sac, Duct, and Canaliculi.—The loAver cana- liculus passes doAvmvard from the punctum for two milli- metres, then turns at a right angle, and passes horizontally inAvard to the lachrymal sac, a distance of about five milli- metres ; the upper canaliculus passes at first upAvard for two millimetres, and then downward and inward to the sac. This sharp turn in the course of the canaliculus, Avhich is an 1 Anatomie Topographique, p. 237 OPERATIONS UPON LACHRYMAL APPARATUS. 283 obstacle to catheterization, can be temporarily removed by draAving the border of the lid outwards. The lachrymal sac lies just behind the tendo oculi, and receives the cana- liculi by a common duct tAvo or three millimetres beloAV its upper extremity, their relations thus resembling those of the ileum and caecum, a resemblance Avhich is increased by the presence of a valve at the opening of the duct into the sac. This valve, described by Huschka, is thought to prevent the reflux of the contents of the sac into the canaliculi. The direction of the sac is dowmvard and backAvard at an angle of 45°; it occupies the lachrymal groove, Avhich is bounded anteriorly by a ridge on the nasal process of the superior maxillary bone at the inner angle of the orbit, and is crossed by the tendo oculi usually at the junction of its upper and middle thirds. The nasal duct is the direct continuation of the sac, and passes doAvmvard, backAvard, and outward; the combined length of the duct and sac is about one inch. It may become necessary to slit up the canaliculus in order to correct a malposition of the punctum, or to facili- tate catheterization of the sac and nasal duct. This little operation is best performed as folloAvs (right eye, loAver lid): The surgeon stands behind the patient, avIio is recumbent, and introduces a fine grooved director (Fig. 181) vertically through the punctum for a distance of two millimetres. Then drawing the border of the lid outward and somewhat doAvnward Avith the forefinger of his left hand, he passes the director horizontally, Avith its groove upAvard, along the canaliculus to the inner side of the sac. Then, shifting the director to the left hand, he engages a sharp-pointed knife in the groove, and slits up the canaliculus throughout its entire length. Bowman's probe-pointed canaliculus knife (Fig. 182) may be substituted for the director and knife. It should be very narrow, and its probe point Arery small. When one punctum has been entirely obliterated, a plan suggested by Mr. Streatfeild may be employed. He diAudes the other canaliculus, passes a fine director, suitably bent, through the wound into the obliterated canaliculus and cuts doAvn upon it. If the divided loAver canaliculus remains everted, Mr. Critchett advises that the posterior lip of the incision be cut 284 OPERATIONS UPON THE EYE. Fig. 182 Fig. 183. Fig. 181. Sharp pointed canaliculus di- rector. Bowman's probe- pointed canaliculus knife. Puncture of the lachrymal sac. off with scissors, "effecting the treble object of drawing the canal more inwards, of forming a reservoir into which the tears may run, and of preventing reunion of the parts." Puncture of the Sac (Fig. 183).—The three guides are the tendo oculi, the anterior margin of the lachrymal groove, and the direction of the sac. While an assistant draAVS the external commis- sure outwards, so as to make the tendo oculi tense and plainly visible, the surgeon, places his left forefinger upon the inner and loAver margin of the orbit, so as to have the bony edge between the nail and the pulp of the finger, and holding the knife in the direction of the canal, that is, nearly parallel to the median plane, and at an OCCLUSION OF EXTERNAL AUDITORY CANAL. 285 angle of 45° with the horizon, he passes it along his finger nail into the sac just beloAV the tendon. It is important to mark the position of the anterior margin of the canal, so as to avoid the not infrequent mistake of passing the knife en- tirely outside of the orbit between the soft parts of the face and the bone. Stricture of the Nasal Duct. Division.—Dr. Stilling, of Cassel^proposes to treat stricture of the nasal duct by internal division. He divides the canaliculus, and ascer- Fig. 184. Stilling's knife. tains the seat of the stricture with a probe, passes his knife (Fig. 184) through it, and divides it in three or four directions. CHAPTER II. OPERATIONS UPON THE EAR AND ITS APPENDAGES. OCCLUSION OF EXTERNAL AUDITORY CANAL. Congenital occlusion of the external meatus is usually associated with absence or defective development of the other portions of the auditory apparatus. Before operating upon such an occlusion, therefore, the hearing power should be tested, and the permeability or impermeability of the bony portion of the canal determined by puncture Avith a needle. If the occlusion consists of a simple membranous dia- phragm it should be divided crucially, and the flaps excised. For deeper and more extensive obstructions cauterization Avith nitrate of silver is to be preferred. 286 OPERATIONS UPON THE EAR. INTRODUCTION OF SPECULUM (ROOSA). The upper portion of the auricle is grasped betAveen the ring and middle fingers of the left hand and draAvn gently upAvards and backAvards. Into the canal thus straightened the speculum is introduced with the right hand, and then held in place Avith the thumb and forefinger of the left, the hand being steadied by resting its ulnar border against the patient's head. Complete control of the speculum is thus obtained, and it can be easily moved about so as to bring every part of the tympanum and canal into vieAV. Light should be thrown into it from a concave mirror perforated in the centre and having a focal distance of six inches. PARACENTESIS OF THE MEMBRANA TYMPANI (ROOSA).1 This should be performed Avhile the head of the patient is Avell supported and a good light is throAvn. upon the mem- brane by a mirror attached to a forehead band. A catar- act needle is the instrument usually employed, and the opening should be made in the posterior inferior quadrant of the membrane. Hinton2 uses a very small double-bladed knife, and seeks especially to open the upper and posterior portion of the tympanum, making the incision behind and parallel to the malleus from the upper border nearly to the loAver. If the knife does not penetrate too deeply, the chorda tympani which passes across the upper portion will not be injured. Tillaux3 calls attention to the fact that all the important elements of the membrane occupy its upper half, and that an incision or rupture near the handle of the hammer may give rise to troublesome and even dangerous hemorrhage. The loAver half is less vascular and less sensitive. If it is desired to maintain the opening for several days, a crucial incision may be made, or a triangular flap excised, but, as a rule, even these incisions heal very quickly. 1 Treatise on the Diseases of the Ear, p. 246. 2 Holmes's System of Surgery, vol. iii. p. 300. 3 Anatomic Topographique, p. 111. CATHETERIZATION OF EUSTACHIAN TUBE. 287 INCISION OF THE PERIOSTEUM AND TREPHINING OF THE MASTOID PROCESS. When the periosteum of the mastoid process has become inflamed by propagation of an inflammatory process either from the periosteum of the auditory canal Avith Avhich it is continuous, or from the cavity of the tympanum through the mastoid cells, an early and free incision doAvn to the bone will give great relief and diminish the danger of in- tracranial complications. The incision should begin a little above the apex of the mastoid process, and be carried up- Avards for an inch or an inch and a half parallel to the at- tachment of the car and about half an inch from it. The posterior auricular artery lies in the groove between the ear and the mastoid process, and Avill not be encountered ; its posterior branch, hoAvever, the course of Avhich is uncertain, will probably be divided and may give rise to troublesome hemorrhage. The artery is so adherent to the skin that it cannot be readily tied or twisted. If ordinary pressure does not suffice, self-retaining forceps should be applied to the bleeding point, and left in place for twenty-four hours. The trephine or drill should be applied at a point in the line of the incision three-fourths of an inch above the apex of the mastoid process. If the bone is much softened by suppuration, it can be easily perforated Avith a stout knife. If it becomes necessary to penetrate to a considerable depth in the bone, the direction of the drill must be forward, in- Avard, and slightly dowmvard. If carried directly iiiAvard it Avould promptly open the lateral sinus. CATHETERIZATION OF THE EUSTACHIAN TUBE. The Eustachian tube is from one and a half to two inches long, its course is from the pharynx upAvard, backAvard, and outAvard. Its pharyngeal orifice is oval and Avell marked except on the lower border, and is situated just above the base of the soft palate. Behind the orifice, betAveen it and the posterior wall of the pharynx, is a depression (Rosen- muller's fossette) in which the beak of the catheter, if carried too far back, may lodge and give the same sensa- 288 OPERATIONS UPON MOUTH AND PHARYNX. tion to the surgeon's hand as if it Avere engaged in the tube. Of the tAvo mistakes most frequently made in performing catheterization, one is to pass the beak of the instrument betAveen the middle and inferior turbinated bones instead of along the floor of the nasal fossa, and the other is to mistake Rosenmiiller's fossette for the orifice. According to Roosa1 the first mistake is best avoided by draAving down the patient's upper lip Avith the left hand, and entering the catheter Avhile it is held in an almost vertical position, its concavity directed toAvards the median line. After the beak has fairly entered the meatus the stem of the catheter is gradually raised to the horizontal position and passed backAvard, its beak resting on the floor of the meatus close to the septum, its convexity upAvards. Tillaux2 gives the folloAving directions for finding the orifice : 1st. Carry the catheter directly backAvard, its con- cavity downward, until it touches the posterior wall of the pharynx. 2d. Withdraw it until the beak rests again upon the hard palate. 3d. Carry the catheter again very gently baclovard, and feel with its beak for the posterior border of the palatine aponeurosis, the firm fibrous continuation of the palatal bone. This aponeurosis feels as hard as bone, and its posterior border can be easily recognized by the softness of the adjoining tissues. 4th. Rotate the beak of the catheter outAvards and upAvards, and it Avill enter the Eusta- chian tube. CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYNX. EXCISION OF THE TONSILS (AMYGDALOTOMY). The tonsils may be excised Avith a knife and Arulsellum, or with a specially contrived instrument, the tonsilotome or guillotine. 1 Diseases of the Ear, p. 94. 2 Anatomie Topographique, p. 140. STAPHYLORAPHY. 289 Anaesthesia is not required. If the patient is young or nervous it is Avell to put a large piece of cork between the jaws on each side to prevent the mouth from being closed. The guillotine (Fig. 185) is composed of tAvo rings and a Tonsilotoine. fork mounted upon stems so arranged that they can be Avorked Avith the thumb and fingers of one hand. The two rings slide flatAvise upon each other, and the inner edge of one is sharp, so that Avhen draAvn across the other it divides anything lying within it. The fork is thrust forward across the ring and drawn away vertically from it by the same movement Avhich draws one ring across the other. The rings having been placed over the tonsil, the hook is driven into the latter by a quick movement of the thumb and finger and draAvs it further into the ring, holding it tense as the other blade cuts across its base. The pain is very slight. If the guillotine cannot be used the tonsil must be seized Avith pronged forceps, and excised between them and the pillars Avith a probe-pointed knife, the posterior portion of the blade being guarded with diachylon plaster so as to avoid injury to the tongue. STAPHYLORAPHY. At the conclusion of his historical account of this opera- tion Yerneuil1 states that it has been invented four different times. The earliest record of the operation is found in a French book, published in 17lh:>,2 in Avhich it is said that a dentist, named Lemonnier, closed a fissure of both hard and soft palates by freshening its edges Avith a knife and bringing them together with sutures. He also closed per- 1 Chirurgie Keparatriee, 187 7. Art. Staphylorrhaphie. 2 Traite des Frineipaux objets de Medecine, par Robert. 25 290 OPERATIONS UPON MOUTH AND PHARYNX. forations of the hard palate by exciting suppuration of their borders. In 1799 Eustache, a physician of Beziers, proposed to reunite by sutures the edges of an incision Avhich he had made the day before in the soft palate of a patient for the purpose of removing a pharyngeal polyp. The patient re- fused the operation. Four years later, in 1783, Eustache sent to the Academie Roy ale de Chirurgie at l'aris a re- markable paper upon congenital fissures in the soft palate, and asked the Society's approval of the operation by Avhich he proposed to close them. The approval Avas Avithheld, and there is no record of any further steps having been taken. In December, 1816, Yon Graefe said, before the Medico- Chirurgical Society of Berlin, that, after many unsuccessful attempts to close fissures of the soft palate, he had at last succeeded by drawing the edges together Avith sutures after freshening them by applying muriatic acid and the tincture of cantharides. This remark Avas reported in the proceed- ings of the society in Hufeland's Journal, January, 1817. Between 1816 and 1820 Yon Graefe repeated the operation three times, each time Avithout success. In 1819, Roux, apparently in entire ignorance of Yon Graefe's attempt, closed a fissure by paring the edges and applying sutures. The case at once became very Avidely known, and had much influence in popularizing the opera- tion. When the extent of the lesion Avhich staphyloraphy is designed to repair is considered, the operation seems to be very simple. It is only necessary to freshen the edges of the gap and draAv them together with sutures. Practically, hoAvever, the operation is a difficult one ; the parts lie at a considerable distance from the surface, the manipulations are constantly interfered Avith by involuntary movements of deglutition, the flow of blood increases the obscurity, and the practical difficulties in the Avay of placing the sutures are great. Finally, unless some of the muscles of the palate are divided, the tension exerted by them upon the sutures is sufficient to prevent union. A great variety of methods have been suggested to over- come these difficulties. Mr. T. Smith diminished the first STAPHYLORAPHY. 291 by the invention of a gag (Fig. 186), designed to hold the jaws apart during the operation. Prof. Yan Buren pre- vented the passage of blood into the trachea during the employment of anaesthesia by placing the patient so° that the head should hang down over the end of the table, and the blood escape through the nose. The same device has been recently employed by Tielat. Fig. 186. Smith's gag. Sir William Fergusson relieved the tension by dividing the levator palati on each side. He did this by passing a knife, bent at a right angle, through the cleft and dividing the muscle from behind forwards Avithout touching the mucous membrane on the anterior face of the palate. ° The incision should be perpendicular to the centre of a line joining the hamular process and the orifice of the Eusta- chian tube. The former can be readily felt just behind the last upper molar tooth, the latter can usually be seen through the cleft in the palate. He also recommended division of the palato-pharyngeus muscle. SeMillot1 divided the muscle from before backward. He 1 Medecine Operatoire, vol. ii. p. 65. 292 OPERATIONS UPON MOUTH AND PHARYNX. dreAv the ATelum downwards and imvards Avith pronged for- ceps, and made an incision doAvnwards and outAvards about one centimetre above and on the outer side of the base of the uvula, and just behind and on the inner side of the last upper molar, crossing the levator palati at right angles (Fig. 188). A length of one centimetre is usually suffi- cient, but it must be increased if the muscular contractions Fig. 187. Fig. 188. Fig. 189. persist. The relaxation of the parts produced by these in- cisions is shoAvn by a comparison of Figs. 187 and 189. Unless the incisions are exceptionally large their sides re- main in contact; in any case they promptly reunite. He then divided the anterior and posterior pillars, seizing each in turn near its centre Avith pronged forceps, and cutting it Avith scissors. Mr. George Pollock1 has modified this slightly by making the incision on the anterior surface of the palate smaller. One of the halves of the palate is draAvn towards the median line by means of a ligature passed through it near the base of the uvula, and a thin, narroAV knife is entered close to the hamular process, a little in front of it and on its inner side, and its point carried upAvard, backAvard, and some- what imvard, until it can be seen through the cleft, having divided on its Avay part, if not all, of the tendon of the tensor palati. The blade noAV lies above most of the fibres 1 Holmes's System of Surgery, vol. iv. p. 4 2G. STAPHYLORAPHY. 293 of the levator (Fig. 190), and by raising the handle and cutting downward, as the knife is withdrawn, an incision of considerable length, including the greater portion of the levator, is made on the posterior surface of the palate, Avhile Fig. 190. Division of muscles of soft palate. that on the anterior surface need not be greater than the breadth of the knife. If the muscle has been effectually divided the palate will be pendulous and flaccid, and will not contract spasmodically Avhen pulled upon. If any re- sistance should persist the knife must be introduced again through the Avound and the incision enlarged doAvmvards. Roux placed his sutures by putting a needle at each end of the thread, and passing them from behind forwards. '25* 294 OPERATIONS UPON MOUTH AND PHARYNX. Trelat used a needle fixed upon a long handle, the point bearing the eye and curved in the form of a U. After having been threaded the point of the needle Avas passed through the palate from behind fonvards, the thread Avas draAvn through with a hook or forceps, and the needle, still threaded, AvithdraAvn and passed in the same manner on the opposite side. The objection to these and to all other methods in which the needle is passed from behind forwards, is that, since the point cannot be seen, it is very difficult to make the punctures on one side correspond properly Avith those on the other. If silk sutures are used each end may be passed from before backAvards, the two tied together loosely, and the knot pulled back through one of the punc- tures, thus bringing the loop behind the palate. The method noAV usually employed is the one introduced by BeVard. A curved needle fixed on a long handle is threaded Avith a ligature three feet long, and its point passed through the palate from before backwards; the thread is caught with hook or forceps on the posterior side, and its end drawn out through the mouth, the needle is then Avith- draAvn and slipped off the thread. It is next threaded Avith a second ligature and passed in the same manner through the opposite half of the palate, the loop seized as before, drawn through a short distance, and held Avhile the needle is withdraAvn, leaving the thread double in the puncture—the loop behind the palate, the two ends in front. The poste- rior end of the first ligature is then passed through the loop of the second one (Fig. 191, b), and, by the AvithdraAval of the latter, drawn through the second puncture (Fig. 191, a). In- stead of using the same needle to pass both ligatures, it is more convenient to have tAvo curved spirally in the opposite directions, one for each side. If silver sutures are used, thread loops should be passed from before backAvard on each side, one end of the Avire en- gaged in each and drawn through. After a suture has been passed, the ends should be brought out through the mouth, and tied together for safety. When all have been passed, the anterior one is drawn upon to bring the edges of the cleft together, and the knot tied. The knot may be an ordinary square one, an assistant holding the first tAvist Avith dressing forceps STAPHYLORAPHY. 295 until the second is made, or it may be a noose, as shown in Fig. 191, c, secured by a second knot. If silver Avire is used, it may be fastened by twisting it, or by clamping a small lead button upon it. Yerneuil first passes the ends of the Avire through the eyes of a shirt button, and then ties or twists. He thinks this favors more accurate adjustment of the edges, and facilitates removal of the Avire. Staphyloraphy ; passing the sutures. The edges of the cleft are pared by seizing the tip of the uvula Avith toothed forceps, making it tense, entering the point of a narroAV-bladed knife one or two millimetres back from the edge, and cutting doAvn to the tip; then turning the knife and cutting up to the anterior angle of the cleft. Care should be taken to do this thoroughly. When the cleft is very short (bifid uvula), Ne'laton employed the method already described under his name for single uncomplicated harelip. The flaps Avere left adherent to each other at the apex (angle of the cleft) and to the uvula at their bases, turned doAvn, and the raAv surfaces draAvn together. When the cleft Avas too long for this he separated the flaps at the apex, shortened them by trimming off the free ends, turned them doAvn, and united as before. There is no settled rule of practice establishing the order in Avhich the different steps of the operation shall be exe- 296 OPERATIONS UPON MOUTH AND PHARYNX. cuted, except that most surgeons are agreed upon the ad- visability of paring the edges of the cleft before passing the sutures. Mr. Callender recommended that the muscles should be divided a day or two before the attempt to close the cleft, on the ground that the second operation is much sim- plified by the freedom from the bleeding occasioned by divi- sion of the muscles. Mr. Smith, on the other hand, stretched the palate by draAving upon all the sutures, divided the palato-pharyngeus and levator palati, and then, if the edges of the cleft did not come easily together, made tAvo lateral oblique cuts, one on either side, above the higher suture, separating, to a limited extent, the soft from the margin of the hard palate. Bonfils, according to Dubrueil, closed an opening left at the upper part of the palate by the partial failure of an operation for staphyloraphy, by taking a flap from the hard palate, according to the Indian method of autoplasty (q. v.). URANOPLASTY. Yerneuil1 attributes the success of modern uranoplastic operations to the use of the method by double flaps, adherent at both ends and brought together laterally (lambeaux en pont), and to the retention of the periosteum in the flaps. He ascribes the first use of double flaps to Dieffenbach, and thinks the retention of the periosteum was brought about by Ollier's most valuable experimental and clinical researches upon the properties of this tissue. To Yon Langenbeck, by Avhose name the method is usually knoAvn, he gives only the credit of being the first to adopt Ollier's suggestion, and to make it a rule of practice. This estimate of the facts does not seem to be entirely correct. It is true that Dieffenbach used double lateral flaps, but a large part of the success of the modern method is due to the greater breadth noAV given to the flaps. Tillaux has shoAvn that the branches of the posterior palatine artery are given off like the plumes of a feather, and that to avoid division of these branches, and insure the nutrition of the 1 Chirurgie Reparatrice, Art. Uranoplastic URANOPLASTY. 297 flap, the incision must be made close to the alveolar process. This necessity is as absolute in the case of a small perfora- tion as in that of a large one. As for the retention of the periosteum, Yon Langenbeck Avas certainly the first to point out its importance as a means of preventing gangrene of the flap. Ollier's investigations turned upon its value in favor- ing reproduction of the bone. Fissure of the hard and soft palate endangers an infant's life by interfering Avith the ingestion of food. The exact measure of this danger has not yet been established by statistics, but it is certainly considerable.1 On the other hand, all recorded operations for cleft palate upon children less than one month old have terminated fatally, and those undertaken during the first five or six months of the child's life, although not so fatal, shoAv but feAv successes. Billroth and Simon think- the operation should be performed about the eighth month, but most surgeons are agreed upon the propriety of postponing it until the third or fourth year. If a child has lived six months Avithout operation, it has cer- tainly learned to overcome the mechanical difficulties in the Avay of its nourishment, and there is, consequently, no reason to interfere surgically until the second indication arises. That is found in the defective articulation and phonation occasioned by the lesion, and, as children Avith cleft palate do not begin to speak before the third or fourth year, the operation may be safely postponed until that time. The special instruments required are a speculum oris, or tAvo blunt hooks to be placed at the angles of the mouth and fastened together by a rubber band passing behind the head, pronged forceps Avith long handles, curved needles of the pattern selected, a periosteum elevator bent at a right angle on the flat, and sponges on long handles. The edges of the perforation or fissure are first freshened by the removal of a strip one or tAvo millimetres thick. An incision is then made on each side close to the gum, extend- ing from the last molar tooth forwards as far as may be necessary, and exposing the bone throughout. The elevator is introduced into this incision and the periosteum separated from Avithout imvards, care being taken not to injure the 1 Lannelongue, Mem. de la Soc. de Chirurgie, 1877, p. 470. 298 OPERATIONS UPON MOUTH AND PHARYNX. palatine arteries at the anterior and posterior palatine foramina. If the cleft involves the soft palate its sides will be found to round off tOAvard the hamular processes, and the velum to be tightly adherent to the posterior portion. The flaps cannot be brought together until the attachments of the tAvo halves of the velum at these points are entirely separated, a step Avhich is best accomplished by means of a small, curved, sharp elevator introduced through the lateral in- cisions. The bleeding during this stage of the operation is very free, but, as Ehrmann1 has remarked, usually ceases as soon as the flaps are completely liberated. If it continues pres- sure should be made for a few moments Avith the finger, or ice applied. Trelat carries his incisions further back, stop- ping from one-fourth to one-half an inch behind the pos- terior border of the hard palate, and entirely disregarding the posterior palatine artery. The flaps are brought together in the median line and the sutures applied, beginning at the anterior extremity of the cleft. The sutures should be left in at least four days and then removed, not all at once, but by instalments. If the fissure is unilateral, the vomer remaining attached on the other side, Yon Langenbeck recommends that the lateral incision along the gum should be made only upon the side occupied by the fissure. The flap on the other side should be dissected up from the median line outAvards. If the fissure extends through the dental arch and is Avide at the point, Rouge2 recommends that one of the flaps should be detached in front also and SAvung in sideAvays upon the posterior attachment as a centre. Fergusson's Osteoplastic Method?—In 1874 Sir William Fergusson described a plan Avhich he had successfully em- ployed to close gaps in the hard palate left by the partial failure of a previous operation, adding that it Avas equally applicable to those cases, frequent in his OAvn experience, 1 Memoires de l'Acad. de M6decine, vol. xxxi. 2 L'Uranoplastie etles Divisions Cougenit. du Palais, 1871, p. 108. 3 British Medical Journal, April 4th, 1874, and Braithwaite's Retrospect, vol. lxix, p. 217. STAPHYLOPLASTY. 299 in Avhich the front part of the cleft had been left untouched. He made an incision doAvn to the bone on each side of the cleft, midAvay betAveen it and the alveolar process, and over- lapping it a little at each end, and then Avith a chisel cut through the bone at the bottom of the incisions. According to Lannelongue,1 the Aoav of blood at this stage of the ope- ration is very great, but is easily controlled by pressure. The flaps are then brought together in the median line and fastened Avith sutures. Fergusson Avas in the habit of pass- ing the sutures through the bone, and for this purpose drilled holes along the sides of the cleft before he made the incisions. Shortly before his death, he gave up sutures entirely and kept the flaps together by plugging the lateral incisions Avith lint. Lannelongue considers the lint dan- gerous, and uses sutures passed through the mucous mem- brane only. LeDini'longue's Method (nasal flap).—Lannelongue has closed several clefts involving only the hard palate by means of a rectangular flap brought doAvn from the side of the septum of the nose. The flap is marked out by a hori- zontal and tAvo vertical incisions—the former parallel to the edge of the cleft and at a suitable distance above it, the latter extending doAvmvards from each end of the horizontal one to the angles of the cleft. The flap, composed entirely of the mucous membrane of the septum, is dissected from above doAvmvards Avith a curved blunt elevator and left ad- herent at its inferior border. The opposite edge of the cleft is then freshened by the removal of a superficial strip one- quarter of an inch broad, and the upper border of the flap attached to it with sutures. STAPHYLOPLASTY. Schoenborn describes2 a plastic operation performed by him successfully upon a girl seventeen years old, affected with congenital fissure of both hard and soft palates ex- 1 Bulletins de la Soci6te de Chirurgie, 1877, p. 472. 2 Ueber eine neue methode der Staphylorrhaphie. Langenbeck's Arcliiv, 1876, vol. xix. p. 527. 300 OPERATIONS UPON MOUTH AND PHARYNX. tending to the anterior palatine foramen, the halves of the velum being very deficient. The patient Avas anaesthetized, tracheotomy performed, and a tampon-canula1 inserted. After having pared the edges of the fissure he took a flap four or five centimetres long and two centimetres broad from the posterior Avail of the pharynx, its base directed dowmvard, its apex situated as high as possible, so that it Avould reach to the posterior edge of the hard palate Avithout the slightest stretching. The flap Avas composed of the mucous membrane and un- derlying muscle. Its dissection is difficult, and requires a long knife Avith a cutting edge tAvo centimetres long turned doAvn at right angles to the stem. The blade should be sharp on both edges, and it is Avell to have tAvo such knives, one blunt-, the other sharp-pointed. The upper end of the flap Avas caught up Avith a hook, and the dissection made from above doAvmvards, the knife being kept in the cellular tissue betAveen the muscle and bone, and its edge ahvays turned aAvay from the flap. The fibro-mucosa of the hard palate Avas then freely dis- sected up in the usual manner (Yon Langenbeck's method) until it and the soft palate had been made sufficiently movable. The upper corners of the flap Avere then cut off, giving it a triangular shape, and it Avas brought in betAveen the halves of the soft palate and fastened there Avith five points of suture. The fissure in the hard palate Avas closed Avith three points. The tampon-canula Avas replaced next day by a silver one. SwalloAving was very difficult for a feAV days ; suppuration and flow of mucus very abundant. The sutures were taken out on the fifth day. Union Avas complete on the right side and upper part of the left, but had failed for a distance of one centimetre betAveen the tip of the uvula and the flap on the left side, and of three centimetres in the hard palate. The latter Avas closed by another operation (Langenbeck's) in January, 1875. The tone of the voice and the distinctness of articulation 1 A tracheotomy tube, the middle portion of which is enveloped in a rubber pouch which can be expanded so as to fill the trachea and prevent any liquids from finding their way down beside it, the patient meanwhile getting his supply of air through the tube. EXCISION OF THE TONGUE. 301 Avere immensely improved from the first, and, after a feAv days, there Avas no difficulty in SAvallowing or in breathing through the nose. This operation was designed to meet a special indication, of Avhich mention is not often made. It is Avell knoAvn that the nasal quality of the voice often persists after a fissure has been completely closed, and the cause has been supposed to lie in the fact that the soft palate is so short and tense that it cannot be brought into contact Avith the posterior Avail of the pharynx. Passavant proposed to meet the diffi- culty by establishing permanent adhesion between the velum and pharynx, basing the proposition upon cases of such ad- hesion observed by himself in Avhich the objectionable nasal quality Avas absent from the voice. A more extensive ex- perience, hoAvever, has shoAvn that Passavant Avas in error, or that his observations Avere incomplete. If the adhesion is complete, or nearly so, the quality of the voice is seri- ously affected, and other functional troubles are occasioned. It is probable that the good result in Schoenborn's case was due to tAvo causes: free communication left betAveen the upper and loAver parts of the pharynx on each side of the flap, and ability to move the tAvo halves of the palate at will, although only to a limited extent. The method seems to be Avorth further trial. EXCISION OF THE TONGUE. Excision, partial or complete, may be rendered necessary by hypertrophy of the tongue, or by the presence of a tumor. Se lillot1 mentions a case of hypertrophy in which the tongue projected three finger-breadths beyond the lips, and had bent doAvn the anterior portion of the loAver jaAV to such an extent that, Avhen the upper and Ioavci- molar teeth Avere in contact, the distance between the incisors in the median line Avas more than an inch. He removed the projecting part of the tongue by a V-shaped incision, the apex directed backAvards in the median line, and brought the sides together Avith sutures. Recovery Avas complete and prompt. 1 Medecine Operatoire, vol. ii. p. 33. 26 302 OPERATIONS UPON MOUTH AND PHARYNX. Excision may be performed by means of the ligature, knife, ecraseur, or gahano-cautery. The use of a ligature, slowly tightened every day, has fallen into disuse since the invention of the Ecraseur; it is very tedious and painful, and the tongue is liable to SAvell enormously during the process. The use of the knife exposes to severe and dangerous hemorrhage unless the portion removed is small and favora- bly situated. Preliminary ligature of one or both lingual arteries has been employed by some surgeons, as has also the application of the actual cautery to the surface of the incision. Mr. Henry Lee has devised a clamp (Fig. 192) Lee's clamp to prevent bleeding from the tongue. by Avhich hemorrhage from the anterior portion of the tongue can be completely controlled. The tongue is draAvn Avell fonvard, the tumor or portion to be removed seized with double pronged forceps and rapidly excised by a V-shaped incision made with a blunt- pointed bistoury so as to avoid injury to the vessels in the floor of the mouth ; all bleeding points are then secured and the sides of the Avound brought together Avith sutures. Regnoli, of Pisa, published in 1838 the description of a EXCISION OF THE TONGUE. 303 method by which he successfully removed the anterior por- tion of the tongue. He made a semicircular incision through the skin along the Ioavci* border of the jaAV, begin- ning and ending at the angles, and added a second one to it in the median line, extending to the hyoid bone. The tegumentary flaps Avere dissected back, and the muscles divided at their attachments to the inferior maxilla. The tongue Avas then drawn doAvn through the large opening thus made, its anterior portion readily excised, and the Avound closed. Se lillot, commenting upon this case, expresses the opinion that the excision could have been accomplished quite as readily through the mouth, and, as he also found by ex- periments upon the cadaver that the tongue cannot be brought far enough fonvard through such an opening to facilitate excision at or near its base, he suggested and em- ployed division of the inferior maxilla in the median line as a preliminary operation. Sedillofs Method.—One of the median incisor teeth on the loAver jaAV having been drawn, an incision is made in the median line from the free border of the loAver lip to the hyoid bone, and the jaAV saAvn through in the line of the incision, or, better, by tAvo oblique lines forming a <, the apex directed to one side. The attachments of the genio- hyo-glossus muscles to the bone are next divdded, the tAvo halves of the jaAV draAvn apart, the tongue pulled forward and to one side, and its attachments to the hyoid bone divided on the other side, in doing Avhich the lingual artery is divided and must be tied at once. The tissues on the other side are then divided in a similar manner, and the other lingual artery having been tied the remaining attach- ments are severed and the tongue removed. The divided maxilla is fastened together again Avith siher sutures passed through holes pierced in it Avith a drill, the sides of the incision in the lip accurately adjusted to each other, and the loAver angle of the Avound left open for drainage. Removal by the Ecraseur (Fig. 193).—The chain of the deraseur, a stout Avire, or a Avhip-cord is passed about the tongue or its attachments at the selected point by means 304 OPERATIONS UPON MOUTH AND PHARYNX. of a needle and thread or a trocar and canula, and sloAvly tightened until the parts included in the loop are cut Fig. 193. Fig. 194. Hutchinson's gag. through. As the operation is compa- ratively bloodless, anaesthesia should be used and the mouth held open by a gag. Hutchinson's gag (Fig. 194) is very convenient and takes up but little room. Many different ways have been suggested for passing the Avire or chain. For removal of the anterior portion a needle carrying a ligature may be passed transversely under the tongue and used to conduct a chain beloAV it and back across its dorsum. After the tongue has been thus divided transversely the chain is passed again through the incision, including in its loop the inferior at- tachments of the anterior portion. Or the first ligature may be double ficraseur. and tAvo £craseurs used simultane- ously. Mirault carried a double ligature through the centre of the tongue from below upwards by means of a needle passed through a small incision in the skin in the median line of EXCISION OF THE TONGUE. 305 the supra-hyoid region. The ligature was then cut in two, each end carried around a lateral half of the tongue and brought out through the original opening. A third ligature was then carried horizontally about the inferior attachments of the portion to be removed. Cloquet removed a lateral portion of the tongue by pass- ing a double ligature in the manner just described, and placing one of the loops in an antero-posterior position so that it divided the tongue along the median line. Sir James Paget drew the tongue forward, divided the mucous membrane and the soft parts of the floor of the mouth close to the bone, including the attachments of the genio-hyo-glossi to the symphysis, and then passed the chain of the ecraseur around the root of the tongue as low doAvn as possible, so as to encircle it and all the remaining infe- rior attachments. The galvano-cautery is used either in the form of a knife or as the wire of an ecraseur; no additional directions are required beyond the caution that the temperature should be raised to red-heat only. At a higher temperature the parts are divided more rapidly, and bleeding is likely to occur. Langenbuck1 has devised a method of so placing tAvo temporary ligatures upon the tongue that bleeding is en- tirely prevented during the removal by the knife of any portion of the anterior half or even tAvo-thirds of the mem- ber. He enters the point of a Avell-curved needle carrying a stout ligature a little to the left of the median line of the tongue behind the part Avhich is to be removed, passes it deeply doAvn through the substance of the tongue, and brings it out on the right side through the floor of the mouth so as to include the branches of the lingual artery in its loop. To prevent slipping, the needle is then passed through the edge of the tongue; another is passed in the same manner on the opposite side, and each tied tightly. The ends may then be used to draAv the tongue forward. It has also been suggested, that, Avhen it is necessary to operate very far back upon the tongue, its base can be brought fonvard by dislocating the loAver jaAV doAvmvards and forwards simultaneously on both sides. 1 Archiv fiir Klinische Chirurgie, vol. xxii. part I. 1878, p. 72. 26* 306 OPERATIONS UPON MOUTH AND PHARYNX. DIVISION OF THE FRENUM. The tip of the tongue is raised upon the handle of a director, in the slit of which the frenum is engaged, and divided with curved scissors close to the director. Only the semi-transparent edge of the constricting band should be cut, and then the rest torn by pressing the tongue up towards the roof of the mouth. If the ranine vessels should chance to be divided the bleeding can be controlled by touching the points Avith nitrate of silver or, if necessary, Avith the actual cautery. J. L. Petit reported a case of suffocation caused by the tongue falling back upon the glottis after division of the frenum, and Gudrin mentions another. RANULA. The anterior Avail of the cyst should be caught up Avith toothed forceps and excised. A director should be passed at intervals between the sides of the incision to prevent re- union, and the filling up of the sac may be hastened by painting its interior with nitric acid or tincture of iodine. In some cases it is sufficient to pass a thread or Avire seton through the cyst. SALIVARY FISTULA. Salivary fistula communicating directly Avith portions of the parotid gland can usually be closed by cauterization and compression, but Avhen the fistula communicates with Steno's duct the cure is much more difficult. If the distal portion of the duct is still permeable a leaden Avire may be passed through it from the mouth into the proximal portion of the duct. The saliva will folloAV the Avire, and if the fistula does not close spontaneously its edges should be pared and brought together Avith sutures. The orifice of the duct is readily found opposite the second upper molar tooth. SALIVARY FISTULA. 307 When the distal portion of the duct is obliterated either one of tAvo methods may be employed. The first is that of Deguise, and consists in the formation of a neAV channel in the cheek for the saliva ; the second is that of Prof. Yan Buren, and consists in the bodily transfer of the fistulous orifice from the outer to the inner surface of the cheek. I)eguise's Method.—Deguise made a puncture through the fistulous opening obliquely backAvards to the inner sur- face of the cheek and passed one end of a leaden Avire through it; he next made through the same opening a second puncture directed obliquely forwards, brought the other end of the Avire through it and tied the tAvo ends together. The loop of the Avire being thus draAvn into the fistula the saliva folloAved its tAvo branches into the mouth, and the fistula healed at once. Some surgeons use a silk ligature and tie it tightly so as to cut through the tissues included in the loop. Prof. Van Buren1 cured a salivary fistula, the result of a gunshot Avound, by passing tAvo fine silver Avires through the skin at opposite points on its edge, then isolating the duct and fistulous opening for half an inch by dissection backwards from the latter, makinsr an incision through the Avound to the inner side of the cheek, drawing the fistulous opening through it, and fastening it there by means of the Avires. The gap left on the cheek Avas then closed Avith fine silver sutures. The duct Avas so short, the fistula being an inch behind the anterior margin of the masseter, that it could not be brought quite to the inner surface of the cheek. The Avires, hoAvever, Avhich Avere left in place until the fifth Aveek, kept open a track, Avhich became permanent, for the passage of the saliva from the end of the duct to the mouth. 1 Xew York Medical Journal, vol. i. p. 53, and Contributions to Practical Surgery, 18G5, p. 20o. 308 OPERATIONS UPON THE NECK. CHAPTER IY. OPERATIONS PERFORMED UPON THE NECK. BRONCHOTOMY. Tins is a general term covering operations undertaken to open the larynx or cervical portion of the trachea. These operations are : Laryngotomy, tracheotomy, and laryngo- tracheal) my. Laryngotomy is further subdivided into sub- hyoid laryngotomy (called supra-laryngeal bronchotomy by Se'dillot, and indirect laryngotomy by Planchon), thy- roid laryngotomy, and crico-thyroid laryngotomy. The names indicate the points at Avhich the opening is made into the air-passages. Sub-hyoid Laryngotomy.-—This operation, originally per- formed upon animals by Bichat for the purpose of studying the movements of the vocal cords, Avas afterwards proposed by Yidal to give access to an abscess situated in the glotto- epiglottidean folds, and by Malgaigne to allow the removal of a foreign body lodged in the upper part of the larynx. It is also applicable to the removal of polyps situated at the same point and not accessible through the mouth. Follin thus removed ten from the anterior surface of the arytenoid cartilages. A transverse incision tAvo inches long, its centre in the median line, is made through the skin immediately below the hyoid bone, and the platysma, sterno-hyoid muscles, and thyro-hyoid membrane divided. The mucous mem- brane lying betAveen the epiglottis and the base of the tongue then presents in the incision, is draAvn doAvmvard with forceps, and opened Avith the knife or scissors. The epiglottis is then seized with a hook or pronged forceps and draAvn out through the Avound, freely exposing the larynx to view. LARYNGOTOMY. 309 Yelpeau made the first incision in the median line, di- vided the thyro-hyoid membrane transversely, and then plunged the knife backwards and doAvnwards, making a vertical incision in the base of the epiglottis through Avhich he passed the blades of a pair of forceps and AvithdreAV the foreign body. Thyroid Laryngotomy.—In this operation the thyroid cartilage is divided vertically in the median line, between the anterior attachments of the vocal cords. It is suitable for the removal of foreign bodies or polyps from the inte- rior of the larynx. Steadying the larynx Avith the thumb and forefinger of his left hand, the surgeon makes an incision along the pro- jecting angle of the thyroid cartilage in the median line, from its upper border to the cricoid cartilage. As soon as the crico-thyroid membrane is exposed, he makes a small opening in it near its upper border and passes one blade of a strong blunt-pointed pair of scissors through it to the upper border of the larynx, keeping exactly in the median line, and thus divides the thyroid cartilage throughout its entire length. Or a grooved director may be passed through the opening made in the crico-thyroid membrane, and the cartilage divided upon it Avith a curved bistoury. Or, again, the division may be made Avith the knife, layer by layer, from before backwards. Crico-thyroid Laryngotomy.—In this operation the open- ing is made in the crico-thyroid membrane. The French writers, Sdlillot, Dubrueil, Chauvel, speak of this method as having been entirely abandoned because the opening cannot be made sufficiently large. Holmes, on the other hand, considers it suitable in all cases in Avhich only the vocal cords or the tissues above them are involved, and says it is practised in spasm of the glottis from any cause, in erysipelatous affections spreading down the throat, and in cases of foreign body lodged in or above the glottis. If the opening proves to be too small it can be enlarged doAvn- wards through the cricoid cartilage (laryngo-tracheotomy). The operation may be required in cases of urgency Avhen no tube is at hand. A pair of forceps or scissors, a hair- 310 OPERATIONS UPON THE NECK. pin, or pieces of bent Avire will suffice to keep the Avound open, and the incision can be made Avith a penknife. Operation.—Dorsal decubitus, shoulders raised upon a cushion or narroAV pillow so that the head may fall back and keep the throat tense. The surgeon, standing at the patient's right side, fixes the larynx Avith his left thumb and middle finger placed on either side, and the index upon its upper border, and makes a cutaneous incision in the median line corresponding to the crico-thyroid membrane. He draws the sterno-thyroid muscles apart, lays bare the mem- brane, and divides it transversely or vertically;. in the latter case the incision should begin a short distance below the inferior border of the thyroid cartilage, so as to avoid a small artery which crosses at that point, and extend to the cricoid cartilage. (For the method of inserting the canula see Tracheotomy.) Laryngo-tracheotomy.—The opening occupies part of the crico-thyroid membrane, the cricoid cartilage, and the first tAvo or three rings of the trachea. The upper border of the isthmus of the thyroid usually corresponds to the second ring of the trachea ; it should not be divided. Dorsal decubitus, Avith shoulders raised, head throAvn back, and neck slightly stretched. The larynx is fixed as for crico-thyroid laryngotomy, and an incision made through the skin in the median line from the loAver border of the thyroid cartilage to about one inch beloAV the cricoid. The muscles are carefully drawn apart, the isthmus of the thy- roid depressed if necessary, the point of the bistoury en- tered in the crico-thyroid membrane, and made to cut doAvn- Avard through the cricoid cartilage and one or tAvo rings of the trachea. The edges of the incision are then held apart and the canula introduced, or the forceps if the operation has been undertaken with a vieAv to the removal of a foreign body or a polyp. De Saint Gerniaiti's Method.—Dorsal decubitus, shoul- ders raised, neck extended. The surgeon feels for the cricoid and thyroid cartilages, and the depression betAveen them. Then, standing upon the patient's right side, he places his left thumb and middle finger on either side of the larynx, and by pressing them in between it and the ver- TRACHEOTOMY. 311 tebral column pushes the larynx fonvard, makes tense the skin covering it, and at the same time marks the situation of the lower border of the thyroid cartilage Avith the nail of his left forefinger. The knife, a straight sharp-pointed bistoury, is held like a pen, its back directed upAvards, and the middle finger so placed upon its side as to limit to half an inch the depth to Avhich the point can penetrate. It is then entered Avith a quick sharp stab in the median line close against the nail of the left forefinger and made to cut downwards Avith a saAving motion through the cricoid cartilage and one or tAvo tracheal rings, care being taken to make the incision in the skin fully as long as that in the trachea. The Avound is held open Avith a " dilator," and the canula introduced be- tAveen its branches ; the pressure of the latter is usually sufficient to arrest hemorrhage, but ligatures can be easily applied if necessary. In only one case out of ninety-seven did Saint Germain injure the posterior Avail of the trachea, and in only three did hemorrhage occur.1 Tracheotomy.—The trachea may be opened at any point betAveen the cricoid cartilage and the upper border of the sternum, a distance averaging in the adult from tAvo and one-half to three inches, in the child under ten years of age from one and one-half to tAvo and one-half inches. Its course is obliquely backAvards as Avell as downwards, so that Avhile its upper end is almost subcutaneous it becomes deeply placed before it passes behind the sternum. It is crossed at its upper end by the isthmus of the thyroid gland, the breadth, thickness, and vascularity of which vary Avithin very Avide limits, although its upper border usually corresponds to the second ring of the trachea. A communicating branch unit- ing the tAvo inferior thyroid arteries crosses just below the loAver border of the isthmus. The loAver portion is covered anteriorly by the thyroid veins, ahvays greatly distended Avhen the respiration is obstructed, and by the thymus gland in children under tAvo years of age, and occasionally in un- healthy older ones. To the dangers depending upon the normal arrangement of 1 Bull, de la Society de Chirurgie, 1877, pp. 271 and 327. 312 OPERATIONS UPON THE NECK. the parts are added those of not infrequent anomalies in the origin and course of the arteries and veins. Thus, the left brachio-cephalic vein may cross the trachea Avell above the sternum, the left carotid may arise from the innominate, and sometimes an inferior thyroid artery is given off from the transverse portion of the arch of the aorta, and ascends along the anterior surface of the trachea in the median line. Finally, an aneurism of the innominate, or of the arch of the aorta, may rise in front of this portion of the trachea. Operation.—The patient is placed upon his back, Avith shoulders raised and head throAvn back. A trustAvorthy assistant, standing behind the head, holds it firmly in a straight line Avith the body ; others control the patient's limbs if he has not been anaesthetized. The surgeon, stand- ing at the patient's right side, recognizes with his finger the hyoid bone and thyroid and cricoid cartilages, and, marking with his left forefinger the lower border of the cricoid carti- lage, makes an incision doAvmvard from it in the median line from one and one-half to two inches in length, according to the size of the patient. He carries the incision through the skin and fascia, separates the sterno-hyoid and sterno-thyroid muscles with the handle of his knife, and lays bare the isthmus of the thyroid. If any large veins are encountered, they must be carefully draAvn aside or divided between tAvo ligatures, but bleeding from smaller ones may be safely dis- regarded, for, as Trousseau pointed out, it will cease as soon as the trachea is opened, and the venous congestion relieved by the admission of air to the lungs. It is Avell to have one or two assistants hold the sides of the incision apart during the dissection, if they can be de- pended upon to do so Avithout disturbing the relations of the parts by draAving too forcibly towards one side or the other. The isthmus of the thyroid is next draAvn upAvard with a blunt hook, and three or four rings of the trachea exposed beloAV it, and divided from below upAvards. If for any reason it is desirable to make the incision higher up, or if the isthmus is unusually broad, it may bo divided betAveen tAvo ligatures, in Avhich case the incision of the trachea should be made from the lower border of the cricoid cartilage doAvn- Avards. The incision in the trachea should ahvays be free enough TRACHEOTOMY. 313 to admit the canula readily, and should be made by a quick thrust with a sharp-pointed knife, which must be prevented from penetrating too deeply at first, by holding it close to its point. After the puncture has been thus made, it is enlarged by gentle sawing movements of the knife, or with scissors. The knife is retained in the trachea, as a guide, until the dilator or bivalve canula (Figs. 105 and 196) has been in- Fig. 195. Fig. 196. Bivalve canula closed. Bivalve canula with tube in place. troduced. The best dilator is the three-bladed one ; it is introduced closed, its blades then expanded, and the perma- nent canula passed in betAveen them. The canula should be curved, double to facilitate cleaning, and with an opening on its convexity, through Avhich the expired air can pass to the larynx. Some surgeons steady the trachea by draAving it toward the chin with a tenaculum introduced at the loAver edge of the cricoid cartilage. Gurdon Buck used for this purpose a rather narroAV lance-shaped knife, bent at a right angle on the flat, and also grooved on the back for use as a director. Galvano- or Thermo-cautery.—The danger of hemor- rhage, especially in the adult, has led many surgeons to use the galvano- or thermo-cautery. Its hemostatic advantages, hoAvever, are offset by a large eschar Avhich it causes, and 27 314 OPERATIONS UPON THE NECK. the possible necrosis of the tracheal cartilages.1 The cautery should be used only to divide the soft parts, the trachea should be opened Avith the knife. Saint Germain has also sought to prevent hemorrhage by making the incision with a red-hot bistoury. CESOPHAGOTOMY. The oesophagus begins in front of the sixth cervical ver- tebra in the median line, or just behind the cricoid cartilage; at first it inclines slightly towards the left, then returns to the median line as it passes behind the sternum, inclines to the right at the arch of the aorta, and again to the left as it approaches the diaphragm. The left recurrent laryngeal nerve lies betAveen its cervical portion and the trachea, the right recurrent nerve lies upon its outer side. It is covered anteriorly by the trachea and left lobe of the thyroid gland, and crossed by the left inferior thyroid artery and vein. The guide to it is the trachea. The operation of external oesophagotomy may be required for the relief of stricture, or the removal of a foreign body. In the former case, it may be performed above or at the level of the stricture for the purpose of dividing or dilating it, or beloAV the stricture so as to alloAV the introduction of food into the stomach. Vacca-Beiiinghieri's oesophageal sound. The left side of the oesophagus is more accessible in the neck than the right, and the incision may be made in the median line or parallel to the inner border of the sterno- cleido-mastoid muscle. As the walls of the oesophagus are 1 See the discussion in the Society de Chirurgie, May 9th to June 13th, 1877. 03SOPHAGOTOMY. 315 flaccid, a guide should be used if it is possible to introduce one. The best one is the instrument known as Yacca-Ber- linghieri's sound (Fig. 197). It is a hollow metallic in- strument, curved at one end like a urethral sound, but to a less degree, Avith a long opening in the concavity or on the left side, extending not quite to the end. Within this sound is an elastic staff, the side of Avhich can be made to project through the opening and distend the oesophagus, its point being engaged in the cul-de-sac at the extremity of the sound. In some cases the foreign body can be used as a guide. Lateral Incision.—Dorsal decubitus, head extended, face turned slightly to the right. The surgeon, standing at the patient's left, makes an incision through the skin, subcutane- ous cellular tissue, and the platysma a little on the inner side of the inner border of the sterno-cleido-mastoid from a point one inch above the sternum to the level of the upper border of the thyroid cartilage. If the external or anterior jugular is encountered, it must be draAvn aside or divided between two ligatures. The fascia is then divided, the omo-hyoid muscle draAvn aside, and the carotid and internal jugular separated from the tracheal muscles by means of a director, and drawn outAvard. Yacca's sound is then introduced through the mouth, its elastic staff projected through the lateral opening so as to distend the oesophagus, and recognized by the finger at the bottom of the Avound. The surgeon, having satisfied himself that the recurrent laryngeal nerve and inferior thyroid artery are out of the Avay, punctures the oesophagus, and enlarges the opening Avith scissors or a blunt-pointed bistoury. Median Incision.—The incision is the same as in trache- otomy. After the trachea has been exposed in the median line, the surgeon separates it on the left side with a director from the sterno-thyroid and sterno-hyoid muscles, and opens the oesophagus on the outer side of the recurrent laryngeal nerve. 316 OPERATIONS UPON THE THORAX. CHAPTER V. OPERATIONS UPON THE THORAX. AMPUTATION OF THE BREAST. The patient is placed upon her back, inclined someAvhat towards the opposite side, and the arm abducted so as to make the skin and pectoral muscle tense. Tavo curved in- cisions are made, one on each side of the nipple, inclosing an elliptical strip of skin of greater or less breadth accord- ing to circumstances, the long axis of Avhich is directed towards the axilla; that is, upwards and backwards. The upper and lower skin flaps are then dissected off the anterior surface of the gland, its upper border turned, exposing the pectoral muscle, if necessary, and the loose cellular tissue betAveen it and the muscle rapidly divided Avith a few strokes of the knife, beginning at the upper border or the inner angle, Avhile the gland is draAvn aAvay from the chest Avail, and the removal completed along the lower incision, or at the axillary angle of the Avound. Bleeding during the operation must be controlled by digital pressure upon the bleeding points, and the vessels secured afterwards with ligatures or by torsion. If the axillary glands are involved, the incision may be extended upward into the axilla, and the glands torn out Avith the fingers, or a ligature thrown around the pedicle of each before its division. The glands are usually in very intimate relations with the sheath of the vessels, and unless their removal is conducted Avith great caution serious hemor- rhage may ensue. PARACENTESIS OF THE THORAX. The term thoracentesis is sometimes used in a restricted sense to indicate puncture of the thorax Avith a trocar or the PARACENTESIS OF THE THORAX. 317 needle of an aspirator; empyema is similarly used to denote the making of a free incision into the pleural cavity to eva- cuate a purulent collection. Each of the loAver posterior intercostal arteries enters its corresponding intercostal space near the spinal column, and passes obliquely from below upAvards across the space to shelter itself in a groove on the inner side of the loAver border of the upper rib. It occupies this groove until it reaches the anterior third of the space, Avhen it leaves it to anastomose with the branches of the anterior intercostal artery coming from the internal mammary. At this point, hoAvever, it is so small that its division is not of much con- sequence. The only part of its course Avhere its injury is to be feared is in the posterior third of the intercostal space before it has passed behind the lip of the rib. Consequently, if an opening is to be made into the pleural cavity, either Avith a knife or trocar, a point in the middle third of one of the intercostal spaces should be selected, preferably the seventh, certainly not higher than the sixth, nor loAver than the eighth on the right side, the ninth on the left. Fig. 198. Paracentesis of thorax. After determining the position of the intercostal space, often a matter of considerable difficulty in consequence of the infiltration of the parts, make an incision parallel to it, one or one and one-half inches in length. Divide the tissues layer by layer, until the rib can be distinctly felt Avith the 318 OPERATIONS UPON THE THORAX. finger introduced into the Avound. I'lace the end of the finger upon the upper border of the lower rib, and, keeping the knife close to the border, divide the muscles and pleura. If a trocar or the aspirator is used, it must be thrust in Avith a sharp push so as to certainly penetrate the pleura, Avhich is often thick and tough. The outer end of the canula should be Avrapped in a long sleeve of moistened gold-beater's skin, Avhich will hang doAvn over its orifice, and, Avhile permitting the escape of the pus, will prevent the entrance of the air (Fig. 198). PARACENTESIS OF THE PERICARDIUM. Normally the pericardium is in contact Avith the chest Avail only in the median line under the sternum; but Avhen its sac is distended Avith liquid the area of contact becomes much larger, especially by extension downwards and to the left. The heart is at the same time pressed upward and backward. The limits of the pericardium can be ascer- tained Avith great accuracy by percussion and auscultation, and this should always be done before puncturing. At the point selected for puncture the pulsations of the heart should be imperceptible, or at least very faint, and it should be abso- lutely flat on percussion. It should also be remembered that the internal mammary artery runs parallel to the side of the sternum and a finger's breadth from it. If the knife is used the tissues must be divided layer by layer, and the finger should ahvays be introduced into the wound before the pericardium itself is incised, to make sure that the heart is nol in contact with it. PARACENTESIS OF THE ABDOMEN. 319 CHAPTER VI. OPERATIONS UPON THE ABDOMINAL WALL, STOMACH, AND INTESTINES. PARACENTESIS OF THE ABDOMEN. In order to avoid injury to the different viscera, and espe- cially to the internal epigastric artery, Avhich runs from the middle of Poupart's ligament toAvards the umbilicus, the puncture should be made either in the median line midAvay betAveen the umbilicus and the symphysis pubis, or midAvay between the umbilicus and the anterior superior spine of the ilium. The* instrument used is a trocar and canula or an aspirator. The depth to Avhich it shall be allowed to penetrate is regulated by the finger placed upon its side, and it should be plunged in sharply, Avithout a preliminary incision, at the selected point, Avhich should be absolutely flat upon percussion. As there is a possibility of syncope occurring during the operation, in consequence of the with- draAval of pressure, it is prudent to first pass a broad, many-tailed flannel bandage about the abdomen, crossing its ends behind, so that an assistant standing at each side can draAv upon them and tighten the bandage as the liquid escapes. It is usually sufficient, hoAvever, to have an as- sistant make steady pressure Avith one hand on each side of the abdomen. During the operation the patient should be seated or inclined tOAvard one side. Should hemorrhage ensue, the attempt must first be made to control it by the pressure of the canula or of a larger gum catheter introduced through the puncture. This fail- ing, the entire thickness of the abdominal Avail must be pinched up and compressed, or, in extreme cases, an acu- pressure needle or harelip pin passed across the course of the bleeding vessel and pressure made by a tAvisted suture throAvn around its ends. When it is necessary to practise paracentesis upon a 320 OPERATIONS UPON ABDOMINAL WALL, ETC. pregnant woman, Ollivier recommends the selection of the neighborhood of the umbilicus for the puncture ; Scarpa preferred the left hypochondrium, Yelpeau the left flank. GASTROTOMY AND GASTROSTOMY. The Avord gastrotomy, Avhich Avas first used to indicate an operation by Avhich an incision Avas made through the ab- dominal Avails, whether for the removal of a tumor, the relief of strangulation of the intestines, or the opening of the stomach, is now generally restricted to the latter, that is, to an opening made through the abdominal Avail into the cavity of the stomach. When the opening is made a per- manent one, the term gastrostomy (yao-r^p stomach, and mbfia mouth) is used. Laparotomy (t^andpa the flank), a term originally applied to the operation for the relief of lumbar hernia, is now generally substituted for gastrotomy in the sense formerly given to that Avord, to indicate an in- cision through the abdominal Avails. It is sometimes used in combination also, as laparo-enterotomy,—ileotomy,— typhlotomy,—colotomy, to indicate incision of the large or small intestine, but the use of the terms enterotomy and colotomy in this sense is much more general. The operation of gastrotomy, the earliest recorded ex- ample of Avhich dates back to the first half of the seven- teenth century, has been a very successful one. Of thirteen cases collected by various Avriters1 only one terminated fatally, and in that case the cause of death is not knoAvn. Gastrostomy, on the other hand, is a much more recent and very fatal operation. The editor of the Gazette Hebdo- madaire, May, 1876, mentions tAventy-two cases, all of Avhich terminated fatally. This discouraging series has since been broken by Verneuil's successful case, reported in the same journal October 27th, 1876, but this again Avas followed by tAvo fatal ones, one by Callender, the other by Lannelongue ; perhaps the latter of these should be classed as a success, for the patient survived the operation twenty- six days and died asphyxiated in consequence of the per- 1 Eleven of these are given with details in an article by Dr. Pooley, in the Richmond and Louisville Med. Journal, April, 18 75. GASTROTOMY AND GASTROSTOMY. 321 foration of a bronchus by the cancer, which occupied the oesophagus and led to the operation. As the operative methods are essentially the same in both operations, the cause of this difference in result must be sought elseAvhere ; and it is not difficult to find. While gastrotomy has always been undertaken for the purpose of removing a foreign body from the stomach of a healthy person, gastrostomy has been performed as a last resource upon individuals reduced by starvation and usually in a condition of cachexia produced by malignant disease. In twenty of the tAventy-three fatal cases the oesophagus Avas obstructed by cancer ; in the re- maining three the stricture was traumatic, but of doubtful nature; in Arerneuil's successful case the stricture Avas traumatic; in Lannelongue's it Avas cancerous. When the stomach is distended, it is in contact Avith the anterior abdominal Avail over quite a large area below the left lobe of the liver; Avhen it is empty, this area of contact becomes ATery small, and lies betAveen the left lobe of the liver and a transverse line draAvn at the level of the anterior Fig. 199. Anatomical relations of the stomach with reference to gastrotomy. end of the ninth rib. The guide to this line, as Tillaux1 has shoAvn, is the anterior end of the tenth rib, Avhich can be readily felt projecting beyond the border of the cartilages of the false ribs, and can be made to yield a sort of friction sound by rubbing it against the ninth. Sedillot2 claimed that when the stomach Avas empty, it Avas noAvhere in contact 1 Anatomic Topographique, p. 792. 2 Med. Operat., vol. ii. p. 274. 322 OPERATIONS UPON ABDOMINAL AVALL, ETC. Avith the anterior abdominal Avail, being separated from it by the liver and transverse colon, and recommended that it should be approached by a crucial incision through the left rectus muscle two or three inches beloAV the xiphoid appen- dix of the sternum. He passed his finger along the border of the left lobe of the liver to the diaphragm, encountered the stomach there, seized it Avith pronged forceps intro- duced along the finger, and dreAv it up to the incision Avhile pressing the colon doAvnward. Although, as stated, more recent investigations have shoAvn that the normal stomach when empty is still in contact with the anterior abdominal wall, these directions for finding the stomach may be useful in cases where it has been drawn back and bound down to the posterior Avail by inflammatory adhesions or neoplasms. The place at AAdiich the incision should be made into the stomach itself, is determined in gastrotomy someAvhat by the position of the foreign body Avithin the viscus; in gastros- tomy it should lie midAvay betAveen the greater and lesser curvatures, and at the junction of the cardiac and pyloric portions. This junction is often rendered plainly visible by an annular narroAving of the stomach at that point, and in any case can be readily determined by its distance from the pylorus, Avhich can be reached Avith the finger. The curva- tures can be recognized by the vessels running along them. Anaesthesia is usnally employed, although a serious objec- tion to its use in gastrostomy is found in the vomiting which it is so likely to cause, and the consequent tearing out of the sutures uniting the stomach to the abdomen. The external incision is the same for both operations. The incision made in the wall of the stomach should, in gas- trotomy, be only large enough to permit the removal of the foreign body; if this is small, the elasticity of the parts and the mobility of the mucous membrane may be sufficient to close the opening, and prevent the subsequent escape of the contents of the stomach, but in most cases one or more sutures will be necessary. Sedillot used a continuous suture, and brought the end out through the abdominal wound, Avhich Avas then closed with interrupted sutures; he found no difficulty in Avithdrawing the thread a few days later. A silver or catgut suture applied according to one of the methods hereinafter described under the head of LAPAROTOMY, ABDOMINAL SECTION. 323 suture of the intestines, with both ends cut short, Avould noAV be preferred. Labbe united the sides of the incision in the stomach to those of the incision in the abdominal Avail, and alloAved the gastric fistula thus created to close spontane- ously. Operation.—An incision, from one and one-half to tAvo inches in length, is made parallel to, and half an inch on the inner side of, the cartilages of the left false ribs ending beloAV at the level of the base of the cartilage of the ninth rib, which corresponds to the depression that can be felt just above the point of the tenth rib (Fig. 199). The incision is carried doAvn layer by layer, and the peritoneum divided upon a director. The stomach is recognized just beloAV the left lobe of the liver by its Avhite color, smooth surface, and the arrangement of its arteries. If it does not present in the Avound, it must be sought for by passing the finger along the border of the liver, and pressing the transverse colon dowmvard. When found, the stomach is seized Avith pronged forceps, and draAvn up into the abdominal wound. At this stage, Yerneuil secured the stomach by transfixing its Avail Avith tAvo long acupressure needles crossing the cutaneous wound at right angles, incised it, and fastened the edges of the tAvo incisions together Avith fourteen silver sutures. Labbe, before opening the stomach, fastened it to the abdominal Avail by eight silver sutures passed by means of sharply curved needles, Avhich Avere made to transfix the abdominal Avail nearly half an inch from the edges of the incision. By this means the tAvo peritoneal surfaces, visceral and parietal, adjoining the incisions Avere maintained in contact, and their immediate union favored. Peritonitis threatened in Labbd's case, but Avas checked by the application of a thick layer of collodion over the entire abdomen, immobilizing the latter so completely that the respiration became purely supra-costal. LAPAROTOMY, ABDOMINAL SECTION (GASTROTOMY). Laparotomy may be undertaken for the relief of occlusion of the intestines, or, as in the case reported by Dr. Samuel 324 OPERATIONS UPON ABDOMINAL AVALL, ETC. White, of Hudson, N. Y., in 1806,1 for the removal of a foreign body from the small intestine. When the nature and seat of the obstruction can be determined beforehand, and especially in cases of intussusception, as Dr. Sands has shown,2 the operation, if not too long delayed, offers a reasonable chance of success; but in chronic invagination, and when, the cause and location of the obstruction being unknoAvn, the chances of finding it, or of relieving it when found, are very slight, and the dangers of laparotomy very great, Nekton's operation of enterotomy should be pre- ferred. An exception to this preference for enterotomy must be noted in those rare cases Avhere the obstruction is situated very high up, probably near the duodenum; for then the portion of intestine above the obstruction will not be able to absorb sufficient food, even if it is long enough to permit of the establishment of an artificial anus in the groin. In such a case any surgical interference must be directed to the immediate removal of the obstruction. Operation.—The point for making the incision may some- times be determined by the position of the obstruction or the foreign body, but in most cases it should be made in the median line below the umbilicus. After having recognized the peritoneum and divided it upon a director, a finger should be introduced, and the obstruction sought for. In the case of an intussusception, the invaginated portion should be gently AvithdraAvn; if any difficulty is experienced in accomplishing this, the loop should, if possible, be brought out through the incision, and disinvagination effected by pulling the outer or ensheathing layer doAvuward, and squeezing back the loAver end of the intussusceptum. If the invagination can- not be reduced, or if it is found to be gangrenous, it has been proposed to excise it, and unite the divided ends of the intestine by sutures, or to insert the upper end into the caecum, and close the loAver end Avith a ligature. Leichten- stern3 has collected three cases of the latter operation, only one of which Avas successful. 1 Republished in Amer. Journ. of l\fcd. Sciences, July, 1876, p. 279. 2 In a valuable paper upon The Treatment of Intussusception by Abdominal Section, iY. Y. Med. Journ., June, 187 7. 3 Ziemssen's Cyclopaedia, New York, vol. vii. p. 662. RIGHT INGUINAL ENTEROTOMY. 325 RIGHT INOUINAL ENTEROTOMY (NELATON's OPERATION). As long ago as 1819, it Avas proposed to establish an artificial anus in the ileum in case the intestinal obstruction could not be found or removed by laparotomy; but Ne'laton Avas the first (1840) to substitute this for the other opera- tion, giving up the search after the obstruction entirely. His theory Avas that many obstructions would relieve them- selves in time, if a temporary outlet should be furnished to the accumulation above; in some cases, on the other hand, where the obstruction is permanent, an artificial anus in the ileum meets the "vital indication" perfectly—for example, Avhen the obstruction is in the lower portion of the small intestine; Avhile in others, again, Avhere the occlusion occurs beloAV the ileo-caecal valve, and the relief afforded would, consequently, be imperfect, the obstruction is usually due to malignant disease, Avhich in itself Avould soon destroy life, and against Avhich neither laparotomy nor any other operation would avail. It is also essential to the proper nourishment of the patient that the greater part of the small intestine should remain serviceable ; that is, that the opening should be made in the loAver part of the ileum. Of course, this cannot be accom- plished Avhen the obstruction is situated high up, but, in other cases, Ne'laton found that the intestinal loops nearest the obstruction ahvays occupied the right iliac fossa, and he, therefore, cut through the abdominal Avail just above the outer half of Poupart's ligament on the right side, and opened the first loop that presented in the incision. The portion of the intestine beloAV an obstruction is always empty and shrunken, and does not come into contact Avith the ante- rior abdominal wall, so that there is no danger of making the opening in it by mistake. It occasionally happens when the obstruction is situated in the colon, that the distended caecum fortunately presents in the incision, and the artificial anus is established beloAV the ileo-caecal valve. The operation is simple (Fig. 200). Make an incision parallel to and about an inch above Poupart's ligament, beginning at the anterior superior spine of the ilium, and 28 326 OPERATIONS UPON ABDOMINAL AVALL, ETC. Fig. 200. W ending opposite the internal inguinal ring. Divide the tissues layer by layer, open the peritoneum upon a director for one and One-half inches, and fasten the intestinal loop Avhich presents in the opening to the abdominal Avail, first by a Avire suture at each end of the incision, and then by two or three others on each side. Open the intestine by a longitudinal inci- sion betAveen the tAvo roAvs of sutures. The sutures should not include the skin, and are best placed by means of a sharply curved needle, Avhich is first passed into the intestine, and then brought out through it and the deep edge of the incision. By • this means the peritoneal surfaces are kept so closely in contact, that Avhen the intestine is opened its contents cannot make their Avay into the peri- toneal cavity. For description of the operation by Avhich the continuity of the intestine may be restored in cases in Avhich the occlu- sion is ultimately relieved, see Closure of Artificial Anus, p. 329. Right inguinal enterotomy. Nelaton. COLOTOMY. The colon may be opened in its ascending or descending portions by an incision in the lumbar region not involving the peritoneum, or at the sigmoid flexure by an incision in the left inguinal region opening the peritoneal cavity. The latter is knoAvn as Littre's operation, the former as Callisen's or Amussat's, or as lumbar colotomy. Littre's operation is noAV restricted almost exclusively to cases of imperforate anus, Avhile the other has come into very general use as a palliative operation in cases of cancer of the rectum, Avith or without obstruction of the passage of the feces. COLOTOMY. 327 Littre's Colotomy.—Huguier asserted that the sigmoid flexure in infants is very long, and is to be usually found in the right iliac region, but more recent investigations have shoAvn this position to be an infrequent abnormality; conse- quently the intestine must still be sought for on the left side, as Littre recommended. An incision, one inch in length, is made parallel to and a little above the outer half of Poupart's ligament, and the tissues, including the peritoneum, divided layer by layer. The sigmoid flexure, which can be recog- nized by its irregular lobulated surface and its comparative immobility, is then sought for, draAvn into the Avound, fast- ened to its edges, and opened in the manner described under Right Inguinal Enterotomy. Lumbar Colotomy.—This operation Avas first suggested by Callisen,1 in 1797, as a substitute for Littre's, Avith a view to avoiding the dangers incidental to an incision through the peritoneum. He proposed to open the descending colon in the posterior third of its periphery, where it is not covered by peritoneum. So far as knoAvn, Amussat Avas the first to perform the operation in 1839, and although he opened the ascending colon, and by a transverse instead of a vertical incision, the operation Avas essentially the same as that pro- posed by Callisen. All that portion of the descending colon Avhich lies above the crest of the ilium is usually uncovered by peritoneum on its posterior aspect, and although the actual breadth of the uncovered portion varies Avith the degree of distension of the boAvel, it usually amounts to one- third of the entire circumference, and is bounded on each side by one of the three longitudinal bundles of unstriped muscle characteristic of the colon. In position it corre- sponds nearly to the outer border of the quadratus lumbo- rum, and very exactly to a vertical line draAvn a full half inch behind the centre of a transverse one, uniting the anterior and posterior superior spines of the ilium (Mason). On the right side (ascending colon) the uncovered portion is more often smaller, and the existence of an actual meso- 1 Frskine Mason, Six Cases of Lumbar Colotomy, Am. Journ. of Med. Sciences, Oct. 1873. 328 OPERATIONS UPON ABDOMINAL WALL, ETC. colon, although rare, is yet more frequent than upon the left side. Callisen proposed a vertical incision a little external to the outer border of the erector spinas; Amussat made a transverse one midAvay between the last rib and the crest of the ilium, Avhile Baudens and Bryant used an oblique one passing doAvmvards and outAvards at an angle of 45°. The latter is to be preferred, because, Avhile giving sufficient room, it inflicts less injury upon the vessels and neiwes of the parts, the general direction of which is the same as that of the incision. The operation is performed as folloAvs: The patient is etherized, and placed in the prone position Avith a slight inclination to the right, a hard cushion being placed under the left side of the abdomen to raise and support it. Mason1 says the operation has been performed Avith the patient seated and leaning forward over the back of another chair, local anaesthesia being obtained by means of the ether spray. The anterior and posterior superior spines of the left ilium are then recognized, and a vertical line draAvn upwards from a point one-half to three-quarters of an inch behind the centre of a transverse line draAvn from one to the other. This vertical line should be marked with iodine or nitrate of silver, in order to serve as a guide during the operation. If the occlusion of the intestine has not been complete, and there is reason to suppose that the colon will be found empty, it must noAV be distended by injecting air or Avater through the rectum. Mason prefers air, and gives good reasons for the preference. A transverse or an oblique incision four or five inches long is then made, its centre lying in the vertical line above mentioned midway between the last rib and the ilium. The underlying tissues are recognized and divided layer by layer, until the fascia transversalis and quadratus lumbo- rum are reached. The former is next carefully divided, and, if the adipose tissue covering the colon does not then appear in the Avound, the latter should be enlarged on the inner side by dividing the outer fibres of the quadratus. The intestine must ahvays be sought for in the angle of the Loc cit. CLOSURE OF AN ARTIFICIAL ANUS. 329 wound nearest the spine, and Avhenever it is desired to in- crease its exposed area this must be done in the same direc- tion. Bleeding should be arrested as it occurs, certainly before the intestine is opened. The colon can usually be recognized by its distension and greenish hue, and possibly by one of its longitudinal bands. Additional light may be throAvn upon the correctness of the recognition by noticing Avhether the supposed colon corre- sponds exactly to the vertical line marked upon the skin, and Avhether or not it moves up and doAvn Avith the acts of inspiration and expiration, for while the small intestine has this motion the lumbar colon has it not. Tavo stout ligatures are next passed by means of curved needles through the presenting portion of intestine, and used to draw it up into the Avound, and fasten it to the skin at the sides of the incision. The Avound is then filled Avith sponges or lint, and the boAvel opened by a longitudinal or crucial incision. As soon as the discharge has ceased, the sponges or lint are AvithdraAvn, the parts cleaned, the extre- mities of the tegumentary Avound closed Avith silver sutures, and the edges of the opening in the intestine made fast to the skin with a feAV sutures of fine silk. CLOSURE OF AN ARTIFICIAL ANUS OR FECAL FISTULA. When the opening into the intestine is small and the communication betAveen the portions of the canal lying above and beloAV it free, the fistula will ordinarily close spontaneously, or after one or tAvo applications of a caustic or cautery. But Avhen the opening is larger, the remaining portion of the Avail of the intestine is pressed forward into it, and forms a sort of valve or spur Avhich prevents, more or less completely, the descending current of feces from entering the loAver segment of the boAvel, and turns it out through the opening on the surface. This spur must, there- fore, be removed before an attempt to close the external orifice is made. This is best accomplished by means of Dupuytren's enterotome (Fig. 201), or some similar instru- ment, Avhich by steady pressure upon the spur provokes 330 OPERATIONS UPON ABDOMINAL WALL, ETC. adhesion between its opposing peritoneal surfaces, and cuts through it in four or five days. Dupuytren's enterotome. After the channel has been re-established, the external orifice may be closed. If paring of the edges and approxi- mation by sutures do not suffice, more elaborate plastic methods must be employed. The fistulous tract betAveen the intestine and the skin is lined in most cases Avith mucous membrane, Avhich must be dissected up almost to the peri- toneum, turned imvards, and its raAv surfaces united with sutures. Liberating incisions are then made through the skin and tendon of the external oblique (if the fistula is in the groin), the sides of the opening pared still further if necessary, and brought together. Or lateral flaps left adherent at both ends (lambeaux en pant) may be dissected up, and their sides united to each other along the centre of the opening. It sometimes happens that the loAver portion of the intes- tine does not communicate with the fistula, and cannot be found. If the upper portion is too short for the proper nourishment of the patient, or if he is determined to be rid of his infirmity at any risk, it may be justifiable to seek for the loAver end, and, by attaching it to the opening beside the upper end, make it possible to ultimately restore the continuity of the canal, and close the fistula, as above de- scribed. In a case Avhere the fecal fistula occupied the right groin, Maisonncuve exposed the caecum by an incision pa- SUTURE OF THE INTESTINES. 331 rallel to Poupart's ligament and one inch above it, and established communication between it and a loop of intes- tine situated just above the fistula, by making a longitudinal incision, two inches long, in each, and suturing their edges together with the peritoneal surfaces in contact. The pa- tient did not survive the operation. In a similar case Laugier cut doAvn upon the caecum, stitched it fast to the edges of the cutaneous incision, and then, by means of a specially designed enterotome, Avhich Avas kept applied for seven days, established communication betAveen it and the small intestine. The patient died shortly afterwards, before the fistula had been obliterated, but the method is certainly much better than Maisonneuve's. SUTURE OF THE INTESTINES. Of the great variety of methods Avhich have been pro- posed for closing Avouncls of the intestines, only those deserve mention Avhich are based upon the principle laid down by Jobert of uniting surfaces covrered by peritoneum. The mucous membrane is so freely movable upon the muscular coat that some surgeons think Avounds less than one-quarter of an inch in length may be safely disregarded, because the lack of correspondence between the two openings will pre- vent the escape of the contents of the intestine, and the Avound will close spontaneously. Prof. Gross,1 hoAvever, says that any Avound, no matter how small, is likely to be followed by escape of feces into the cavity of the peri- toneum. On the other hand, when the Avound is so large, or of such a character, that the surgeon is unwilling to trust to a suture, it must be attached to the abdominal Avail, as in enterotomy, and an artificial anus created, Avhich, if it does not close spontaneously, may be afterwards closed by the surgeon. Wounds of intermediate sizes must be closed either by fastening them against the abdominal Avail so that communication betAveen the interior .of the canal and the abdominal cavity will be closed by adhesion between the visceral and parietal surfaces of the peritoneum, or by turn- 1 Am. Journ. of Med. Sciences. April, 1876. 332 OPERATIONS UPON ABDOMINAL WALL, ETC. ing the edges of the Avound inward and fastening them to- gether Avith sutures. It is usual to classify the methods according to their applicability to longitudinal or transverse wounds, although some of them may be used for either. Longitudinal Wounds.—When the wound is small it may be fixed against the inner edges of the abdominal Avail by a suture passed through the centre of its tAvo sides, brought out through the abdominal Avound, and fastened to the skin by adhesive plaster. Reybard kept the edges of the wound in contact Avith each other and Avith the abdominal Avail by means of a small oval piece of Avood, traversed by a ligature at tAvo points on its transverse axis, so that the loop of the ligature lay upon one side and its tAvo ends upon the other. The piece of Avood is placed Avithin the intestine, its long axis corre- sponding to the Avound, and the ends of the ligature brought through the intestine at a short distance on each side of the solution of continuity, and then by a single needle through the abdominal Avail near the external incision. The ends of the ligature are then separated, draAvn tight, and tied over a roll of lint. After three or four days the ligature is cut and withdraAvn, and the piece of Avood is passed Avith the feces. Jobert used the simple interrupted suture, taking the precaution, hoAvever, to roll the edges of the Avound imvard so as to bring the peritoneal surfaces in contact. He some- times cut the ends short, and sometimes brought them out through the abdominal Avound. In the former case they ultimately fell into the in- testine ; in the latter, they Avere Avithdrawn on the fifth or sixth clay. Lembert modified this by making the ligatures in- clude only a narroAV strip of the muscular and none of the mucous coat (Fig. 202). A needle carrying the ligature was entered on the outer surface of the Fig. 202. Suture of the intestines. method Lemlert's SUTURE OF THE INTESTINES. 333 intestine four millimetres from the edge of the wound, and brought out two millimetres from it without having per- forated the mucous membrane. It was then passed in the same manner on the opposite side, and after the necessary number of ligatures had been thus inserted they Avere tied and cut short. The effect of this method of placing the ligatures is to roll the edges of the incision imvard and to avoid the danger of an escape of feces into the abdominal cavity through an opening left by the fall of a ligature. The ligatures should be of silver, carbolized silk, or tough catgut. Gcly used a long ligature Avith a needle at each end, and placed it as shown in Fig. 203. The points of entry should Fig. 203. Suture of the intestines. G^ly's method. be about five millimetres apart. The needles used should be small, and it is well to make a knot at each crossing. Bouisson obtained the same result by passing an insect pin in and out along each side of the wound, as shown in Fig. 204, and drawing them together laterally by ligatures passed through the intervals. One end of each ligature was cut short" and the other brought out at the lower angle of the external wound ; a thread was tied under the head of each pin and brought out at the upper angle of the wound. On the third or fourth day the pins were with- 334 OPERATIONS UPON ABDOMINAL WALL, ETC. draAvn by means of the threads attached to them, and the ligatures, having been thus freed, Avere Avithdrawn at the same time. Fig. 204. Suture of the intestines. Bouisson's method. Berenger-F^raud uses tAvo strips of cork six millimetres wide and thick, and as long as the wound (Fig. 205, A). Fig. 205. Burenger-Feraud's method of closing a wound of the intestine. A. The strips. B. The strips in place. 0. The strips pinned together and the opening closed. Each piece is pierced by pins Avhose points project five or six millimetres on one side, and Avhose heads are sunk in the cork and covered Avith sealing-Avax on the other. They are then placed inside the intestine, one on each side of the Avound and parallel to it, and the pins forced through from within outAvards two or three millimetres from the edge (Fig. 205, B). They are then turned so that the points face each other, and the pins of each driven into the other HERNIOTOMY, KELOTOMY. 335 by pressure through the sides of the intestine. The strips ultimately come aAvay Avith the feces. Dubrueil suggests that the strips should be fixed together more firmly by a bent pin at each end, as represented in the figure ; there Avould then be less clanger of their falling apart and injuring the intestine on their way out. Transverse Wounds.—The old methods of uniting a di- vided intestine end to end over a cylinder of card-board or a calf's trachea introduced Avithin it, or of simply inserting the upper end into the loAver, have fallen into entire disuse. The safest plan in most cases is to make an artificial anus and trust to closing it afterwards, but Avhen that is not prac- ticable, or Avhen the Avound is small, it may be closed by any of the methods aboAre described, modified according to circumstances. Holmes1 says it is entirely justifiable, even in cases of total division, to unite the edges Avith the con- tinuous suture, cut it short, and let it ulcerate through Fig. 206. into the bowel. Jobert turned the loAver end of the boAvel in upon it- self, and then introduced the upper one, fastening them together Avith tAvo ligatures Avhich he brought out. at the abdominal Avound (Fig. 206). When the division was incomplete, he used only one ligature. The principle of this method is correct, for it brings two peritoneal surfaces into contact, but it is ahvays difficult and sometimes impossible to deter- mine Avhich is the loAver and which the upper end. Reunion of intestines divided trans- versely. A. The lower end doubled in- ward upon itself. Jobert's method. HERNIOTOMY, KELOTOMY. Under this heal are to be described the operations for the relief of strangulated inguinal, femoral, umbilical, and 1 Surgery, its Principles and Practice, p. 2:i7, Philada., 1876. 336 OPERATIONS UPON ABDOMINAL AVALL, ETC. obturator hernias, and those for the radical cure of the first three varieties. It has been Avell said that there is no operation in Avhich the unforeseen has a larger share than in herniotomy, none in Avhich the surgeon is called upon to sIioav more skill, sagacity, and decision. The causes of this are to be found in the absence of absolute guides to the hernial sac, the changes in the sac and overlying tissues brought about by inflammation or time, the character of the hernia—Avhether composed of omentum, intestine, caecum, or bladder, and, lastly, the difficulty of determining not only the extent of the injury done to the strangulated tissues, but eAren, in some cases, the route taken by the hernia in its descent. It is desirable, therefore, that the account of the different operations should be preceded by some general considera- tions upon these subjects. General Directions. A. Recognition of the Sac and Boivel.—The first difficulty encountered in the course of the operation is that of recognizing the sac. The thickness of the connective tissue covering it varies greatly in different cases; each layer must be pinched up Avith forceps, opened Avith the knife lying upon its side, as in opening the sheath of an artery, then raised upon the finger or a director, and divided to the full extent of the cutaneous incision, after having been carefully scrutinized. Occasionally a cyst containing liquid is found in front of the hernia, and may at first be mistaken for it, for usually the sac contains a certain amount of serum. Careful examination of the tissues before division is absolutely necessary, because in those rare cases Avhere there is no sac (hernia of the caecum or of the bladder), and in others Avhere it is quite undistinguish- able, it is only by recognizing the muscular coat Avhen he reaches it, that the surgeon avoids opening the intestine or bladder by mistake. As the sac is approached, each layer should be pinched up in a narroAV fold, and moved gently across the underlying parts; if a smooth globular tumor is felt beloAV, the surgeon makes an opening in the fold, con- fident that the Avail of the intestine is not included in it; but if he is unable to pinch up the fold, or if, instead of the sensation of a smooth globular mass, he gets only that of HERNIOTOMY, KELOTOMY. 337 an empty space, he examines the surface again, divides Avith a probe-pointed bistoury any fibrous bands he may find at the neck of the hernia, and tries to introduce his finger through it into the abdominal cavity. If he succeeds, he knoAvs the sac has been opened; if he does not succeed, he reneAVS the examination and continues the dissection. Maisonneuve said the surgeon may know he has not reached the intestine so long as he is not certain of having done so; but this is not true of all cases; the intestine is not ahvays smooth and shining; it may be dark, dull, con- gested, and thickened, and in hernia of the caecum it may have no peritoneal coat. When the hernia is small and recent the sac is bluish, and can be pinched up between the thumb and finger, so that its smooth opposing surfaces can be felt to glide upon one another. When it is large and of long standing, the sac may be exceedingly thin and unrecognizable, or very thick and adherent. If small, it should be thoroughly iso- lated, and its boundaries everyAvhere defined; if large and adherent, its neck alone should be cleared. B. Opening of the Sac.—The propriety of opening the sac has long been a subject of dispute. The only objection to it, but that a serious one, is the danger of thereby setting up peritonitis. On the other side is the danger of returning the hernia into the abdomen in a gangrenous condition, or unreduced Avhen the stricture is formed by the sac itself. Admitting that the opening of the sac is in itself an evil, and, therefore, to be avoided Avhenever possible, tAvo general rules may be laid doAvn. The sac should be opened: 1st. Whenever there is good reason to fear that the boAvel is gangrenous, Avhen there has been long-continued vomiting and tenderness on pressure. And 2d. AVhenever the hernia cannot be completely returned into the abdomen. In esti- mating the chances of gangrene, it must be remembered that it occurs much more promptly after the symptoms of strangu- lation appear in sudden recent hernias, than it does in old ones. The liquid Avhich, as has been already mentioned, is usu- ally contained in the sac, may not only serve to call atten- tion to its accidental opening, but may also be taken advan- tage of to open it safely Avhen it has been recognized, and 29 338 OPERATIONS UPON ABDOMINAL WALL, ETC. its opening has been determined upon. It, of course, col- lects at the most dependent point, and there intervenes between the sac and the boAvel, so that the former can be pinched up and opened without injury to the latter. When this is not the case, the surgeon must pinch up a very small fold of the sac wherever he can do so, or do as Mr. Liston did in a case Avhere, as he says, "there was no possibility of pinching up the sac, either with the finger or forceps; it contained no fluid, and was impacted most firmly Avith bowel; very luckily the membrane was there; and, observ- ing a pelleton of fat underneath, I scratched very cautiously with the point of the knife in the unsupported hand, until a trifling puncture Avas made, sufficient to admit the blunt point of a narrow bistoury."1 The opening should be en- larged until the finger can be introduced, and then the sac slit up on it as a guide. If the omentum is then found fill- ing the sac, it must be cautiously cut into, for it is probable, especially in umbilical hernia, that a strangulated loop of in- testine will be found in its centre. If such a loop is found, the finger must be passed along the boAvel, the director in- serted beloAV the ring of the omentum, and the constriction incised just sufficiently to admit of the return of the boAvel. C. Division of the Stricture.—The left forefinger is passed up into the neck of the sac to the stricture, the pulp upAvards, the nail pressing against the intestines ; if the stricture is found to be caused by a fibrous band beloAV the neck of the sac, it may be divided freely Avithout risk; but if it is situated at the opening in the abdominal wall through which the hernia made its escape, the division must be made Avith reference to the anatomy of the region. If the divi- sion cannot be made at the desired point, but only at some other Avhere an incision of the necessary extent Avould be dangerous, the stricture must be slightly nicked at that point, and advantage then taken of the partial liberation to make a second cut in the proper place. The end of the finger, or its nail, is gently engaged in the stricture, its pulp against the selected point of division, and the knife, a probe-pointed, slightly curved bistoury, 1 Op. Surgery, p. 462, quoted by Jos. Bell, Manual of Surgical Operations, p. 231. HERNIOTOMY, KELOTOMY. 339 passed on the flat along its palmar surface until the point has passed through the stricture. The surgeon then turns its edge upward and presses it against the stricture Avith the end of the finger on Avhich it rests. A slight crackling announces the division, Avhich must be extended or repeated at different points until the finger can be passed freely through into the abdomen. Instead of an ordinary probe-pointed bistoury, a specially constructed hernia knife (Fig. 207) is often used. It is Fig. 207. Hernia knife. probe-pointed and its cutting edge not more than an inch long. The knife may also be guided upon a director instead of the finger. The "hernia director" is broader than the ordinary one, and sometimes has a broad flange on each side to keep the boAvel from rolling over against the edge of the knife. D. Examination and Return of the Boivel.—The boAvel should be draAvn out about an inch in order that the con- stricted part itself may be examined, for it is very likely to be badly damaged.1 If the entire loop is in suitable con- dition it must be carefully cleaned of all blood and gradually returned into the cavity of the abdomen. It is not always easy to decide, hoAvever, Avhether or not its condition is suitable for return, and some surgeons have recommended that in cases of doubt it should be covered Avith Avarm, Avet cloths and kept under observation for some time, the stric- ture of course having been previously divided. A very great change in the color of the loop is far from proving the existence of gangrene. A deep red, vinous, even violet color does not preclude recovery, especially if 1 Holmes considers this improper practice unless there is evidence of actual perforation, because the traction may be sufficient to rup- ture the intestinal wall already weakened by ulceration of its mucous coat. 340 OPERATIONS UPON ABDOMINAL WALL, ETC. the surface has not lost its lustre ; but if it is black, or deep broAvn, or grayish yelloAV, or if it is dull, flaccid, or Avrinkled, it is certainly gangrenous. Of course, when the charac- teristic gangrenous odor, or the fecal odor consequent on perforation, exists, there can be no doubt. If the loops are in good condition but bound fast to one another, or to the omentum, or to the sac by firm adhesions, great caution must be exercised in dealing Avith them. The stricture must be freely divided and the loops emptied of their contents by pressure ; but the adhesions, Avhich have probably existed for a long time Avithout inconvenience to the patient, should in most cases be left undisturbed, the Avound closed, and the hernia treated as an irreducible one. It is not ahvays easy to return the intestines even after the stricture has been divided. The surgeon should try to reduce one end at a time, by squeezing its contents back into the abdomen and pushing the gut in aftenvards. If the bowel is very tense the gas may be draAvn off Avith a fine aspirator, or small punctures made Avith the point of a knife. If rupture occurs, and the boAvel is othenvise in good condition, it must be closed Avith the continuous suture (Holmes) and returned into the abdomen. If the intestine is gangrenous an artificial anus must be formed, and it is Avell to stitch the boAvel fast to the edges of the hernial ring, as in enterotomy. If the gangrene extends to the point of stricture and the boAvel cannot be draAvn further out, the stricture must not be divided, lest the bowel should slip back and feces escape into the peri- toneal cavity. The gangrenous portion must be incised, and then if the feces pass freely nothing more need be done, beyond taking measures to prevent the boAvel from slipping back, such as making its edges fast to the sides of the incision, or passing a stout ligature through the mesen- tery and fastening it to the skin Avith adhesive plaster. But if the stricture still prevents the flow of feces, Gosselin's plan of dilating it by introducing the finger into the intes- tine should be adopted. E. Treatment of the Omentum.—If only a small amount of omentum is found in the sac, and if it is in good condi- tion, it may be returned ; but if there is much of it, or if it is inflamed, suppurating, or gangrenous, it must be kept HERNIOTOMY, KELOTOMY 341 out. Holmes says the practice at St. George's Hospital is to transfix its base Avith a stout double ligature and cut it off, bringing the ends of the ligature out through the Avound; some excise it and tie all bleeding points, while others again simply leave it in the wound. Strangulated Inguinal Hernia.—Inguinal hernia may be oblique or direct. The former leaves the abdomen at the internal (deep) abdominal ring, having the deep epigastric artery on its inner side (Fig. 208), passes doAvn the in- Fijr. 208. Hernia. The relations of the femoral and internal abdominal rings, seen from within the abdomen. Eight side. guinal canal, and emerges at the external abdominal ring (Fig. 209); the latter makes its Avay through Hesselbach's triangle, a space bounded by the epigastric artery, Pou- part's ligament, and the rectus abdominis muscle (Fig. 208), and also emerges at the external abdominal ring. The former is by far the more common variety, and the seat of stricture is usually at the internal abdominal ring, 29* 342 OPERATIONS UPON ABDOMINAL AVALL, ETC. but sometimes in the scrotum, at a point Avhere the intestine has forced its way through a fibrous septum limiting an en- cysted hydrocele of the cord. In the second variety the stricture may be at the external ring or at the conjoined tendon, the epigastric artery lying at its outer side. Inguinal hernia, showing the transversalis muscle, the trans the internal abdominal ring. Operation.—The parts having been well shaved the patient is anaesthetized and placed upon his back with his shoulders slightly raised, thighs flexed and adducted The surgeon pinches up a broad fold of skin and subcutaneous tissue across the long axis of the swelling, transfixes it at its base with a straight bistoury, and cuts vertically'through HERNIOTOMY, KELOTOMY. 343 it, thus dividing most of the tissues Avithout danger of injury to the sac or intestine; if necessary, this incision must be lengthened, so that its upper extremity will lie at or above the external abdominal ring, and its loAver extremity beloAV the bottom of the hernial sac. The underlying layers are then pinched up one by one with the thumb and finger, or with fine forceps, and divided upon a director until the sac is reached. If the sac is recognized, and if it is thought best not to open it, its limits must be Avell cleared and defined, unless it is very large, and the finger passed into the external abdominal ring. If the ring is tight, the internal pillar must be divided directly upAvards Avith a probe-pointed knife, all constricting bands about the neck of the sac raised upon the director and cut, and the canal and internal ring explored Avith the left forefinger. If the stricture, Avhich is usually situated at the internal ring, is then found to be external to the sac, it must be cautiously nicked directly upAvards Avith a narrow probe-pointed bistoury or a hernia knife (Fig. 207). This nicking may be repeated, if necessary, at one or two points on the upper and outer side, until it becomes possible to press the intestines back into the abdomen. The sac itself is then reduced, unless the hernia is an old one, or adhe- sions have formed, and the Avound is closed with sutures except at its loAver angle. If, however, the sac is to be opened, every precaution must be taken to avoid injury to the intestines. The best point for opening it is at its extreme lower end, because a little serum is usually collected there, separating it from the boAvel. It must be pinched up, if possible, at the point selected, and an opening made with the knife held flat against it; a director or the finger is then passed through the opening, and the full length of the sac slit up. The constriction is then sought for, and, if found above the external ring, must be nicked or divided upwards, as before described. If it can be positively made out that the hernia is of the oblique variety, the cutting should be done on the outer side, for the epigastric artery lies close to the inner side of the internal ring, through which this variety passes; and if it is known to be of the direct variety, the cutting must be 344 OPERATIONS UPON ABDOMINAL AVALL, ETC. done upon the inner side. But, unfortunately, in most cases the dragging of the hernia brings the two rings immediately opposite each other, so that the inguinal canal can no longer be said to exist, and the diagnosis cannot be made with cer- tainty. The incision must then be made upwards, parallel to the course of the epigastric artery. The intestine must next be examined to ascertain if it is in a fit condition to be returned; and here it must not be forgotten to draw down an inch or more of each end so that the part which has undergone constriction may also be exa- mined. If the condition is satisfactory, the boAvel is re- turned gradually, not en masse, the sac also, if free; and the Avound closed, except at the dependent angle. Malgaigne's Method.—Malgaigne made a small incision directly over the supposed seat of the stricture, and divided all the tissues doAvn to the sac. If a fibrous ring Avas the cause of the strangulation, it Avould be divided in the course of the incision, and the hernia could then be reduced Avithout opening the sac. If, on the other hand, the stricture Avas caused by the neck of the sac, he divided the latter from without imvards very cautiously, or, if it Avas very tight, made a small opening in the peritoneum above and below, passed a director through the neck, and cut upon it. This method is entirely inapplicable Avhenever it is neces- sary to examine into the condition of the boAvel; and the persistence of a pouch in Avhich pus can accumulate is a great objection Avhenever the sac has to be opened. The only advantage which it possesses over the ordinary opera- tion in the class of rarer cases Avhere the stricture is situ- ated outside of the sac is the comparatively unimportant one of requiring a smaller incision. Strangidated Femoral Hernia.—The intestine in its descent occupies a canal Avhich begins at the femoral rino1 under Poupart's ligament, betAveen the free arched border of Gimbernat's ligament and the femoral vessels (Fi<*. 208), and ends at the saphenous opening in the fascia lata of the thigh. After passing through the opening it turns upwards over the groin. The normal length of the canal is about an inch, but in hernias of long standino- it is much shortened by the approximation of its tAvo ends. The seat HERNIOTOMY, KELOTOMY. 345 Fig. 210. Variations in origin and course of obturator artery. of stricture is noAV thought to lie in most cases at the saphe- nous opening, and not at the base of Gimbernat's ligament, as was formerly supposed; free division is possible at the former point on the upper and inner side Avithout the risk of injury to any organ, except possibly the spermatic cord, and that is at such a distance as to be practically out of harm's Avay. Under ordinary circumstances, Gimbernat's ligament can also be safely divided on the inner side, but in about one and one- half per cent, of cases the obtu- rator artery pursues the anoma- lous course shoAvn in. Fig. 210, and then lies directly in the Avay of the knife. The neck of the sac under such circum- stances is entirely surrounded; on its outer side are femoral vessels, above are the spermatic cord and common trunk of the epigastric and obturator arte- ries, on its inner side the obturator artery, beloAV it the bone. The only safe plan of relieving the stricture, there- fore, is to nick it slightly, to the depth of one or two milli- metres, at several points on its upper and inner borders, feeling carefully with the tip of the finger for pulsation be- fore cutting. The coverings of the hernia are thin and composed of the skin, subcutaneous tissue, cribriform fascia sometimes, septum crurale, and peritoneum. The incision may be straight or curved, the convexity directed downwards and outwards, or T-shaped, the hori- zontal branch being made along Poupart's ligament, the other passing directly downward over the saphenous open- ing. The horizontal incision should be made by transfixing a vertical fold of skin and subcutaneous tissue pinched up between the thumb and fingers, the other should be made from without inwards. The underlying tissues must be divided, and the sac exposed or opened in the manner de- scribed under General Directions, and the seat of stricture sought for and divided according to the rules above laid down. If the operator has decided to perform the so-called minor operation—that is, not to open the sac—the edge of the 346 OPERATIONS UPON ABDOMINAL AVALL, ETC. saphenous opening must be carefully exposed and divided on its upper and inner side, the finger passed into the canal, and Gimbernat's ligament nicked if necessary. Malgaigne pursued the same method as in femoral hernia, cutting doAvn upon the seat of the stricture, tearing the edge of the saphenous opening with a blunt spatula instead of cutting it, and not opening the sac unless he had good rea- son to suppose the sac Avas already damaged. It is par- ticularly unsafe to reduce a femoral hernia unopened; first, because the boundaries of the canal are so tough and un- yielding that gangrene follows promptly on strangulation, especially in a small recent hernia ; and secondly, because the reduction may seem to be complete while a strangulated knuckle of intestine still remains Avithin the stricture. 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