-': : : :
 
 Fowler & Colwell 
 
 BOOKSELLERS
 
 OP 
 
 OPERATIVE STJRG-ERY 
 
 \k 
 
 JOSEPH D. BRYANT, M. D. 
 
 PROFESSOR OF ANATOMY AND CLINICAL SURGERY, AND ASSOCIATE PROFESSOR OF ORTHOPEDIC 
 SURGERY, BELLEVUE HOSPITAL MEDICAL COLLEGE ; VISITING SURGEON TO BELLEVUE HOSPI- 
 TAL ; CONSULTING SURGEON TO THE BUREAU OF MEDICAL AND SURGICAL RELIEF, 
 OF BELLEVUE HOSPITAL ; CONSULTING SURGEON TO THE NEW YORK 
 LUNATIC ASYLUM, AND TO THE NORTHWESTERN DISPENSARY. 
 
 WITS ABOUT EIGHT BVKDSED ILLUSTRATIONS 
 
 NEW YORK 
 D. APPLETON AND COMPANY 
 
 1890
 
 COPYRIGHT, 1886, 
 BY D. APPLETON AND COMPANY. 
 
 All rights reserved.
 
 TO 
 
 STEPHEN SMITH, M.D. 
 
 AND 
 
 TO MY PRECEPTOR 
 
 GEORGE W. AVERT, M.D. 
 STjjfs Volume 
 
 IS RESPECTFULLY INSCRIBED 
 
 THOUGH BUT A MEAGER RECOGNITION OF THE MANY KINDNESSES 
 SHOWN BY THEM TO 
 
 THE AUTHOR
 
 PEEFAOE. 
 
 THE frequent request on the part of those whom it has been my 
 pleasure to instruct in operative surgery during the past few years, 
 to make a book based somewhat on the plan I have employed in 
 teaching this subject, is the principal incentive to my action. The 
 field of operative surgery is too well cultivated already for one to do 
 more in this brief space than aid the student of surgery to acquire 
 established facts. The works of Ashhurst, Agnew, Gross, Erichsen, 
 Holmes, Smith, Esmarch, Packard, Stimson, and many others, to- 
 gether with the current medical literature, have been consulted. 
 The illustrations, which are numerous, have been selected in most 
 instances from standard works, although a considerable number of 
 original and modified illustrations have been introduced. Mr. "W. 
 F. Ford, of the reputable firm of Caswell, Hazard & Co., of this 
 city, kindly provided the instrumental cuts, as is to be seen by the 
 " Index of Illustrations." The author desires to acknowledge the 
 aid derived from the above-mentioned sources, and trusts the reader 
 will find something to commend in the pages that are to follow. 
 The author regrets that sufficient data are not at hand to permit the 
 " results " to be given in all instances as modified by the antiseptic 
 method of treatment. The operations peculiar to the female sex, 
 and the eye and ear, have not been considered, since they are en- 
 titled, in the opinion of the author, to a more extended considera- 
 tion than the intentional scope of this work will admit. The au- 
 thor desires to acknowledge the valuable services of Drs. Glover, 
 C. Arnold, and Herman M. Biggs, in connection with the proof- 
 reading, and of Dr. Arnold also for the complete indices of the 
 book. The assistance of Dr. A. H. Doty in preparing many of the 
 original illustrations is likewise gratefully acknowledged. 
 
 JOSEPH D. BRYANT, M. D. 
 
 66 W. THIRTY-FIFTH STREET, NEW YORK, October 28, 1886.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 GENERAL CONSIDERATIONS. 
 
 PAQB 
 
 Definition of operative surgery Facts to be ascertained before operating Season 
 of the year for operating Time of day Surroundings of the patient Tem- 
 perature of the room Place for an operation Nursing Preparatory treatment 
 Diet Essential and preparatory requirements Anaesthetics Inflammability 
 of ether Chloroform more dangerous than ether Varieties of inhalers 
 Amount of ether required Purity of the anaesthetic Dangers of How to pre- 
 pare a patient for anaesthesia Method of administering ether Treatment for 
 an overdose of ether Intestinal etherization Local anaesthesia Instruments 
 necessary for operating Methods of holding the scalpel Forms of incisions 
 Instruments should be plain Receptacle for instruments Operating table 
 Empty vessels Clean towels and old linen Antiseptic solutions Sponges . 1 
 
 CHAPTER II. 
 
 AGENTS FOB CONTROLLING HEMOBBHAGE. 
 
 Styptics Position Elastic bandage Compresses Digital pressure Davy's lever 
 Petit's tourniquet Trendelenburg's rod Acupressure Torsion Forceps 
 Tenacula Cautery Ligatures Assistants Patient prepared . . . .23 
 
 CHAPTER III. 
 
 TREATMENT OF OPERATION WOUNDS. 
 
 Sutures Needles Needle-holders Various forms of sutures Drainage-tubes 
 Canalization Antiseptic spray Antiseptic douche Antiseptic dressings Anti- 
 septic solutions Quietude of patient Common preparations for an antiseptic 
 operation Open dressings Precautionary requirements of operations Special 
 emergencies of operations .41 
 
 CHAPTER IV. 
 
 LIGATURE OF ARTERIES. 
 
 Guides to ligaturing Making primary incision Opening the sheath of a vessel 
 Passing the ligature Instruments required for ligaturing Ligature of abdomi- 
 nal aorta Of common iliac arteries Of internal iliac artery Of gluteal artery 
 Of sciatic artery Of internal pudic artery Of dorsalis pedis artery Of ex- 
 ternal iliac artery Of epigastric artery Of deep circumflex artery Of femoral 
 artery Of innominate artery Of subclavian artery Of vertebral artery Of
 
 v iii CONTENTS. 
 
 PAGE 
 
 internal mammary artery Of axillary artery Of brachial artery Of radial 
 artery Of ulnar artery Of superficial palmar arch Of common carotid artery 
 Of the common carotids Of the external carotid artery Of the internal 
 carotid artery Of the superior thyroid artery Of the lingual artery Of the 
 facial artery Of the temporal artery Of the occipital artery . . . . 56 
 
 CHAPTER V. 
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 Ligature of veins Operations for varicose veins Injection Acupressure -Subcu- 
 taneous ligaturing Hemorrhoids Operation for internal hemorrhoids Ex- 
 cision Crushing Ligaturing Ligature with incision Injection Varicocele, 
 treatment of By excision of the scrotum By compression with wires or pins 
 By subcutaneous ligaturing Venesection Transfusion With blood With 
 saline solutions With milk Mother's mark Treatment of Naevi Treatment 
 of Cirsoid growths Treatment of , . . .117 
 
 CHAPTER VI. 
 
 OPERATIONS ON THE NERVOUS SYSTEM. 
 
 Operations for hydrocephalus For meningocele For hydrorachis Trephining the 
 cranium Instruments for Precautions- in Location of special functions of 
 brain Operations on supra-orbital nerves On infra-orbital nerves On supe- 
 rior maxillary nerves On inferior dental nerve On lingual nerve On facial 
 nerve On great occipital nerve On auricularis magnus nerve On spinal 
 accessory nerve On musculo-cutaneous nerve On musculo- spiral nerve On 
 median nerve On radial and ulnar nerves On great sciatic nerve On internal 
 popliteal nerves On external popliteal nerves On small sciatic nerves On 
 anterior and posterior tibial nerves On plantar nerves On perineal nerves 
 On anterior crural nerve On long saphenous nerve On short saphenous nerve 
 Nerve suturing Nerve transplantation 134 
 
 CHAPTER VII. 
 
 OPERATIONS ON TENDONS, FASCIA, AND MUSCLES. 
 
 Instruments for tenotomy Rules for tenotomy Tenotomy of flexor sublimis and 
 profundus digitorum muscles Of extensor communis digitorum Of extensor 
 primi internodii, secundi internodii, and ossis mclacarpi pollicis Of flexor carpi 
 radialis Of flexor carpi ulnaris Of biceps of forearm Of tibialis posticus 
 Of flexor longus digitorum of leg Of flexor longus pollicis of leg Of tendo 
 Achillis Of peroneus longus and brevis Of tibialis anticus Of extensor pro- 
 prius pollicis Of extensor longus digitorum Of peroneus tertius Of biceps 
 of leg Of inner hamstring tendons of leg Of the quadriceps extensor tendon 
 Of pectineus Of adductor longus Of tensor vaginae femoris Of sartorius 
 Of multifidus spinso Of latissimus dorsi Of erector spinae Of sterno-cleido- 
 mastoid Of the plantar fascia Of the palmar fascia Dupuytren's contraction 
 Tendon suturing 151 
 
 CHAPTER VIII. 
 
 OPEEATIONS ON BONES. 
 
 Gouging Instruments necessary for Sequestrotomy Instruments necessary for 
 Direct method of Indirect method of Excision Time of operating Instru-
 
 CONTENTS. IX 
 
 PAGE 
 
 ments necessary for Treatment of excision wounds Excision of the upper 
 j aw Special instruments for Complete removal of Operation by median in- 
 cision Excision below floor of orbit Subperiosteal excision of The superior 
 maxilla? may be removed simultaneously Excision of the inferior maxilla 
 Excision of central portion of Of lateral portion of Of half of Of entire 
 bone Of the alveolar process of Operations for anchylosis of Excision of 
 the sternum Excision of a portion of a rib Excision of the clavicle Ex- 
 cisions of the scapula Excisions of the humerus Excision of glenoid angle 
 of scapula Excisions of the elbow-joint Excision of the ulna Excision of 
 the radius Excisions of the wrist-joint Excision of the lower extremities Of 
 the bones of the forearm Of the metacarpo-phalangeal joints Of the phalan- 
 geal joints Of the metatarso-phalangeal joints Of the metatarso-tarsal joints 
 Of the tarsal joints Excision of the calcaneum Of the astragalus Excis- 
 ions of the ankle-joint Excision of the bones of the leg Excisions of the 
 knee-joint Excision of the patella Of the great trochanter Excisions of 
 the hip -joint Excision of the coccyx Osteotomy Instruments employed 
 for Neck of femur, sections of Supra-condyloid osteotomy Osteo-arthrot- 
 omy Osteotomy for genu varum For " bow-legs " For hallux valgus Os- 
 teoplasty ... 161 
 
 CHAPTER IX. 
 
 AMPUTATIONS. 
 
 General considerations Care in making flaps Classification of flaps Comparative 
 merits of different forms of flaps Agents required for an amputation Proper 
 manner of holding amputating knife Proper manner of carrying it around the 
 limb Proper manner of using the saw How to operate Use of retractors 
 Amputations at the phalangeal articulations Amputations at the metacarpo- 
 phalangeal articulations Amputations at the carpo-metacarpal articulations 
 Amputations through the sietacarpal bones Amputations at the wrist-joint 
 Amputations at the elbow-joint Amputations of the forearm Amputations of 
 the arm Amputations at the shoulder-joint Amputations above the shoulder- 
 joint * 222 
 
 CHAPTER X. 
 
 AMPUTATIONS OF THE LOWER EXTREMITIES. 
 
 Amputations of the phalanges in their continuity Amputations of single toes Am- 
 putations of adjoining toes Amputation of toes at metatarso-phalangeal joints 
 Amputation through metatarsal bones Amputation of great toe, with its 
 metatarsal bone Amputation of the fifth toe, with its metatarsal bone Lis- 
 franc's amputation Chopart's amputation Forbes' modification of Chopart's 
 amputation Sub-astragaloid disarticulation Hancock's amputation Tripier's 
 method Molliere's method Syme's amputation Modification of Syme's opera- 
 tion Roux's operation Pirogoff's amputation Modifications of PirogofFs am- 
 putation Le Fort's modification of Pirogoff s amputation Esmarch's modifica- 
 tion of Le Fort's operation Mikulicz's amputation Supra-inalleolar amputa- 
 tion Amputations at the lower third of the leg Amputations at the middle 
 third of the leg Amputations at the knee-joint Amputations through the con- 
 dyles of the femur Garden's method Gritti's method Stokes' method Ampu- 
 tations of the thigh Amputations at the hip-joint 255
 
 x CONTEXTS. 
 
 PAGE 
 
 CHAPTER XI. 
 
 DEFORMITIES. 
 
 Brisement force Barton's operation for anchylosis Curvature of the spine Plaster- 
 of-Paris jacket for Webbed fingers, treatment for Ingrown nail Ogston's 
 treatment of flat-foot Stokes' treatment of Tarsectomy 297 
 
 CHAPTER XII. 
 
 PLASTIC SURGERY. 
 
 Preparation of patient for Formation of flaps Methods of transfer of flaps Skin- 
 grafting Rhinoplasty Mechanical appliances for deformed nose Hare-lip 
 Cheiloplasty Stomatoplasty Staphyloplasty Staphyloraphy Uranoplasty 
 Elongated uvula, treatment of 304 
 
 CHAPTER XIII. 
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND OESOPHAGUS. 
 
 Salivary fistula, treatment of Excision of tonsils Treatment for tongue-tie For 
 ranula Excision of the tongue QEsophagotomy Dilatation of the oesophagus 
 (Esophagectomy (Esophagostomy 335 
 
 CHAPTER XIV. 
 
 OPERATIONS ON HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 
 
 Indications to be met Forms of sutures employed for sewing serous surfaces 
 Gastrostomy Gastrotomy Gastro-enterostomy Duodenostomy Jejunostomy 
 Resection of the pylorus Cholecystotomy Cholecystectomy Laparotomy 
 Enterotomy Enterectomy Colotomy Iliac abscess, operation for Artificial 
 anus, treatment for Nephrotomy Nephrcctomy Nephro-lithotomy Nephror- 
 raphy Splenectomy Paracentesis abdominis Hernia Radical cure of 
 Kelotomy 348 
 
 CHAPTER XV. 
 
 OPERATIONS ON THE ANUS AND RECTUM. 
 
 Examination of anus Operation for imperforate anus For absence of anus For 
 fistula in ano Surgical anatomy of rectum Operations for prolapsus ani For 
 cancer of rectum For stricture of rectum For imperforate rectum . . . 401 
 
 CHAPTER XVI. 
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 Introduction of a catheter OF sound into the bladder Introduction of whalebone 
 guides Aspiration of bladder Cystotomy Digital exploration of bladder 
 Treatment of extroversion of bladder Puncturing bladder Lithotrity Litho- 
 lapaxy Lithotomy 416 
 
 CHAPTER XVII. 
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 Operations for hydrocele Castration Circumcision Treatment of paraphymosis 
 Methods of amputation of penis Extirpation of penis Operations for hypo-
 
 CONTENTS. x i 
 
 PAGE 
 
 spadias Operations for epispadias Urethroraphy Urethroplasty External 
 perineal urethrotomy Internal urethrotomy Tapping the urethra . . . 455 
 
 CHAPTER XVIII. 
 
 MISCELLANEOUS OPEBATIONS. 
 
 Tapping the pericardium Extirpation of the breast Extirpation of the axillary 
 glands Extirpation of the parotid gland Paracentesis thoracis Perforation of 
 the antrum Plugging posterior nares Removal of nasal polypi Removal of 
 naso-pharyngeal polypi Deviation of the septum nasi, operations for Laryn- 
 gotomy Tracheotomy Laryngo-tracheotomy Intubation of the larynx Phar- 
 yngotomy Laryngectomy Removal of goitre Arthrectomy Wiring patella 
 Movable bodies in joints, operation for Ganglion, operations for Wiring of 
 bones for compound fractures 479
 
 ILLUSTKATICOTS. 
 
 PAGB 
 
 ABDOMINAL sections, location of incisions for. Fig. 563. Original. 352 
 
 Acupressure. Figs. 45-47. Thomas Bryant. 32 
 
 Allinghara's screw crushing instrument for hemorrhoids. Fig. 170. 
 
 Caswell, Hazard & Co., W. F. Ford, N. T. 120 
 
 Amputating knife, how to grasp. Fig. 315. Original. 231 
 
 Amputating knife, how to carry around limb. Fig. 316. Original. 232 
 
 Amputating knife, how to carry around limb, another method. Fig. 317. S. timith. 232 
 Amputating knife, how carried around limb, a common method. Fig. 318. Esmarch. 232 
 Amputation, catching bleeding points. Fig. 327. Packard. 234 
 
 Amputation by circular method. Fig. 303. Esmarch. 224 
 
 Amputation by circular method, dissecting up flap. Fig. 304. Esmarch. 225 
 
 Amputation by circular method, dissecting up flap, how not to do it. Fig. 305. Esmarch. 225 
 Amputation by circular method, circular division of muscles. Fig. 306. Esmarch. 226 
 Amputation, circular method, sawing the bone. Fig. 324. Ashhurst, modified. 234 
 
 Amputation, circular, stump after. Fig. 307. Esmarch. 226 
 
 Amputation, circular, modified. Fig. 308. Ashhurst. 227 
 
 Amputation, equilateral flaps. Fig. 313. Esmarch. 229 
 
 Amputation, Hancock's. Figs. 402, 403. Esmarch. 266 
 
 Amputation, periosteal flap. Figs. 425, 427. Original. 274, 275 
 
 Amputation, rectangular flap. Figs. 311, 312. Gross. 229 
 
 Amputation, sawing the bone. Fig. 324. Ashhurst, modified. 234 
 
 Amputation, Teale's method. Figs. 311, 312. Gross. 229 
 
 Amputation, flap by transfixion. Figs. 309, 310. Gross. 228 
 
 Amputation, De Lignerolles'. Figs. 398-403. Esmarch. 264-266 
 
 Amputation at medio-tarsal articulation, Chopart's. Fig. 386. New. 260 
 
 Amputation at medio-tarsal articulation, Chopart's. Figs. 392-397. Esmarch. 262-264 
 Amputation at metatarso-phalangeal articulation, square-flap method, of all the toes. 
 
 Figs. 380-383. Esmarch. 258, 259 
 
 Amputation, sub-astragaloid. Figs. 398-i03. Esmarch. 264-266 
 
 Amputation, sub-astragaloid, De Lignerolles'. Figs. 398-401, 403. Esmarch. 264-266 
 
 Anaesthetics, administering, drawing the tongue forward. Fig. 9. Esmarch. 13 
 
 Anaesthetics, administering, pressing the jaw forward. Fig. 10. Esmarch. 14 
 
 Anchylosis, bony, Barton's operation for. Fig. 461. Gross. 298 
 
 Aneurism needle and director combined. Fig. 97. C., H. & Co., Ford. 59 
 
 Aneurism needle, Fletcher's. Fig. 100. C., H. & Co., Ford. 60 
 
 Aneurism needle, Mott's. Fig. 99. C., H. & Co., Ford. 60 
 
 Aneurism needle, Syme's. Fig. 98. C., H. & Co., Ford. 60 
 
 Aneurism needle, " Student's." Fig. 100. C., H. & Co., Ford. 60 
 
 Ankle-joint, disarticulation at the. Figs. 404-409, 413-415, 417-424. 
 
 Esmarch. 267, 268, 270, 271-273 
 
 Ankle-joint, disarticulation at the. Fig. 410. Original. 269 
 
 Ankle-joint, amputation at, modification of Syme's. Fig. 410. Original. 269 
 
 Ankle-joint, amputation at, removal of the entire foot, Syme's. Figs. 404-409. 
 
 Etmarch. 267, 268
 
 XIV 
 
 ILLUSTRATIONS. 
 
 Ankle-joint, amputation at, Koux'8. Figs. 411, 412. 
 
 Ankle-joint, amputation at, Esmarch's. Figs. 421-424. 
 
 Ankle-joint, amputation at, Brans'. Fig. 420. 
 
 Ankle-joint, excision of, internal incisions. Fig. 275. 
 
 Ankle-joint, excision of, removal of lower end of fibula. Fig. 274. 
 
 Ankle-joint, excision of. Fig. 272. 
 
 Ankle-joint, anatomy of. Fig. 273. 
 
 Ankle-joint, anatomy of, inner side. Fig. 276. 
 
 Ankle-joint, amputation at, Pirogoff's. (Figs. 418-415 
 
 Ankle-joint, amputation at, Pirogoff's. Fig. 416. 
 
 Ankle-joint, amputation at, Pirogoff's. Fig. 417. 
 
 Ankle-joint, amputation at, Le Fort's. Figs. 418-419. 
 
 Anklets and wristlets, Pritchard's. Fig. 695.- 
 
 Antiseptic adhesive plaster between sutures. Fig. 77. 
 
 Antiseptic dressing in position. Fig. 90. 
 
 Antiseptic spray apparatus, Weir's. Fig. 89. 
 
 Anus, absence of. Fig. 619. 
 
 Anus, artificial, enterotome applied. Fig. 577. 
 
 Aorta, abdominal, and inferior vena cava. Fig. 101. 
 
 Aponeurotome. Fig. 711. 
 
 Arch, palmar, superficial linear guide to. Fig. 161. 
 
 Arm, amputation of, Langenbeck. Fig. 364. 
 
 Arm, amputation of, by long anterior flap. Fig. 366. 
 
 Arm, amputation of, by unequal skin-flaps. Fig. 365. 
 
 Arteries, femoral, deep and superficial, relations of. Fig. 122. 
 
 Arteries, iliac, linear guides to. Fig. 102. 
 
 Arteries, iliac, venous relations of. Fig. 103. 
 
 Arteries, iliac, venous relations of. Fig. 103. 
 
 Arteries, ligature of, opening sheath of vessel. Fig. 92. 
 
 Arteries, ligature of, passing aneurism needle. Fig. 93. 
 
 Arteries, ligature of, passing probe. Fig. 94. 
 
 Arteries, ligature of, primary incision. Fig. 91. 
 
 Arteries of neck, linear guide. Fig. 136. 
 
 Arteries of neck and face, linear guide. Fig. 137. 
 
 Artery, abdominal aorta and inferior vena cava. Fig. 101. 
 
 Artery, axillary, ligature of first portion. Fig. 141. 
 
 Artery, axillary, ligature of first portion. Fig. 142. 
 
 Artery, axillary, ligature of third portion. Fig. 144. 
 
 Artery, axillary, linear guide to third portion. Fig. 143. 
 
 Artery, brachial, digital compression of. Fig. 38. 
 
 Artery, brachial, ligature of, in middle third. Fig. 146. 
 
 Artery, brachial, ligature of, in middle third. Fig. 147. 
 
 Artery, brachial, tourniquet applied. Fig. 41. 
 
 Artery, brachial, ligature of, in lower third. Fig. 148. 
 
 Artery, brachial, ligature of, in lower third. Fig. 149. 
 
 Artery, brachial, linear guide to. Fig. 145. 
 
 Artery, carotid, common, ligature of. Fig. 164. 
 
 Artery, carotid, common, ligature of, below omo-hyoid muscle 
 
 Artery, carotid, common, surgical anatomy of. Fig. 162. 
 
 Artery, carotid, external, surgical anatomy of. Fig. 165. 
 
 Artery compressor, Gross'. Fig. 57. 
 
 Artery compressor, Milne's. Fig. 58. 
 
 Artery compressor, Speir's. Fig. 61. 
 
 Artery, dorsalis pedis. Fig. 130. 
 
 Artery, dorsalis pedis, ligature of. Fig. 131. 
 
 Artery, dorsalis pedis, linear guide to. Fig. 126. 
 
 Artery, epigastric, linear guide to. Fig. 111. 
 
 Artery, epigastric, course of. Fig. 610. 
 
 PAGE 
 
 Gross. 270 
 
 Esmarch. 273 
 
 Esmarch. 272 
 
 Esmarch. 201 
 
 Esmarch. 200 
 
 Esmarch. 199 
 
 Esmarch. 200 
 
 Esmarch. 201 
 Esmarch. 270, 271 
 
 S. Smith. 271 
 
 Esmarch. 271 
 
 'Esmarch. 272 
 
 C., H. & Co., Ford, 443 
 
 Esmarch. 43 
 
 B. A. Watson. 50 
 
 C.,H.& Co., Ford,. 48 
 
 Gross. 403 
 
 Packard. 373 
 
 Sedillot. 61 
 
 C.,H.& Co., Ford. 453 
 
 Gross. 106 
 
 Esmarch. 249 
 
 Esmarch. 250 
 
 Esmarch. 249 
 
 Gray. 77 
 
 Stimson, modified. 61 
 
 Sedillot. 62 
 
 Sedillot. 62 
 
 Gross. 58 
 
 Esmarch. 58 
 
 Esmarch. 58 
 
 Packard. 57 
 
 Stimson, modified. 86 
 
 Original. 89 
 
 Sedillot. 61 
 
 Sedillot. 96 
 
 Mott. 97 
 
 Sedillot. 98 
 
 Jfew. 97 
 
 Esmarch. 28 
 
 Sedillot. 99 
 
 Mott. 100 
 
 Esmarch. 29 
 
 Sedillot. 100 
 
 Mott. 100 
 
 Jfew. 98 
 
 Mott. 108 
 
 Fig. 163. Sedillot. 108 
 
 Sedillot. 106 
 
 Sedillot. 108 
 
 C., H. & Co., Ford. 34 
 
 C.,H.& Co., Ford. 35 
 
 C.,H.& Co., Ford. 35 
 
 Packard. 81 
 
 Sedillot. 82 
 
 Stimson, modified. 79 
 
 Stimson, modified. 70 
 
 Gray. 896
 
 ILLUSTRATIONS. 
 
 XV 
 
 Artery, facial, ligature of. Fig. 168. 
 
 Artery, femoral, compression of, digital. 
 
 Artery, femoral, ligature of, at apex of S 
 
 Artery, femoral, ligature of, at apex of S 
 
 Artery, femoral, ligature of, in Hunter's canal. 
 
 Artery, femoral, ligature of, in Hunter's canal. 
 
 Artery, femoral, ligature of, in upper third. 
 
 Artery, femoral, linear guide to. Figs. 
 
 Artery, femoral, relations of. Fig. 115. 
 
 Artery, femoral, relations of. Fig. 117. 
 
 Artery, femoral, tourniquet applied to. 
 
 Artery, gluteal, ligature of. Fig. 107. 
 
 Artery, gluteal, linear guide to. Fig. 106. 
 
 Artery, iliac, common, incision for ligaturing. 
 
 Artery, iliac, external, ligature of. Fig 
 
 Artery, iliac, external, ligature of. Fig 
 
 Artery, iliac, external, linear, guide to. 
 
 Artery, iliac, primitive, ligature of. Fi 
 
 Artery, lingual, ligature of. Fig. 166. 
 
 Artery, lingual, surgical anatomy of. ] 
 
 Artery, obturator, course of. Fig. 614. 
 
 Artery, occipital, ligature of. Fig. 169. 
 
 Artery, popliteal, ligature of, at lower third. 
 
 Artery, popliteal, ligature of, at upper third. 
 
 Artery, popliteal, linear guide to. Fig. 123. 
 
 Artery, pudic, linear guide to. Fig. 109. 
 
 Artery, pudic, passing needle around. I 
 
 Artery, radial, ligature of, at apex of styloid process. 
 
 Artery, radial, ligature of, at lower third. 
 
 Artery, radial, ligature of, at lower third. 
 
 Artery, radial, ligature of, at upper third. 
 
 Artery, radial, ligature of, at upper third. 
 
 Artery, radial, linear guide to. Fig. 150. 
 
 Artery, sciatic, ligature of. Fig. 108. 
 
 Artery, sciatic, linear guide to. Fig. 106. 
 
 Artery, subclavian, ligature of third portion. 
 
 Artery, subclavian, ligature of third portion. 
 
 Artery, subclavian, surgical anatomy of. 
 
 Artery, temporal, ligature of. Fig. 168. 
 
 Artery, torsion of an. Fig. 49. 
 
 Artery, tibial, anterior, ligature of, at middle third. 
 
 Artery, tibial, anterior, linear guide to. 
 
 Artery, tibial, posterior, ligature of, at lower third. 
 
 Artery, tibial, posterior, ligature of, at middle thirc 
 
 Artery, tibial, posterior, ligature of, at middle third. 
 
 Artery, tibial, posterior, linear guide to. 
 
 Artery, ulnar, ligature of, at junction of i 
 
 Artery, ulnar, ligature of, at junction of i 
 
 Artery, ulnar, ligature of, at lower third. 
 
 Artery, ulnar, ligature of, at lower third. 
 
 Artery, ufnar, ligature of, at wrist. Fig. 
 
 Artery, ulnar, linear guide to. Fig. 150. 
 
 Aspirator, Fitch's. Fig. 581. 
 
 Aspirator, trachea. Fig, 786. 
 
 Aspirator, Potain's. Fig. 580. 
 
 Atomizer, Richardson's. Fig. 14. 
 
 
 PAGB 
 
 
 Sedillot. 116 
 
 Fig. 37. 
 
 Esmarch. 28 
 
 arpa's triangle. Fig. 118. Sedillot. 75 
 
 arpa's triangle. Fig. 119. Mott. 75 
 
 janal. Fig. 120. 
 
 Sedillot. 76 
 
 ;anal. Fig. 121. 
 
 Mott, modified. 76 
 
 d. Fig. 116. 
 
 8. Smith. 73 
 
 11-114. 
 
 Stimson, modified. 70-72 
 
 
 Sedillot. 73 
 
 
 Gray. 74 
 
 Fig. 40. 
 
 Esmarch. 29 
 
 
 S. Smith. 67 
 
 
 Stimson, modified. 66 
 
 ring. Fig. 104. 
 
 Otis, modified, 63 
 
 112. 
 
 S. Smith. 70 
 
 113. 
 
 Mott. 70 
 
 Fig. 111. 
 
 Stimson, modified. 70 
 
 105. 
 
 Otis, modified. 64 
 
 
 Sedillot. 114 
 
 ?. 167. 
 
 Esmarch, modified. 114 
 
 
 Gray. 400 
 
 
 Sedillot. 117 
 
 rd. Fig. 125. 
 
 S. Smith. 79 
 
 rd. Fig. 124. 
 
 Sedillot. 78 
 
 23. 
 
 New. 78 
 
 
 8. Smith. 68 
 
 'ig. 110. 
 
 S. Smith. 68 
 
 )id process. Fig. 155. 
 
 Sedillot. 103 
 
 Fig. 153. 
 
 Sedillot. 103 
 
 Fig. 154. 
 
 Mott. 103 
 
 Fig. 151. 
 
 Sedillot. 102 
 
 Fig. 152. 
 
 Mott. 102 
 
 
 Stimson, modified. 101 
 
 
 S. Smith, 67 
 
 
 Stimson, modified. 66 
 
 on. Fig. 139. 
 
 Sedillot. 91 
 
 .on. Fig. 140. 
 
 Mott. 91 
 
 Fig. 138. 
 
 Sedillot. 90 
 
 
 Sedillot. 116 
 
 
 Esmarch. 33 
 
 idle third. Fig. 129. 
 
 Sedillot. 81 
 
 Fig. 126. 
 
 Stimson, modified. 79 
 
 wer third. Fig. 135. 
 
 Sedillot. 84 
 
 iddle third. Fig. 133. 
 
 Sedillot. 84 
 
 iddle third. Fig. 134. 
 
 Mott. 84 
 
 Fig. 132. 
 
 Stimson, modified. 83 
 
 niddle and upper thirds. 
 
 Fig. 156.' Sedillot. 104 
 
 niddle and upper thirds, 
 
 , Fig. 157. Mott. 104 
 
 Fig. 158. 
 
 Sedillot. 105 
 
 Fig. 159. 
 
 Mott. 105 
 
 160. 
 
 Sedillot. 105 
 
 
 Stimson, modified. 101 
 
 
 C.,H.& Co., Ford. 378 
 
 
 C. S H.& Co., Ford. 497 
 
 
 C., H. & Co., Ford. 878 
 
 
 C., H. & Co., Ford. 17 
 
 Band, compression, Nicaise's. Fig. 29. 
 
 Esmarch. 25
 
 XVI 
 
 ILLUSTRATIONS. 
 
 Bandage, clastic. Fig. 27. 
 
 Bandage, elastic, applied. Fig. 28. 
 
 Bandage, rubber, Martin's. Fig. 33. 
 
 Bistouri cache", Civiale's. Fig. 747. 
 
 Bistouries and scalpels. Fig. 15. 
 
 Bistoury, beaked, Gouley's. Fig. 741. 
 
 Bladder, evacuating apparatus or washer, Bigelow's. Fig. 670. 
 
 Bladder, evacuating apparatus or washer, Otis'. Figs. 671, 672. 
 
 Bladder, evacuating apparatus or washer, Thompson's. Fig. 669. 
 
 Bladder, extroversion of the, Bigelow's operation. Fig. 651. 
 
 Bladder, extroversion of the, Bigelow's operation. Fig. 652. 
 
 Bladder, extroversion of the, Maury's operation. Fig. 650. 
 
 Bladder, extroversion of the, Wood's operation. Figs. 653, 654. 
 
 Bladder, puncturing the. Fig. 657. 
 
 Blow-pipe. Fig. 64. 
 
 Bone pliers, Butcher's. Fig. 487. 
 
 Bougies a boule, Otis'. Fig. 745. 
 
 Bougies, filiform. Fig. 646. 
 
 Bougies, non-metallic. Fig. 746. 
 
 Breast, removal of the. Fig. 753, 754. 
 
 Breast, removal of the, incisions for. Fig. 755. 
 
 Buck's needle conductor. Fig. 48. 
 
 Bunion, with hallux valgus. Fig. 468. 
 
 Esmarcli. 
 
 Esmarch. 
 
 C., H. & Co., Ford. 
 C., H.& Co., Ford. 
 C.,H.& Co. Ford. 
 
 c., H. & Co. 
 
 C.,H.& Co. 
 C., H. & Co. 
 C.,H.<& Co. 
 
 Ford. 
 Ford. 
 Ford. 
 Ford. 
 
 S. Smith. 
 Agnew. 
 
 S. Smith, modified. 
 Gross. 
 
 umstead <& Taylor. 
 
 C., H. & Co., Ford. 
 
 C., H. & Co., Ford. 
 
 C.,H.& Co., Ford. 
 
 C., H. & Co., Ford. 
 
 C.,H.& Co., Ford. 
 
 S. Smith. 
 
 Gross, modified. 
 
 C., H. & Co., Ford,. 
 
 Gross. 
 
 PACK 
 
 24 
 
 25 
 
 27 
 
 475 
 
 18 
 
 471 
 
 432 
 
 433 
 
 432 
 
 424 
 
 424 
 
 423 
 
 425 
 
 426 
 
 36 
 
 316 
 
 475 
 
 420 
 
 475 
 
 479 
 
 480 
 
 32 
 
 302 
 
 Canal, femoral, location of. Fig. 612. 
 
 Canula, Bellocq's. Fig. 757. 
 
 Canula, polypus, nasal. Fig. 760. 
 
 Capillaries, subcutaneous ligaturing of. Figs. 189-194. 
 
 Carpo-metacarpal articulation, amputations at. Figs. 341-345. 
 
 Carpus, ligaments of dorsal surface of. Fig. 266. 
 
 Carpus, ligaments of palmar surface of. Fig. 267. 
 
 Carpus, synovial membranes of. Fig. 265. 
 
 Catheter, chemise. Fig. 694. 
 
 Catheter, double-elbowed, Mercier's. Fig. 636. 
 
 Catheter, elbowed, Mercier's. Fig. 637. 
 
 Catheter, evacuating, Bigelow's. Fig. 673. 
 
 Catheter, evacuating, spiral-tipped, Warren's. Fig. 674. 
 
 Catheter, evacuating and lithotiite combined, author's. 
 
 Catheter-guide, Keyes'. Fig. 640. 
 
 Catheter-guide, Otis'. Fig. 641. 
 
 Catheter, olivary gum. Fig. 642. 
 
 Catheter, passing a. Fig. 644. 
 
 Catheter entering bladder. Fig. 645. 
 
 Catheter, self-retaining. Fig. 638. 
 
 Catheter, self-retaining, Holt's. Fig. 639. 
 
 Catheter, velvet-eye. Fig. 643. 
 
 Catheter, tunneled, and guide, Gouley's. Fig. 649, 742. 
 
 Catlin. Fig. 321. 
 
 Cautery-irons. Fig. 63. 
 
 Cautery, thermo, Paquelin's. Fig. 65. 
 
 Cheek-compressor for hare-lip, Hainsley's. Fig. 496. 
 
 Chisel. Fig. 225. 
 
 Chisels. Fig. 292. 
 
 Cheiloplasty, lower lip, Celsus' method. Fig. 498. 
 
 Cheiloplasty, lower lip, Celsus' method. Fig. 499. 
 
 Cheiloplasty, lower lip, contracted. Buck's method. Figs. 502, 503. 
 
 Cheiloplasty, lower lip, horizontal incision. Fig. 500. 
 
 Cheiloplasty, lower lip, Malgaigne's method. Fig. 504. 
 
 Gray. 398 
 
 G.,H.& Co., Ford. 484 
 C.,H.& Co., Ford. 485 
 
 S. Smith. 133 
 Esmarch. 240, 241 
 
 Esmarch. 194 
 
 Esmarch. 
 
 Esmirch. 
 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 C., H. & Co., Ford. 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 Fig. 677. C., H. <& Co., Ford. 
 C., H. & Co., Ford. 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 Jiumstead & Taylor. 
 umstead & Taylor. 
 C., H. & Co., Ford. 
 C.,E.& Co., Ford. 
 C.,H.& Co., Ford. 
 C . H. & Co., Ford. 
 C., H. & Co., Ford. 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 
 New. 
 Stimson, modified. 
 
 Buck. 322, 323 
 Stimson. 321 
 Stimson. 324
 
 ILLUSTRATIONS. 
 
 XV11 
 
 Cheiloplasty, lower lip, operation by V-shaped incision. Fig. 497. 
 Cheiloplasty, lower lip, Sedillot's method. Fig. 505. 
 Cheiloplasty, Syme's method. Fig. 501. 
 
 Cheiloplasty, upper lip, Dieflfenbach's method. Figs. 508, 509. 
 Cheiloplasty, upper lip, Buck's method. Figs. 506, 507. 
 Cheiloplasty, upper lip, Sedillot's vertical-flap method. Figs. 510, 
 
 Chloroform inhaler, Esmarch's. Fig. 1. 
 
 Clamp, bandage, Langenbeck's. Fig. 32. 
 
 Clamp, Bodenhamer's. Fig. 729. 
 
 Clamp, scrotal, Henry's. Fig. 173. 
 
 Clamps, nasal septum, Adams'. Fig. 771. 
 
 Collins' transfusion instrument. Fig. 185. 
 
 Colon, ascending, surgical relations of. Fig. 572. 
 
 Colon, descending, surgical relations of. Fig. 571. 
 
 Colotomy, left lumbar. Figs. 573-575. 
 
 Colotomy, left lumbar. Fig. 576. 
 
 Colotomy, left lumbar (Amussat), linear guide to colon. Fig. 570. 
 
 Compress, conical. Fig. 36. 
 
 Compress, oblong. Fig. 35. 
 
 Compress, pyramidal. Fig. 34. 
 
 Crutch, Clover's, applied. Fig. 696. 
 
 Dilator, Dolbeau's. Figs. 682, 683. 
 
 Dilators, oesophageal. Fig. 547. 
 
 Dilator, trachea, Chassaignac's. Fig. 780. 
 
 Dilator, trachea, Trousseau's. Fig. 779. 
 
 Dilator, urethral, Gross'. Fig. 714. 
 
 Director, Allingham's. Fig. 629. 
 
 Director, grooved. Fig. 24. 
 
 Director, grooved, and aneurism needle combined. Fig. 97. 
 
 Director, hernial, Levis'. Fig. 603. 
 
 Double hook, Langenbeck's. Fig. 778. 
 
 Drainage, spiral, Ellis'. Fig. 87. 
 
 Drainage-tube, rubber. Fig. 88. 
 
 Drill, bone, French. Fig. 791. 
 
 Elbow-joint, amputation at. Fig. 360. 
 
 Elbow-joint, amputation at, circular. Fig. 361. 
 
 Elbow-joint, amputation at, single-flap. Fig. 362. 
 
 Elbow-joint, disarticulation at. Figs. 360, 361. 
 
 Elbow-joint, disarticulation at. Figs. 362, 363. 
 
 Elbow-joint, excision of, Huter. Fig. 259. 
 
 Elbow-joint, excision of, exposing internal condyle. Fig. 263. 
 
 Elbow-joint, excision of, Langenbeck. Fig. 261. 
 
 Elbow-joint, excision of, Liston. Fig. 262. 
 
 Elbow-joint, ligaments of. Fig. 260. 
 
 Elbow-joint, relations of ulnar nerve to. Fig. 258. 
 
 Elevator. Figs. 198-200. 
 
 Enterectomy, Treves' apparatus for. 
 
 Epispadias, Nelaton's operation for. 
 
 Epispadias, Thiersch's operation for. 
 
 Ether inhaler, Allis'. Figs. 3, 4. 
 
 Ether inhaler, cloth and paper. Fig. 2. 
 
 Ether inhaler, Clover's. Fig. 6. 
 
 Ether-inhaler, Lente's modified. Fig. 5. 
 
 Ether inhaler, Noyes'. Fig. 8. 
 
 Ether inhaler, Squibb's. Fig. 7. 
 
 Etherization, intestinal, apparatus for. Fig. 13. 
 
 Fig. 569. 
 Figs. 734, 735. 
 Fig. 736, 737. 
 
 PAGE 
 
 Stimson. 320 
 
 Stimson. 324 
 
 New. 322 
 
 Agnew. 326 
 
 Buck. 324, 325 
 
 511. 
 
 Stimson, modified. 826 
 
 Esmarch. 6 
 
 C.,H.& Co., Ford. 26 
 
 C., H. & Co., Ford. 462 
 
 C.,H.& Co., Ford. 122 
 
 0., H. & Co., Ford. 492 
 
 Esmarch. 129 
 
 Treves. 370 
 
 Treves. 369 
 
 Original. 371 
 
 Packard. 372 
 
 S. Smith, modified. 867 
 
 Esmarch. 27 
 
 Esmarch. 27 
 
 Esmarch. 27 
 
 Original. 444 
 
 ft, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 440 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 345 
 
 C., 
 
 H. & Co., 
 
 Ford. 
 
 495 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 495 
 
 a, 
 
 E.& 
 
 Co., 
 
 Ford. 
 
 454 
 
 c., 
 
 E.& 
 
 Co., 
 
 Ford. 
 
 407 
 
 a, 
 
 H. & Co., 
 
 Ford. 
 
 20 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 59 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 892 
 
 <7., 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 495 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 46 
 
 a, 
 
 H.& 
 
 Co., 
 
 Ford. 
 
 46 
 
 a, 
 
 E.& 
 
 Co., 
 
 Ford. 
 
 509 
 
 Esmarch. 247 
 
 Esmarch. 247 
 
 ' S. Smith. 248 
 
 Esmarch. 247 
 
 S. Smith. 248 
 
 Esmarch. 189 
 
 Esmarch. 189 
 
 Esmarch. 189 
 
 Esmarch. 189 
 
 Esmarch. 189 
 
 Esmarch. 188 
 
 C., H. & Co., Ford. 136 
 
 Treves. 866 
 
 New. 467 
 
 Stimson. 468 
 
 Heath. 
 Original. 
 
 C., H. & Co., Ford. 
 C., H. & Co., Ford. 
 
 C., H. & Co., Ford. 11 
 C., H. & Co., Ford. 10 
 C., H. & Co., Ford. 17
 
 xvm 
 
 ILLUSTRATIONS. 
 
 Fascial contractions. Fig. 221. 
 
 Fascia] contractions, Dupuytren's incisions for. Fig. 222. 
 
 Fascia, nicking. Fig. 23. 
 
 Fasciatome. Fig. 219. 
 
 Femur, subcutaneous division of neck of, Adams'. Fig. 293. 
 
 Femur, subcutaneous division of neck of, Say re's lines of section. 
 
 Femur, subcutaneous division of neck of, Volkmann's. Fig. 295 
 
 Flexor tendons of fingers, linear guide to. Fig. 161. 
 
 Fingers, amputations of. Figs. 333-340. 
 
 Fistula in ano. Fig. 621. 
 
 Fistula in ano, dividing fistulas. Figs. 626-628. 
 
 Fistula in ano, probing a fistula. Fig. 622. 
 
 Fistula in ano, variations in. Figs. 623, 624. 
 
 Fistula, fecal, enterotome applied. Fig. 577. 
 
 Fistula, salivary, Horner's operation. Fig. 537. 
 
 Fistula, salivary, seton in position. Fig. 536. 
 
 Forceps, artery, Hamilton's (F. H.). Fig. 52. 
 
 Forceps, artery, and needle-holder combined. Fig. 76. 
 
 Forceps, artery, spring-catch, fenostrated, Liston's. Fig. 51. 
 
 Forceps, bone-cutting, curved, Liston's. Figs. 228, 229. 
 
 Forceps, bone-cutting, straight, Liston's. Fig. 227. 
 
 Forceps, bone- holding, Faraboeuf s. Figs. 238, 326. C., 
 
 Forceps, bone-holding, Ferguson's. Fig. 238. 
 
 Forceps, bone-holding, Langenbeck's. Fig. 238. 
 
 Forceps, cross-bar (hemostatic). Fig. 566. 
 
 Forceps, gouge, Hoffman's. Fig. 207. 
 
 Forceps, lion-jaw, Ferguson's. Fig. 325. 
 
 Forceps, lithotomy, curved. Fig. 690. ' 
 
 Forceps, lithotomy, straight. Fig. 689. 
 
 Forceps, mouse-tooth, Liston's. Fig. 53. 
 
 Forceps, needle, Gross'. Fig. 533. 
 
 Forceps, needle, Prout's. Fig. 74. 
 
 Forceps, needle, Sands'. Fig. 75. 
 
 Forceps, needle, Stimson's. Fig. 73. 
 
 Forceps, phymosis, Fisher's. Fig. 718. 
 
 Forceps, phymosis, Henry's. Fig. 717. 
 
 Forceps, polypus, nasal, curved. Fig. 758. 
 
 Forceps, polypus, nasal, straight. Fig. 759. 
 
 Forceps, rectal, Byrnes'. Fig. 620. 
 
 Forceps, rhinoplastos, Adams'. Fig. 770. 
 
 Forceps, sequestrum, Ferguson's. Fig. 203. 
 
 Forceps, sequestrum, Van Buren's. Fig. 202. 
 
 Forceps, serrefine. Fig. 54. 
 
 Forceps, tenaculum, Prince's. Fig. 62. 
 
 Forceps, throat, Burge's. Fig. 553. 
 
 Forceps, throat, Cusco's. Fig. 552. 
 
 Forceps, throat, Mathieu's. Fig. 551. 
 
 Forceps, thumb. Fig. 22. 
 
 Forceps, torsion, Hewson's. Fig. 50. 
 
 Forceps, trachea. Fig. 785. 
 
 Forceps, wire-twisting, Sims'. Fig. 525. 
 
 Foulis' fastening (for elastic bandage) in position. Fig. 30. 
 
 Foulis' fastening (for elastic bandage) with rubber cord. Fig. 31. 
 
 PAGB 
 
 Abbe. 160 
 
 Abbe. 160 
 
 Esmarch. 20 
 
 C., H. & Co., Ford. 152 
 
 Gross. 216 
 
 Fig. 294. Gross. 217 
 
 , Poore. 218 
 
 Gross. 106 
 
 Esmarch. 238-240 
 
 Van Buren. 404 
 
 8. Smith. 406 
 
 Packard. 405 
 
 Van Buren. 405 
 
 Packard. 373 
 
 Packard. 836 
 
 Gross. 336 
 
 C., H. & Co., Ford. 34 
 
 C., H. & Co., Ford. 43 
 
 C.,H.& Co., Ford. 33 
 
 C., H. & Co., Ford. 163 
 
 C., E. d- Co., Ford. 163 
 H. & Co., Ford. 168, 234 
 
 C., H. & Co., Ford. 168 
 
 a, H. & Co., Ford. 168 
 
 <7., //. & Co., Ford. 358 
 
 C.,E.& Co., Ford. 137 
 
 C., H. & Co., Ford. 234 
 
 C., H. & Co., Ford. 442 
 
 C., H. & Co., Ford. 442 
 
 C., H. & Co., Ford. 34 
 
 C.,H.& Co., Ford. 332 
 
 C.,H.& Co., Ford. 42 
 
 C.,H.& Co., Ford. 42 
 
 C., H. & Co., Ford. 42 
 
 C'., H. & Co., Ford. 458 
 
 C.,H.& Co., Ford. 458 
 
 C.,H.& Co., Ford. 485 
 
 C.,H.& Co., Ford. 486 
 
 C., H. & Co., Ford. 404 
 
 C., H. & Co., Ford. 491 
 
 C., H. & Co., Ford. 137 
 
 C.,H.& Co., Ford. 137 
 
 C., H. & Co., Ford. 34 
 
 C., E. & Co., Ford. 35 
 
 C., E. & Co., Ford. 348 
 
 C., E. & Co., Ford. 347 
 
 C.,E.& Co., Ford. 347 
 
 C., E. & Co., Ford. 20 
 
 C., E. & Co., Ford. 33 
 
 C., E. & Co., Ford. 497 
 
 C., E. & Co., Ford. 329 
 
 Esmarch. 26 
 
 Esmarch. 26 
 
 Gastro-enterostomy. Fig. 565. 
 
 Gastrostomy, needles in position. Fig. 564. 
 
 Genu valgum. Fig. 296. 
 
 Genu valgum, Macewen's line of bone section. Fig. 297. 
 
 British Medical Journal. 355 
 
 S. Smith, modified. 353 
 
 Poore. 218 
 
 Macewen. 219
 
 ILLUSTRATIONS. 
 
 XIX 
 
 Genu valgum, Macewen's method. Figs. 298-300. 
 Genu valgum, Ogsten's method. Figs. 301, 302. 
 Gorget, blunt. Fig. 687. 
 Gorget, hooked. Fig. 713. 
 Gouge, curved. Fig. 205. 
 Gouge, straight. Fig. 204. 
 Gouge, Szymanowsky's. Fig. 206. 
 Guides, whalebone, Gouley's. Fig. 647. 
 
 Hare-lip, complicated. Fig. 495. 
 Hare-lip, double. Fig. 494. 
 
 Hare-lip, simple, double-flap method. Figs. 490, 491. 
 Hare-lip, simple, double-flap method, Giraldes'. Figs. 492, 493. 
 Hare-lip, simple, incision for direct union. Fig. 488. 
 Hare-lip, simple, single-flap method. Fig. 489. 
 ' Hernia, femoral, Wood's operation for the radical cure of. 
 
 
 PAGU 
 
 Macewen. 
 
 219 
 
 Macewen. 
 
 219 
 
 C.,H.& Co., Ford. 
 
 441 
 
 C.,H.& Co., Ford. 
 
 454 
 
 C.,H.& Co., Ford. 
 
 137 
 
 C., H. & Co., Ford. 
 
 137 
 
 C.,H.& Co., Ford. 
 
 137 
 
 C., H. & Co., Ford. 
 
 420 
 
 Gross. 
 
 319 
 
 Agnew. 
 
 319 
 
 S. Smith, modified. 
 
 318 
 
 S. Smith, modified. 
 
 318 
 
 Agnew. 
 
 317 
 
 S. Smith, modified. 
 
 318 
 
 Hernia, inguinal, direct. Fig. 611. 
 
 Hernia, inguinal, oblique. Figs. 608, 609. 
 
 Hernia, inguinal, Agnew's apparatus for the radical cure of. 
 
 Figs. 597, 598, 599. 
 
 Stimson. 389, 390 
 
 Packard. 397 
 
 Packard. 395 
 Fig. 586. 
 
 C., H. & Co., Ford. 383 
 Hernia, inguinal, Wood's apparatus for the radical cure of. Fig. 587. 
 
 C.,E.& Co., Ford. 384 
 
 Hernia, inguinal, Wood's operation for the radical cure of. Fig. 588. Gross. 384 
 
 Hernia, inguinal, Wood's operation for the radical cure of. Figs. 589, 590. Stimson. 385 
 
 Hernia, inguinal, Wood's operation for the radical cure of. Fig. 591. Gross. 385 
 
 Hernia, inguinal, Wood's operation for the radical cure of. Figs. 592, 593. Stimson. 386 
 Hernia, inguinal, modification of Wood's operation for the radical cure of. 
 
 Figs. 595, 596. Stimson. ' 386, 387 
 Hernia, inguinal, Wiltzer's apparatus for the radical cure of. Fig. 585. 
 
 C.,H.& Co., Ford. 382 
 
 Hernia, sac of a. Figs. 583. Packard. 380 
 
 Hernia, sac of a, and contents. Fig. 584. Packard. 380 
 
 Hernia, umbilical, instruments for. Fig. 600. C.,H. & Co., Ford. 390 
 Hip-joint, amputation at, by long anterior and short posterior flap, Maenec. 
 
 Figs. 450^53. Esmarch. 290-292 
 
 Hip-joint, amputation at, Dieifenbach's circular method. Figs. 455-457. Esmarch. 293, 294 
 
 Hip-joint, amputation at, elastic ligature for. Fig. 454. Esmarch. 292 
 
 Hip-joint, amputation at, Malgaigne's method. Fig. 458. S. Smith. 295 
 
 Hip-joint, amputation at, Malgaigne's method. Figs. 459, 460. Agnew. 295, 296 
 
 Hip-joint, excision of, Langenbeck's longitudinal incision. Fig. 286. Esmarch. 210 
 
 Hip-joint, excision of, Sayre's line of incision. Fig. 287. Neio. 211 
 
 Hip-joint, excision of, sawing off head of femur. Fig. 285. Esmarch. 210 
 
 Hip-joint, excision of, White's posterior curved incision. Fig. 283. Esmarch. 209 
 
 Hip-joint, external rotator muscles and sciatic nerve. Fig. 284. Esmarch. 209 
 
 Humerus, attachments to head of. Fig. 254. Esmarch. 186 
 
 Humerus, excision of, upper end. Fig. 252. Esmarch. 185 
 
 Humerus, excision of, upper end, raising tendon. Fig. 253. Esmarch. 186 
 
 Humerus, excision of, upper end, sawing head of humerus. Fig. 255. Esmarch. 186 
 
 Hydrocele, rubber bag for injecting. Fig. 716. C.,H.& Co., Ford. 457 
 
 Hydrocele, tapping a. Fig. 715. Gross. 456 
 
 Hypospadias, Anger's operation for. Fig. 731. New. 464 
 
 Hypospadias, Duplay's operation for. Fig. 732. New. 465 
 
 Hypospadias, Gouley's operation for. Fig. 730. Gouley. 464 
 
 Hypospadias, Szymanowsky's operation for. Fig. 733. S. Smith. 466 
 
 Intubation of the larynx, O'Dwyer's instruments for. Fig. 790. C., H. & Co., Ford. 503 
 
 Jaw, the, pressing forward, during administration of anaesthetics. Fig. 10. Esmarch. 14
 
 xx ILLUSTRATIONS. 
 
 PAGE 
 
 Kelotomy. Figs. 604-607. Packard. 393, 395 
 
 Kingsley's nasal lever. Fig. 486. Kinysley. 315 
 
 Knee-joint, amputation at, bilateral method. Figs. 430, 431. Esmarch. 279 
 
 Knee-joint, amputation at, Garden's. Fig. 437. Stimson, modified, 282 
 
 Knee-joint, amputation at, circular method. Figs. 432-434. Esmarch. 280 
 
 Knee-joint, amputation at, Gritti's. Fig. 438. Stimson, modified. 282 
 Knee-joint, amputation at, long anterior and short posterior flap. Figs. 435, 436. 
 
 Esmarch, 281 
 
 Knee-joint, amputation at, Stokes'. Fig. 438. Stimson, modified. 282 
 
 Knee-joint, disarticulation at. Figs. 432-436. Esmarch. 280, 281 
 
 Knee-joint, disarticulation at. Figs. 430, 431. S. Smith. 279 
 
 Knee-joint, disarticulation at. Fig. 437. Stimson, modified. 282 
 
 Knee-joint, excision of, Langenbeck's incision. Fig. 280. Esmarch. 205 
 Knee-joint, excision of, line of oection in, and epiphyseal cartilage of. Fig. 277. 
 
 Stimson. 203 . 
 
 Knee-joint, excision of, Mackenzie's anterior curved incision. Fig. 278. Esmarch. 204 
 Knee-joint, excision of, Mackenzie's operation, lines of division of bone. Fig. 279. 
 
 S. Smith. 205 
 
 Knee-joint, excision of, Ollier's incision. Fig. 282. Stimson. 207 
 
 Knee-joint, tendons at inner side of. Fig. 281. Esmarch 206 
 
 Knife, metacarpal. Fig. 319. C., H. & Co., Ford. 233 
 
 Knife, Langenbeck's, for staphylorrhaphy. Fig. 518. C., H. & Co., Ford. 328 
 
 Knives, amputating. Fig. 314. C., H. & Co., Ford. 231 
 
 Knives, hernial. Figs. 601, 602. C., H. & Co., Ford. 392 
 
 Knot, granny. Fig. 69. Heath. 38 
 
 Knot, rc'ef. Fig. 68. Heath. 38 
 
 Knot, reef, first step in tying. Fig. 70. Heath. 38 
 
 Knot, reef, second step in tying. Fig. 71. Heath. 39 
 
 Knot, reef, third step in tying. Fig. 72. Heath. 39 
 
 Knot, surgeon's. Fig. 67. Heath. 38 
 
 Larynx and trachea, surgical anatomy of. Fig. 774. Gray. 494 
 
 Larynx, external cartilages of. Fig. 773. Esmarch. 493 
 
 Leg, amputation of, bilateral flaps. Fig. 428. S. Smith. 275 
 Leg, amputation of, lower third, with periosteal reflection. Figs. 425-427. 
 
 Original. 274, 275 
 
 Leg, amputation of, long external flap. Fig. 429. Esmarch. 278 
 
 Leg, transverse section of middle third of. Fig. 128. Esmarch. 80 
 
 Leg, transverse section of upper third of. Fig. 127. Esmarch. 80 
 
 Lever, Davy's, applied. Fig. 48. Davy. 30 
 
 Ligature-carrier, Allingham's. Fig. 630. C., H. & Co., Ford. 407 
 
 Ligature of arteries, opening sheath of vessel. Fig. 92. Gross. 58 
 
 Ligature of arteries, passing aneurism needle. Fig. 93. Esmarch. 58 
 
 Ligature of arteries, passing probe. Fig. 94. Esmarch. 58 
 
 Ligature of arteries, primitive incision. Fig. 91. Packard. 57 
 
 Ligature, tying a. Fig. 66. Heath. 37 
 
 Lithoclast, Dolbeau's. Fig. 691 % C., H. & Co., Ford. 442 
 
 Lithoclast, Gouley's. Fig. 681. ' C., H. & Co., Ford. 439 
 
 Lithotome, Briggs' modified. Fig. 710. C., H. & Co., Ford. 452 
 
 Lithotome (double), Dupuytren's. Fig. 699. C., H. & Co., Ford. 447 
 
 Lithotome, Hutchison's. Fig. 700. C., H. & Co., Ford. 447 
 
 Lithotome, Smith's. Fig. 698. C., H. & Co., Ford. 446 
 
 Lithotomy bisector, Wood's. Fig. 707. C'., H. & Co., Ford. 450 
 
 Lithotomy bistoury, Little's. Fig. 705. C.,H.& Co., Ford. 449 
 
 Lithotomy conductor and scoop. Fig. 688. C., H. & Co., Ford. 441 
 
 Lithotomy director, Little's. Fig. 704. C., H. & Co., Ford. 448 
 
 Lithotomy knife, Blizard's. Fig. 686. C., H. & Co., Ford. 441 
 
 Lithotomy knife, Dupuytren's. Fig. 685. C., H. & Co., Ford. 441
 
 ILLUSTRATIONS. 
 
 XXI 
 
 Lithotomy, lateral incision of the prostate in. Fig. 697. 
 
 Lithotomy, medio-lateral method, Buchanan. Fig. 709. 
 
 Lithotomy, perineal, external incisions in. Fig. 708. 
 
 Lithotomy scoop, Luer's. Fig. 692. 
 
 Lithotomy staff. Fig. 689. 
 
 Lithotomy staff. Fig. 684. 
 
 Lithotomy staff and bisector, Wood's. Fig. 706. 
 
 Lithotomy staff, Little's. Fig. 701. 
 
 Lithotomy staff, Markoe's. Fig. 702. 
 
 Lithotomy staff, rectangular. Fig. 703. 
 
 Lithotrite and evacuating catheter combined, author's. '. 
 
 Lithotrite, Bigelow's. Fig. 664. 
 
 Lithotrite, fenestrated blades, Bigelow's. Fig. 666. 
 
 Lithotrite, fenestrated jaws. Fig. 662. 
 
 Lithotrite, Keyes'. Figs. 667, 668. 
 
 Lithotrite, non-fenestrated blades, Bigelow's. Fig. 665. 
 
 Lithotrite, non-fenestrated jaws. Fig. 663. 
 
 Lithotrite, Thompson's. Fig. 661. 
 
 Lithotrity, perineal, Dolbeau's method, first step. Fig. 678. 
 
 Lithotrity, perineal, Dolbeau's method, second step. Fig. 
 
 Lithotrity, perineal, Dolbeau's method, third step. Fig. 6 
 
 Little's searcher. Fig. 659. 
 
 Location of fissure of Rolando and special areas. Fig. 212. 
 
 Loops, Ricord's. Fig. 180. 
 
 Mallet, lead. Fig. 208. 
 
 Maxillae, superior, removal of both. Fig. 246. 
 
 Maxilla, inferior, linear guide for removal of half. Fig. 247. 
 
 Maxilla, inferior, severing connections of. Fig. 248. 
 
 Maxilla, superior, linear guide for removal of. Fig. 243. 
 
 Maxilla, superior, division of processes of. Fig. 244. 
 
 Maxilla, superior, excision of, subperiosteal. Fig. 245. 
 
 Medio-tarsal articulation, amputations at. Fig. 386. 
 
 Metacarpal bones, amputation of last four, by transfixion. 
 
 Metacarpal bone, amputation through one. Fig. 346. 
 
 Metacarpal bone, amputation through one. Fig. 347. 
 
 Metacarpal bone, stump after amputation through third. 
 
 Metacarpa! bones, amputation of last four, appearance of stump. 
 
 Metacarpal bones, amputation of last four, line of dorsal flap. 
 
 Metacarpal bones, amputation of last four, line of palmar flap. 
 
 Metacarpal bones, amputation through fourth and fifth. 
 
 Metacarpal bones, disarticulation of last four. Figs. 349-352. 
 
 Metacarpo-phalangeal articulation, disarticulation at. 
 
 Metatarso-phalangeal articulation, excision of, U-shaped incision. 
 
 Metatarso-phalangeal articulation, amputation at. Fig. 375. 
 
 Metatarso-phalangeal articulation, amputation of all the toes. Figs. 380-383. 
 
 Esmarch. 258, 259 
 Metatarso-phalangeal articulation, amputation at, removal of a single toe. Fig. 376. 
 
 8. Smith. 256 
 Metatarso-phalangeal articulation, amputation at, removal of great toe, lateral-flap 
 
 method. Fig. 377. Esmarch. 256 
 
 Metatarso-phalangeal articulation, amputation at, removal of great toe, lateral-flap 
 
 method, completion of operation. Fig. 378. Esmarch. 257 
 
 Metatarso-phalangeal articulation, amputation at, square-flap method. Fig. 379. 
 
 Esmarch. 257 
 
 Metatarso-phalangeal articulation, disarticulation at the. Figs. 380-385. Esmarch. 258,259 
 Miculicz's amputation of foot. Fig. 386. New. 260 
 
 Mouth-gag, Mason's. Fig. 514. C"., E. & Co., Ford. 827 
 
 PAGE 
 
 Van Buren & Keyes. 445 
 
 Van Buren & Keyes. 
 
 451 
 
 S. Smith. 
 
 450 
 
 C.,H.& Co., Ford. 
 
 442 
 
 C., H. & Co., lord. 
 
 441 
 
 C.,TI.& Co., Ford. 
 
 441 
 
 C.,H.& Co., Ford. 
 
 449 
 
 C., H. d* Co., Ford. 
 
 448 
 
 U., H. & Co., Ford. 
 
 448 
 
 C.,H.& Co., Ford. 
 
 440 
 
 \. 677. C.,H.& Co., Ford. 
 
 436 
 
 C.,H.& Co., Ford. 
 
 431 
 
 C., H. & Co., Ford. 
 
 431 
 
 C.,H.& Co., Ford. 
 
 429 
 
 C., E. & Co., Ford. 
 
 431 
 
 C., H. & Co., Ford. 
 
 431 
 
 C.,H.& (Jo., Ford. 
 
 429 
 
 C.,H.& Co., Ford. 
 
 429 
 
 3. Gouley. 
 
 437 
 
 679. Gouley. 
 
 438 
 
 .80. Gouley. 
 
 438 
 
 C.,H.& Co., Ford. 
 
 427 
 
 Soberts. 
 
 141 
 
 Eicord. 
 
 125 
 
 C., H. & Co., Fofd. 
 
 137 
 
 New. 
 
 174 
 
 :7. New. 
 
 177 
 
 Agnew. 
 
 177 
 
 New. 
 
 171 
 
 Agnew. 
 
 172 
 
 New. 
 
 173 
 
 New. 
 
 260 
 
 Fig. 350. Esmarch. 
 
 243 
 
 Watson. 
 
 240 
 
 Stimson. 
 
 241 
 
 ?ig. 348. Watson. 
 
 243 
 
 ;ump. Fig. 352. Esmarch. 
 
 243 
 
 p. Fig. 351. Esmarch. 
 
 243 
 
 lap. Fig. 349. Esmarch. 
 
 243 
 
 ig. 347. Watson. 
 
 242 
 
 52. Esmarch. 
 
 243 
 
 3. 339-345. Esmarch. 240, 
 
 241 
 
 icision. Fig. 270. New. 
 
 197 
 
 i. Esmarch. 
 
 256
 
 XX11 
 
 ILLUSTRATIONS. 
 
 PAGX 
 
 Narcs, posterior, plugging the. Fig. 756. C., H. & Co., Ford. 484 
 
 Nasal plugs, ivory. Fig. 772. C., H. & Co., Ford. 492 
 
 Nerve, circumflex. Fig. 257. Gray. 188 
 
 Nerve, crural, anterior, exposed. Fig. 216. Agnew. 149 
 Nerve, 'maxillary, superior, Pancoast's lines of incision for exposing. Fig. 213. 
 
 Pancoast, modified. 143 
 
 Nerve, musculo-spiral. Fig. 257. Gray. 188 
 
 Nerve, sciatic, great, exposed. Fig. 215. Agnew. 148 
 
 Nerve, sciatic, great, linear guide to. Fig. 123. New. 78 
 
 Nerve, spinal accessory, De Morgan's operation. Fig. 214. Agnew. 146 
 
 CEsophagotomy, internal, Sands' instrument for. 
 Os calcis, excision of. Fig. 271. 
 Osteotomes. Fig. 292. 
 Osteotrite, Marshall's. Fig. 226. 
 
 Fig. 548. C.,H.& Co., Ford. 346 
 
 Gross. 198 
 
 C.,H.& Co., Ford. 215 
 
 C., //. & Co., Ford. 163 
 
 Palate, cleft, degrees of deformity. Figs. 528, 529. 
 
 Palate, cleft, freshening borders in. Fig. 530. 
 
 Palate, soft, muscles of the. Fig. 532. 
 
 Paracentesis abdominis, introducing trocar. Fig. 582. 
 
 Paraphymosis. Fig. 724. 
 
 Paraphymosis, reduction of, first method. Fig. 726. 
 
 Paraphymosis, reduction of, second method. Fig. 727. 
 
 Paraphymosis, reduction of, third method. Fig. 728. 
 
 Paraphymosis, results of the constriction. Fig. 725. 
 
 Patella, wiring the, fragments united. Fig. 793. 
 
 Patella, wiring the, wire introduced. Fig. 792. 
 
 Perios'teotome, Goodwillie's. Fig. 522. 
 
 Periosteotomc, Sands'. Fig. 237. 
 
 Periosteotome, Sayre's. Figs. 232, 521. 
 
 Phalangeal articulations of the hand, disarticulation at. 
 
 8. Smith. 
 
 Packard. 
 
 Gray. 
 
 S. Smith, modified. 
 8. Smith. 
 S. Smith. 
 S. Smith. 
 S. Smith. 
 S. Smith. 
 
 British Medical Journal. 
 
 British Medical Journal. 
 
 C.. H. & Co., Ford. 
 
 C., H. & Co., Ford. 
 
 C., H. & Co., Ford. 164, 329 
 
 Figs. 333-338. Esmarch. 238, 239 
 
 Phalangeal articulations of foot, disarticulation at. Fig. 375. Esmarch. 256 
 
 Phalangeal articulations of foot, disarticulation at. Fig. 376. S. Smith. 256 
 
 Phalangeal articulations of foot, disarticulation at. Figs. 377-379. Esmarch. 256, 257 
 
 Phalanges of hand, attachment of tendons. Fig. 332. Original. 237 
 
 Phalanx of hand, amputation of, making flap. Fig. 334. Esmarch. 238 
 
 Phalanx of hand, amputation of, flap completed. Fig. 335. Esmarch. 238 
 
 Phalanx of hand, amputation of, by transfixion. Fig. 336. Esmarch. 238 
 
 Phalanx of hand, amputation of, opening joint. Fig. 337. Esmarch. 238" 
 
 Phalanx of hand, flexed. Fig. 333. Esmarch. 238 
 
 Phymosis, clamping foreskin. Fig. 720. S. Smith. 459 
 
 Phymosis, dorsal slit. Fig. 723. Gross. 400 
 
 Phymosis, Keyes' operation for. Fig. 722. Keyes. 460 
 
 Phymosis, steps of operation. Fig. 721. Original. 459 
 
 Pin-carrier, Post's. Ing. 85. C.. E. & Co., Ford. 46 
 
 Pincers, intestinal, Abbe's. Fig. 567. C., H. & Co., Ford. 358 
 
 Pins, adjustable pointed. Fig. 86. C., H. & Co., Ford. 46 
 
 Pins, hare-lip. Fig. 84. C., H. & Co., Ford. 46 
 
 Pins, Wood's rectangular. Fig. 594. Stimson. 386 
 
 Plastic surgery, jumping method. Fig. 474. Prince. 306 
 
 Plastic surgery, paper protective. Fig. 469. Prince. 305 
 
 Plastic surgery parallel incisions. Figs. 470, 471. Prince. 305 
 
 Plastic surgery, transverse incisions. Figs. 472, 473. Prince. 306 
 
 Polypus, nasal, removing by snare. Fig. 764. Packard. 486 
 
 Polypus, nasal, removing, double canula in position. Fig. 765. Gross. 487 
 
 Polypus, nasal, removing, lines of incision. Fig. 766. New. 487 
 
 Polypus, nasal, removing, Nelaton's operation. Fig. 768. New. 488 
 
 Polypi, naso-pharyngeal, removing, Langenbeck's incisions. Fig. 767. New. 488
 
 ILLUSTRATIONS. 
 
 XX111 
 
 Probang, bristle. Fig. 549. 
 
 Probang, bucket. Fig. 550. 
 
 Probang, sponge. Fig. 550. 
 
 Prolapsus ani. Fig. 631. 
 
 Prolapsus ani, complete, with peritoneum. Fig. 633. 
 
 Prolapsus ani, with invagination. Fig. 632. 
 
 Pylorus, resection of, outlines of incisions for. Fig. 568. 
 
 Eectum ending in a blind pouch. Fig. 635. 
 Eectum, imperforate. Fig. 634. 
 
 PAGE 
 
 C.,H.& Co., Ford. 347 
 
 C., H. & Co., Ford. 347 
 
 C., H. & Co., Ford. 347 
 
 Van Buren. 410 
 
 Van Buren. 411 
 
 Van Buren. 410 
 
 Billroth. 359 
 
 Van Buren. 
 Gross. 
 
 415 
 
 414 
 
 Eelations of fissures and convolutions of brain to external surface of skull. 
 
 Fig. 211. 
 
 Eespiration, artificial, first movement. Fig. 11. 
 Eespiration, artificial, second movement. Fig. 12. 
 Eetractor, in amputations for one bone. Fig. 329. 
 Eetractor, in amputations for two bones. Fig. 328. 
 Eetractor, in amputations, three-tailed, applied. Fig. 330. 
 Eetractor, in amputation, two-tailed, applied. Fig. 331. 
 Eetractor, in tracheotomy. Fig. 776. 
 Eetractor, cheek. Fig. 515. 
 Eetractor, Mott's. Fig. 95. 
 Eetractor, Parker's. Fig. 96. 
 Eetractors. Figs. 235, 236. 
 
 Ehinoplasty, closure by transverse incision. Fig. 475. 
 Ehinoplasty, Dieflenbach's method. Fig. 481. 
 Ehinoplasty, Indian method. Fig. 483. 
 Ehinoplasty, Italian method. Fig. 484. 
 Ehinoplasty, Ollier's method. Fig. 485. 
 Ehinoplasty, repair by jumping. Figs, 478, 479. 
 Ehinoplasty, repair by sliding. Figs. 476, 477. 
 Ehinoplasty, Verneuil's method. Fig. 482. 
 Eongeur. Fig. 201. 
 
 Saphenous opening. . Fig. 613. 
 
 Saw, Adams'. Fig. 289. 
 
 Saw, bow, Butcher's. Fig. 323. 
 
 Saw, bow, common. Fig. 322. 
 
 Saw, broad-bladed. Fig. 320. 
 
 Saw, chain. Fig. 239. 
 
 Saw, chain-carrier. Fig. 240. 
 
 Saw, Langenbeck's. Fig. 288. 
 
 Saw, Langenbeck's key-hole. Fig. 231. 
 
 Saw, Lente's. Fig. 230. 
 
 Saw, lifting-back, metacarpal. Fig. 241. 
 
 Saw, oral, Goodwillie's. Fig. 526. 
 
 Saw, Shrady's. Fig. 290. 
 
 Saw, Shrady's, modified. Fig. 291. 
 
 Saw, Szymanowski's. Fig. 242. 
 
 Scalpel, method of holding, first position. , Fig. 16. 
 
 Scalpel, method of holding, first position. Fig. 17. 
 
 Scalpel, method of holding, second position. Figs. 18, 19. 
 
 Scalpel, method of holding, third position. Figs. 20, 21. 
 
 Scalpel, trachea. Fig. 775. 
 
 Scalpels. Figs. 233, 234. 
 
 Scalpels and bistouries. Fig. 15. 
 
 Scapula, excision of body. Fig. 250. 
 
 Scapula, excision of entire. Fig. 249. 
 
 Scapula, excision of glenoid angle. Fig. 256. 
 
 Roberts. 140 
 
 Esmarch. 15 
 
 Esmarch. 16 
 
 Esmarch. 236 
 
 Esmarch. 236 
 
 Esmarch. 236 
 
 Esmarch. 237 
 
 C., H. & Co., Ford. 495 
 
 C., H. & Co., Ford. 328 
 
 C., H. & Co., Ford. 59 
 
 C.,H.& Co., Ford. 59 
 H. & Co., Ford. 164, 167 
 
 New. 308 
 
 Die/enbach. 310 
 
 New. 312 
 
 Stimson. 312 
 New. 
 Buclc. 
 New. 
 New. 
 C.,E.& Co., Ford. 
 
 Gray. 399 
 
 C., H. & Co., Ford. 213 
 
 C.,H.& Co., Ford. 233 
 
 C., H. & Co., Ford. 233 
 
 C., H. & Co., Ford. .233 
 
 C., H. & Co., Ford. 168 
 
 C., H. & Co., Ford. 168 
 
 C.,B.& Co., Ford. 212 
 
 C., H. & Co., Ford. 164 
 
 C., H. & Co., Ford. 164 
 
 C.,H.& Co., Ford. 169 
 
 C.,H.& Co., Ford. 329 
 
 C.,H.& Co., Ford. 213 
 
 C., H. & Co., Ford. 213 
 
 C., H. & Co., Ford. 169 
 
 Bernard and Huette. 18 
 
 Packard. 19 
 
 Bernard and Huette. 19 
 
 Bernard and Huette. 19 
 
 C., H. & Co., Ford. 495 
 
 C., H. & Co., Ford. 164 
 
 C., H. & Co., Ford. 18 
 
 New. 1S3 
 
 New. 182 
 
 Esmarch. 187
 
 ILLUSTRATIONS. 
 
 PAGE 
 
 Scapula, excision of subperiosteal. Fig. 251. New. 184 
 
 Scoop and conductor, lithotomy. Fig. 688. C., H. & Co., Ford. 441 
 
 Scoop, Hebra's. Fig. 224. C., H. & Co., Ford. 162 
 
 Scoop, Volkmann's. Fig. 223. C., H. & Co., Ford. 162 
 
 Scissors, Allingham's. ' Fig. 629. C., H. & Co., Ford. 407 
 
 Scissors, curved. Fig. 25. C., II. & Co., Ford. 21 
 
 Scissors, curved for staphylorrhaphy, etc. Fig. 520. C., H. & Co., Ford. 829 
 
 Scissors, pbymosis, Taylor's. Fig. 719. C., H. & Co., Ford. 459 
 
 Scissors, straight, probe-pointed. Fig. 26. C., H. & Co., Ford. 21 
 
 Searcher, Gouley's. Fig. 660. C., H. d- Co., Ford. 427 
 
 Searcher, Little's. Fig. 659. C., H. <k Co., Ford. 427 
 
 Searcher, Thompson's. Fig. 658. C., H. & Co., Ford. 427 
 
 Serrefine, Langenbeck's. Fig. 55. C., H. & Co., Ford. 34 
 
 Serrefine, wire. Fig. 56. C., H. & Co., Ford. 84 
 
 Shoulder-joint, amputation at, by circular incision, flaps united. Fig. 371. Esmarch. 254 
 Shoulder-joint, amputation at, by circular incision, removal of bone. Fig. 370. 
 
 Esmarch. 253 
 
 Shoulder-joint, amputation at, oval, Larrcy. Fig. 372. 8. Smith. 254 
 
 Shoulder-joint, amputation at, oval, Larrey, forming inner flap. Fig. 373. S. Smith. 254 
 
 Shoulder-joint, amputation at, Spenee's method. Fig. 374. Esmarch. 254 
 
 Shoulder-joint, disarticulation of, Dupuytren. Fig. 367. Esmarch. 251 
 
 Shoulder-joint, disarticulation of, Dupuytren, flaps united. Fig. 369. Esmarch. 252 
 
 Shoulder-joint, disarticulation of, Dupuytren, making inner flap. Fig. 368. Esmarch. 252 
 
 Skull, course of arteries and sinuses of. Fig. 209. Esmarch. 138 
 
 Snare, polypus, nasal, Codman and ShurtleiFs. Fig. 762. C., H. & Co., Ford. 486 
 
 Snare, polypus, nasal, Jarvis'. Fig. 763. C., H. & Co., Ford. 486 
 
 Snare, polypus, nasal, Sexton's. Fig. 761. C., H. & Co., Ford. 486 
 
 Sonde a dart. Fig. 712. C., H. & Co., Ford. 454 
 
 Sound, tunneled, Gouley's. Fig. 648. C.,H.& Co., Ford. 421 
 
 Speculum, rectal, Allingham's. Fig. 618. C., H. & Co., Ford. 402 
 
 Speculum, rectal, bivalve. Fig. 616. C., H. & Co., Ford. 402 
 
 Speculum, rectal, Williams'. Fig. 617. C., H. & Co., Ford. 402 
 
 Speculum, rectal, Thebaud's dilating. Fig. 625. C., H. & Co., Ford. 406 
 Spine, curvature of the, Sayre's apparatus for. Figs. 462-464. C., H. & Co., Ford. 298, 299 
 
 Staphylorrhaphy, freshening borders. Fig. 531. Packard. 330 
 
 Staphylorrhaphy, looped suture in. Fig. 534. 8. Smith. 333 
 
 Stomatoplasty. Fig. 512. Buck. 327 
 
 Suspensory, Morgan's. Fig. 172. Gross. 121 
 Suture, continuous, or Glover's. Figs. 80, 555. Esmarch. 44, 349 
 
 Suture, hare-lip. Figs. 82, 83. Esmarch. 45 
 
 Suture, Interrupted. Fig. 78. Esmarch. 44 
 
 Suture, intestinal, Czerny-Lembert's. Fig. 561. Mosetig-Moorhof. 351 
 
 Suture, intestinal, Gely's, external appearance. Fig. 557. Stimson. 350 
 
 Suture, intestinal, Gely's, internal appearance. Fig. 558. Otis. 350 
 
 Suture, intestinal, Gussenbauer's. Fig. 562. Mosetig-Moorhof. 351 
 
 Suture, intestinal, Jobert's. Figs. 559, 560. Esmarch. 351 
 
 Suture, intestinal, Lerabert's. Figs. 554-556. Esmarch. 349 
 
 Suture, quilled. Fig. 81. Thomas Bryant. 44 
 
 Sutures, tension of. Fig. 79. Thomas Bryant. 44 
 
 Syringe, debris, Van Buren's. Fig. 693. C., H. & Co., Ford. 443 
 
 Tampon, trachea, Trendelenburg's. Fig. 769. , H. & Co., Ford. 491 
 
 Tarso-metatarsal articulation, amputations at. Fig. 386. New. 260 
 
 Tarso-metatarsal articulation, amputation at, Lisfranc's. Fig. 386. New. 260 
 Tarso-metatarsal articulation, amputation at, Bauden's modification of Lisfranc's. 
 
 Fig. 386. New. 260 
 Tarso-metatarsal articulation, amputation at, Hey's modification of Lisfranc's. 
 
 Fig. 386. New. 260
 
 ILLUSTRATIONS. 
 
 Tarso-metatarsal articulation, amputation at, Skey's modification of Lisfranc's. 
 
 Fig. 386. New. 260 
 
 Tarso-metatarsal articulation, disarticulation at. Figs. 387-391. Esmarch. 261, 262 
 
 Tarso-metatarsal articulation, disarticulation at. Figs. 411, 412. Gross. 270 
 
 Tarso-metatarsal articulation, disarticulation at. Fig. 410. Original. 269 
 
 Tarso-metatarsal articulation, disarticulation at. Fig. 416. S. Smith. 271 
 Tenaculum. Figs. 59, 519. <7., H. & Co., Ford. 35, 328 
 
 Tenaculum, application of, to vessels. Fig. 60. Packard. 35 
 
 Tenaculum-retractor. Fig. 777. C., H. & Co., Ford. 495 
 
 Tendon, dividing a. Fig. 220. Sayre. 152 
 
 Tendons, flexor, of fingers, linear guide to. Fig. 161. Gross. 106 
 Tenotomes. Figs. 217, 218. C., H. & Co., Ford. 151, 152 
 
 Thigh, amputation of, bilateral flaps. Fig. 428. S. Smith. 275 
 
 Thigh, amputation of, Celsus' single circular incision. Figs. 442, 443. Esmarch. 286 
 Thigh, amputation of, circular-integumentary flap, amputated portion. 
 
 Fig. 441. Gross. 285 
 Thigh, amputation of, circular-integumentary flap, conical cavity of stump. 
 
 Fig. 440. Gross, modified. 284 
 
 Thigh, amputation of, periosteal flap. Fig. 439. Esmarch, modified. 284 
 
 Toe, amputation at the metatarso-phalangeal articulation. Fig. 375. Esmarch. 256 
 Toes, amputation of all, at the metatarso-phalangeal articulation. Figs. 380-383. 
 
 Esmarch. 258, 259 
 Toe, amputation of a single, at the metatarso-phalangeal articulation. Fig. 376. 
 
 S. Smith. 256 
 Toe, amputation of a single, at the metatarso-phalangeal articulation, lateral-flap 
 
 method. Fig. 377. Esmarch. 256 
 Toe, amputation of a single, at the metatarso-phalangeal articulation, lateral-flap 
 
 method, completion of operation. Fig. 378. Esmarch. 257 
 Toe, amputation of a single, at the metatarso-phalangeal articulation, square- 
 flap method. Fig. 379. Esmarch. 257 
 
 Toe, great, amputation of, at proximal end of metatarsal bone. Fig. 384. Esmarch. 259 
 
 Toe, little, amputation of, and metatarsal bone. Fig. 385. Esmarch. 259 
 
 Toe-nail, ingrowing. Fig. 467. Gross. 302 
 
 Tongue, excision of, e'craseur in position. Fig. 544. Agnew. 341 
 
 Tongue, excision of, Kocher's operation. Fig. 546. Kocher. 343 
 
 Tongue, excision of, Regnoli's incision. Fig. 545. Gross. 342 
 
 Tongue, excision of, removal of a V-shaped piece. Fig. 541. S. Smith. 339 
 
 Tongue, excision of, removal of a V-shaped piece, flaps united. Fig. 542. 8. Smith. 339 
 
 Tongue, hypertrophy of. Fig. 543. Buck. 340 
 
 Tongue, the, drawing forward, during administration of anaesthetics. Fig. 9. Esmarch. 13 
 
 Tonsillotome, Hamilton's. Fig. 539. C., H. & Co., Ford. 337 
 
 Tonsillotome, Mackenzie's. Fig. 540. C., H. & Co., Ford. 338 
 
 Tonsillotome, Tiemann's. Fig. 538. C., H. & Co., Ford. 337 
 
 Tourniquet, abdominal, Brandis'. Fig. 449. Esmarch. 289 
 
 Tourniquet, abdominal, compression pad and elastic band. Fig. 448. Esmarch. 288 
 
 Tourniquet, abdominal, elastic ligature. Fig. 454. Esmarch. 292 
 
 Tourniquet, abdominal, Esmarch's. Fig. 445. C.,H.& Co., Ford. 287 
 
 Tourniquet, abdominal, Esmarch's, applied. Fig. 446. C., H. & Co., Ford. 288 
 
 Tourniquet, abdominal, Lister's. Fig. 447. C., H. & Co., Ford. 288 
 
 Tourniquet, abdominal, Pancoast's. Fig. 444. C., H. & Co., Ford. 287 
 
 Tourniquet, Knebel's improved. Fig. 42. Esmarch. 29 
 
 Tourniquet, Petit' 9. Fig. 39. Esmarch. 28 
 
 Tourniquet, Petit's, applied to femoral artery. Fig. 40. Esmarch. 29 
 
 Trachea and larynx, surgical anatomy of. Fig. 774. Gray. 494 
 
 Trachea, opening the. Fig. 787. EsmarcJi. 498 
 
 Trachea, vascular relations of the. Fig. 789. Packard. 499 
 
 Transfusion apparatus, Bull's. Fig. 187. C., H. & Co., Ford. 130 
 
 Transfusion apparatus, Collins'. Fig. 185. Esmarch. 129
 
 XXVI 
 
 ILLUSTRATIONS. 
 
 Transfusion apparatus, Fryer's. Fig. 184. 
 
 Transfusion, direct. Fig. 183. 
 
 Transfusion, introducing tube. Fig. 182. 
 
 Transfusion, removing fibrin from blood. Fig. 186. 
 
 Transfusion, straining blood. Fig. 188. 
 
 Trendelenburg's rod. Fig. 44. 
 
 Trephine, crown. Fig. 195, 196. 
 
 Trephine, crown, application of. Fig. 210. 
 
 Trephine, Gait's. Fig. 197. 
 
 Trocar and canula. Fig. 579. 
 
 Trocar, rectum. Fig. 655. 
 
 Trocar, rectum, Buck's. Fig. 656. 
 
 Trocar, Wood-Harris. Fig. 578. 
 
 Tube (curved) and guide, Keyes'. Fig. 676. 
 
 Tube (straight) and guide, Keyes'. Fig. 675. 
 
 Tube, trachea, bivalve. Figs. 783, 784. 
 
 Tube, trachea, hard rubber. Fig. 782. 
 
 Tube, trachea, in position. Fig. 788. 
 
 Tube, trachea, silver. Fig. 781. 
 
 Uranoplasty. Fig. 535. 
 
 Urethra, tapping the. Fig. 752. 
 
 Urethrometer, Otis'. Fig. 748. 
 
 Urethroplasty. Fig. 738. 
 
 Urethroplasty, Nelaton's operation. Fig. 739. 
 
 Urethroplasty, Rigaud's operation. Fig. 740. 
 
 Urethrotome, Otis'. Figs. 749, 750. 
 
 Urethrotome, Feet's. Fig. 751. 
 
 Urethrotomy, operation of, drawing apart lips of the incision. 
 
 Urethrotomy staff, grooved, Syme's. Fig. 743. 
 
 Variocele, Keyes' needle for. Fig. 179. 
 Varicocele, treatment by elastic traction. Fig. 178. 
 Varicocele, treatment by occlusion by pins. Fig. 174. 
 Varicocele, treatment by Eicord's loops. Fig. 180.* 
 Varicocele, Videl's operation. Figs. 175-177. 
 Veins, spermatic, varicose. Fig. 171. 
 Venesection with scalpel. Fig. 181. 
 
 Webbed fingers. Fig. 465. 
 
 "Webbed finders, Ndlaton's operation. Fig. 466. 
 
 Whitchead's forceps. Figs. 516, 517. 
 
 Whitehead's hoe. Fig. 527. 
 
 Whitehead's mouth-gag. Fig. 513. 
 
 Whitehead's spiral needle. Fig. 523. 
 
 Wrist-joint, amputation at, circular method. Fig. 353. 
 
 Wrist-joint, amputation at, flaps united. Fig. 354. 
 
 Wrist-joint, amputation at, double flap. Figs. 355, 356, 358. 
 
 Wrist-joint, amputation at, single palmar flap. Fig. 357. 
 
 Wrist-joint, amputation at, double flap, appearance of stump. 
 
 Wrist-joint, excision of, Langenbeck's incisions. Fig. 268. 
 
 Wrist-joint, excision of, lateral incisions. Fig. 264. 
 
 Wrist-joint, excision of, Lister's incisions. Fig. 269. 
 
 C., H. & Co., Ford,. 
 C., H. & Co., Ford. 
 
 Esmarch. 
 
 Esmarch. 
 
 Esmarch. 
 
 C., H. & Co., Ford. 
 G., H. & Co., Ford. 
 
 Esmarch. 
 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 C.,& & Co., Ford. 
 C.,H.& Co., Ford. 
 C., H. & Co., Ford. 
 C.,H.& Co., Ford. 
 C., H. & Co., Ford. 
 C.,H.& Co., Ford. 
 C.,H.& Co., Ford. 
 Esmarch, modified. 
 C., H. & Co., Ford. 
 
 PAGE 
 
 128 
 128 
 127 
 129 
 131 
 31 
 136 
 138 
 136 
 378 
 425 
 425 
 378 
 434 
 434 
 496 
 496 
 498 
 496 
 
 Gross. 
 
 Humstead & Taylor. 
 
 (7., H. & Co., Ford. 
 
 Stimson. 
 
 Original. 
 
 334 
 478 
 476 
 470 
 470 
 471 
 C., E. & Co., Ford. 476, 477 
 
 C.,H.& Co., Ford. 477 
 Fig. 744. Original. 473 
 
 C.,H.& Co., Ford. 472 
 
 a, H. & Co., Ford. 124 
 
 Gross. 124 
 
 Packard. 123 
 
 Eicord. 125 
 
 Packard. 123 
 
 Gross. 121 
 
 Esmarch. 125 
 
 Annandale. 300 
 Annandale. 301 
 C.,H.& Co., Ford. 
 
 328 
 330 
 327 
 
 C.,H.& Co., Ford. 
 
 C.,H.& Co., Ford. 
 
 C., H. & Co., Ford. 329 
 
 Esmarch. 244 
 
 Esmarch. 244 
 
 Esmarch. 245. 246 
 
 8. Smith. 245 
 
 Fig. 359. Esmarch. 246 
 
 Esmarch. 195 
 
 Esmarch. 193 
 
 Stimson. 196
 
 OPERATIVE SURGERY. 
 
 CHAPTER I. 
 GENERAL CONSIDERATIONS. 
 
 Operative Surgery treats of the manual procedures necessary to 
 properly accomplish the surgical object in view. The operation to be 
 done is the execution of a verdict that is, or should be, based upon 
 surgical principles and laws in a sense comparable to legal proceedings 
 in the Courts of Justice. The surgeon, in most instances, however, 
 holds the threefold position of judge, jury, and executioner. It is, 
 therefore, very essential for the welfare of the patient that he properly 
 interpret the surgical laws and principles relating to the case, in order 
 that the verdict to follow may be just, and its execution cast no oppro- 
 brium upon himself or his profession. To be able to operate under- 
 standingly, requires not only a thorough knowledge of the principles 
 of surgery, but a fair knowledge of the ways and means of accomplish- 
 ing the desired purpose. 
 
 It is not enough to be able to remove in a skillful manner an offend- 
 ing member or disease, but it is equally important for the surgeon to 
 so prepare the patient and himself that no unanticipated complication 
 can occur immediately prior to, during, or subsequent to the opera- 
 tion. 
 
 Regarding the principles of surgery proper, the reader is referred 
 to the many works upon that subject ; since it is not the intention of 
 the author to intrude upon this department of surgery, except in so 
 far as it may be found expedient to apply them to the immediate safety 
 of the patient during and subsequent to the operation. 
 
 Prior to an operation, especially if it be one of any magnitude, it 
 is essential that the following facts be ascertained : 
 
 First. The physical condition of the heart, lungs, kidneys, brain, 
 and great vessels. 
 
 Second. If there be an acute surgical or other complication of the 
 essential organs of the body, joints, serous cavities, etc. 
 
 Third. If the patient be suffering from shock. 
 1
 
 2 OPERATIVE SURGERY. 
 
 Fourth. If the patient be anaemic or scorbutic. If he have syphi- 
 lis, phthisis, epilepsy, diabetes, or be in danger of delirium tremens. 
 
 Fifth. If he be willing and ready for the operation. 
 
 Upon the healthful condition of the heart, lungs, brain, etc., may 
 depend the expediency of giving an anaesthetic, and the choice be- 
 tween them. If the kidneys be diseased, it may be inadvisable to 
 operate upon the urethra or bladder, or even to give an ana3sthetic ; if 
 the great vessels be dilated or atheromatous, much discretion must be 
 employed in its selection and administration. It should not be for- 
 gotten, however, that the mental emotion and physical suffering at- 
 tendant upon an operation, when performed without anaesthesia, may 
 be of greater moment than with its use. 
 
 If the injury demanding an operation be recent, and the patient 
 be suffering from a severe shock, it should be deferred until reaction 
 is established. If the shock be out of proportion to the visible injury, 
 a careful examination of the patient must be made to ascertain its 
 cause. If a complicating injury be discovered, which of itself im- 
 perils the life of the patient, all idea of an immediate operation must 
 be deferred. These thoughtful attentions will lessen the pungency of 
 the oft-repeated satirical expression, " The operation was successful, 
 but the patient succumbed." 
 
 If the patient be already anaemic, or scorbutic, the loss of blood 
 added to the shock of the operation may expose him to greater dangers 
 than if the operation be postponed. Unfortunately, however, in a 
 majority of cases, the conditions calling for operative interference are 
 the prime factors which determine the degree of the blood changes, 
 and will not, of themselves, admit of any delay. 
 
 The existence of syphilis, phthisis, diabetes, etc., exerts a marked 
 influence on the recovery, and their importance must not be under- 
 estimated in connection with this fact. If a patient be addicted to 
 the continuous use of intoxicating beverages, and worse still, if he 
 receive an injury during a prolonged debauch, it seriously complicates 
 his case, not only directly from the previous effects upon his bodily 
 vigor, but from the impending danger of delirium tremens. 
 
 It is not necessary to the successful issue of an operation that the 
 patient be ready and willing ; yet, if such a fortunate combination be 
 present, it will weigh heavily in favor of ultimate success. It is 
 prudent, however, that he should be ready in a legal sense ; that is, 
 that his consent be gained. 
 
 If the operation be a dernier ressort he should be given the oppor- 
 tunity of adjusting his business and spiritual affairs. If they be pre- 
 maturely adjusted if such be possible the knowledge of it, and the 
 quiet of mind resulting therefrom, will become valuable aids toward 
 his recovery. 
 
 ticason of the Year. Autumn and spring are the best seasons for
 
 GENERAL CONSIDERATIONS. 3 
 
 surgical operations. Still, it is not always practicable to render this 
 knowledge available. It is best to avoid, as far as possible, extremes 
 of temperature. Fair weather with an ascending barometer is more 
 propitious than the reverse. 
 
 The time of day should be such as to secure a good light until the 
 completion of the operation. 
 
 The surroundings of the patient subsequent to the operation are 
 to be studied with great care. The sick-room should be commodious 
 and sunny, and, when possible, be on the second floor, with a southern 
 exposure, and with the door and windows so arranged that it can 
 be easily ventilated without exposure to improper air-currents. All 
 sewer-connected wash-basins or other receptacles of waste must be 
 excluded from the room. The plainer the walls and ceilings the 
 better ; for, if the patient become delirious, the outlines and figures 
 of modern decorations may invite and form the basis of exciting 
 illusions. It is better at all times, for hygienic reasons, that the 
 room be as plain as possible, and that all unnecessary articles be re- 
 moved therefrom, especially when it is to be reoccupied as a sick- 
 room. During convalescence, and after all dangers from septic in- 
 fluences are passed, objects of interest may be placed upon the man- 
 tels and walls, which can be varied from time to time to please the 
 fancies of the patient. 
 
 The temperature of the room should be maintained at about 70 
 Fahr. Pure air is quite as essential to a rapid recovery as good food. 
 The room should be thoroughly ventilated at least once each day ; this 
 can be readily done by opening the windows and doors, thereby creat- 
 ing a through-and-through current, at the same time using caution 
 that the patient be protected from direct draughts, and be well cov- 
 ered till the temperature shall have resumed a suitable standard. The 
 presence of flowers and other odoriferous agents are not to be en- 
 couraged in the sick-room, although they may exert a good moral 
 influence, in that they remind the patient of the existence of sympa- 
 thizing friends without. It must always be made as cheerful as pos- 
 sible, consequently all annoyances are to be removed whenever the 
 fancies of the patient indicate their presence. 
 
 Place for an Operation. The office of the surgeon is not a proper 
 place to do operations of any magnitude, or even those requiring the 
 use of an anaesthetic, because the rest and quiet that should follow the 
 former can not be had if the patient be removed ; and, moreover, 
 ansesthesia is often followed by persistent nausea and vomiting, and 
 not infrequently by prolonged noisy delirium. 
 
 Nursing. All who require the services of a nurse should, if possi- 
 ble, secure one who has had considerable experience and is a professional. 
 The well-intended attentions and observations of solicitous friends are 
 often burdensome to the patient, and misguiding to the surgeon, and are
 
 4 OPERATIVE SURGERY. 
 
 as apt to be controlled by their sympathy for the patient, as by the de- 
 sire to consult the express wishes of the medical attendant. It is well 
 to remember, however, that a discreet friend is a far better attendant 
 than a garrulous self-sufficient nurse. The attendant who proffers his 
 views and experience in the sick-chamber, hoping thereby to honestly 
 impress all present with his worth, is as detrimental to the moral at- 
 mosphere of the room, as closed windows and doors are to the physical. 
 
 Preparatory Treatment. This should be directed to the improve- 
 ment of the patient's general condition ; also to directly combating 
 the constitutional diseases which may affect the ultimate result. 
 
 Diet. Precisely the variety and amount of food to be given are 
 matters which must be determined by the requirements of the indi- 
 vidual cases. Milk, eggs, milk-punch, stimulants, etc., are stereo- 
 typed articles, the usefulness of which is well established. They 
 should not, in any instance, if it be possible to avoid it, be substituted 
 by the traditional beef-tea, and more elaborate chemical extracts with 
 which the market is cloyed. 
 
 The requirements necessary to secure favorable results in surgical 
 operations may be divided into the essential and the precautionary. 
 
 The essential requirements consist of such implements, agents, and 
 information as are necessary to the proper performance of an opera- 
 tion, as well as to a due consideration of the result. 
 
 The precautionary are those which are useful in the various emer- 
 gencies that may complicate an operation ; and it is necessary, if they 
 are to be of practical utility, that they should be at hand and be pre- 
 pared for immediate use. 
 
 ESSENTIAL REQUIREMENTS. 
 
 First. A knowledge of the usual result of the operation about to 
 be performed. 
 
 Second. A practical knowledge of the anatomy of the parts in- 
 volved in the operation. 
 
 Third. Anaesthetics ; proper means of administering, and of com- 
 bating their dangers. 
 
 Fourth. The necessary implements and a knowledge of their use. 
 
 Fifth. Suitable trays to hold instruments. 
 
 Sixth. Operating-table, sponges, empty vessels, antiseptic solu- 
 tions, and rubber cloths. 
 
 Seventh. Agents for controlling hemorrhage. 
 
 Eighth. Assistants of suitable number and proficiency. 
 
 Ninth. A patient properly prepared for the procedure. 
 
 Tenth. Proper materials for dressing wounds and a knowledge of 
 their use. 
 
 A knowledge of the usual result of the operation about to be per- 
 formed is one of the chief factors to be employed to determine its
 
 GENERAL CONSIDERATIONS. 5 
 
 propriety ; and is, therefore, entitled to be first considered. This 
 knowledge can be gained from only two sources : First, the personal 
 experience of the operator and of those from whom he may be able to 
 obtain an opinion. Second, the recorded experience of the profession. 
 The first implies the calling of a consultation, which should always 
 be done whenever a doubt exists in the mind of the operator ; such a 
 course not only offers to the patient every available chance, but, in un- 
 fortunate results, frequently serves to sooth the feelings of disappoint- 
 ment experienced by all concerned. If a consultation be not feasible, 
 the surgeon must then rely upon the recordod practical knowledge of 
 the profession, a knowledge which is modified from year to year by the 
 improvement and increase of surgical expedients ; consequently, the 
 statistics of a certain operation must be recent, if they are to be of the 
 greatest practical utility. 
 
 A practical understanding of the anatomy of the part involved in an 
 operation is always essential to the comfort of the operator, and often 
 to the safety of the patient. This knowledge is somewhat difficult to 
 obtain and is always of uncertain tenure. In the case of the general 
 practitioner, it consists chiefly of that which can be gleaned from text- 
 books and anatomical plates : often called " Flat Anatomy," added to 
 the anatomical knowledge retained since graduation. Those who reside 
 in large cities can avail themselves of the ample opportunities afforded, 
 to rehearse important operations. When the dead can be made gen- 
 erally subservient to the welfare of the living, then all medical men can 
 avail themselves of the only means of becoming fully able to surgically 
 "Do unto others as they would that others should do unto them." 
 
 Anaesthetics. The anesthetics in established use are ether, chloro- 
 form, and nitrous oxide or laughing-gas. 
 
 Ether. This is employed far more in surgery than both the oth- 
 ers combined. The chief objections to its use are its pungency, the 
 liability of its causing nausea and vomiting, its inflammability, and 
 production of cerebral excitement. 
 
 Its disagreeable pungency can be lessened, in fact, almost entirely 
 obviated, by allowing a good volume of air to mingle with it during 
 the first moments of its administration. One has but to cover his own 
 face with the well-charged ether-cone in common use, to realize the 
 sense of impending suffocation, which is experienced by the unwary 
 patient, whose struggles to resist it are often violent, and suggestive of 
 the belief that, upon his part, the struggle is for life. Scenes of this 
 kind should always be avoided, more especially when the patient is 
 suffering from any complications which will expose him to an addi- 
 tional peril. The nausea and vomiting following, are not of sufficient 
 importanco to contra-indicate the use of ether, except in such cases in 
 which it would be otherwise objectionable. 
 
 The resultant vomiting is chiefly dangerous, where solid food has
 
 6 OPERATIVE SURGERY. 
 
 been recently taken, in often causing suffocation by its entering the 
 larynx and trachea. 
 
 Inflammability. This is only to be regarded while operating in 
 the presence of artificial light or with the actual cautery. There is, 
 however, but little danger, since the weight of the vapor causes it to 
 create a downward current, thereby tending to remove it from contact 
 with the igniting agent. It is safer, however, for all concerned, to 
 treat it on such occasions as if it were only awaiting the slightest 
 opportunity to assert its power. The cerebral excitement which often 
 precedes complete anaesthesia may be due to an idiosyncrasy, or be aug- 
 mented by surrounding circumstances. The patient should be assured 
 that no harm will attend its administration ; it should be given in a 
 gentle manner, slowly in the beginning, that the mucous membranes 
 may not suffer too great irritation, and complete quietude on the part 
 of all present should be maintained, since talking often serves to excite 
 the inebriated fancies, and forms the basis of disorderly actions. The 
 handling of the part to be operated upon, prior to complete insensi- 
 bility, is a fertile source of annoyance, and is often suggestive to the 
 patient of the impending operation. These are precautions which 
 should be observed durinsr the administration of all anaesthetics. 
 
 FIG. 1. Esmarch's chloroform inhaler. 
 
 Chloroform is more dangerous than ether, and should not be used, 
 unless the contra-indications to the use of ether are exceedingly strong. 
 Although it has a pleasant odor and is devoid of pungency, is less liable to 
 induce vomiting and cerebral excitement, is non-inflammable and more 
 rapid in action than ether, yet these facts weigh but little as against 
 the additional dangers incurred by its use. At the present time its 
 application as an anaesthetic is almost entirely limited to children, and 
 to obstetrical practice. Chloroform can be administered by pouring a 
 few drops on a napkin which is held a short distance from the nose, 
 or by the agency of an inhaler devised by Esmarch (Fig. 1), which
 
 GENERAL CONSIDERATIONS. 7 
 
 consists simply of a properly shaped wire frame-work covered by flan- 
 nel and fastened to the head. 
 
 Nitrous oxide is the most agreeable and least dangerous of the 
 aneesthetics in general use. Its employment is limited to operations 
 of short duration. It can not be classed as a practical anaesthetic, 
 since the expense, the cumbersome apparatus for administration, and 
 its transient effects unfit it for general use. It is, however, often 
 employed where the presence of cardiac or other organic diseases con- 
 tra-indicate the use of ether or chloroform. 
 
 Inhalers. The variety of inhalers for administering anaesthetics is 
 large. It is no part of my intention to discuss the comparative virtues of 
 the various forms ; but rather to select those in common use, and aid the 
 general practitioner residing at a distance from the basis of surgical sup- 
 plies to extemporize at least one which will meet the pressing indications. 
 
 The simplest method of administering any anaesthetic, and the one 
 generally employed with chloroform, is by moistening a towel or nap- 
 kin. In the case of ether, this is very unsatisfactory ; inasmuch as it 
 involves an unnecessary expenditure of time and of ether, and produces 
 a less satisfactory anaesthesia than any other method. There are other 
 pertinent objections to it, but those already mentioned are of suffi- 
 cient weight to dismiss its further consideration. 
 
 The simplest form of an ether cone, or inhaler, is the one that has 
 been for a long time in common use in many 
 of the hospitals of this city (Fig. 2). 
 
 The method of its construction is simple, 
 and the materials employed are always accessi- 
 ble. A sheet of paper of strong texture, or, 
 three or four layers of an ordinary newspaper, 
 two feet in length and eighteen or twenty 
 inches in width, together with a strong piece 
 of cloth, the dimensions of which shall exceed 
 those of the paper two or three inches, and a FlG ' 2 '~ C ^ t n h e and P&per 
 dozen ordinary pins, are all that is required to 
 
 construct it. Place the cloth a towel is usually employed and the 
 paper on a table, with the paper uppermost ; fold them in the middle of 
 their long diameter, which will bring the cloth on the outer surfaces and 
 the paper within. Then fold them in the short diameter, the length of 
 the fold corresponding to the distance from the symphysis mentis to 
 the root of the nose of the patient ; when thus folded, pin the outer 
 and inner extremities firmly through the whole texture of the sides, 
 using care that the pins be so placed that they will not stick in the 
 patient's face, or in the hands of the administrator of the anaesthetic. 
 Several pins are now to be passed through all the textures in various 
 situations to hold them firmly together. One end of this tube must 
 now be closed, which is easily and quickly accomplished by turning
 
 '6 
 
 OPERATIVE SURGERY, 
 
 inward its borders, and securely pinning them to each other. It is 
 better to close the end corresponding to the free extremities of the 
 material, thereby giving a firmer basis to the cone. Into the top of 
 the cone is then crowded a good-sized sponge, or a piece of coarse- 
 textured cloth, always observing that it be beyond the reach of the 
 nose and face of the patient. Absorbent cotton or several layers of 
 muslin may be interposed between the surfaces of the upper end, in- 
 stead of their being closed by turning and pinning as just described, 
 when, if this material be now confined in position by means of pins, 
 and the end covered with a layer of thin gauze, the ether can then be 
 poured upon the interposed material and administered without remov- 
 ing the cone from the face. It likewise admits the requisite amount 
 of air. The advantages which this simple inhaler possess over the per- 
 manent and more expensive ones are quite numerous. It can not be 
 damaged by the patient, nor will the face be bruised by its borders 
 during his struggles ; it is a temporary affair, and therefore need never 
 be used a second time a fact which is obviously of considerable im- 
 portance in a fastidious and hygienic sense. It does not, however, 
 admit of the easy regulation of the amount of ether to be given, nor 
 the amount of air to be admitted ; it is also liable, unless care be used 
 in replenishing it with ether, to permit the anaesthetic to flow into the 
 eyes and upon the face of the patient ; in addition, the air-space is 
 almost invariably contracted during the struggles of the patient ; yet 
 these are objections which can be easily surmounted by a requisite 
 amount of caution. The amount of ether required with this appara- 
 tus is less than if a napkin be used alone, while it exceeds that em- 
 ployed in the more perfect inhalers. 
 
 Attis' Inhaler, which consists of a fenestrated metallic frame-work 
 
 FIGS. 3, 4. Allis' inhaler. 
 
 for the support of cloth partitions, surrounded by an adjustable leather 
 or rubber covering, is simple, efficient, portable, and can be quite 
 easily cleansed (Figs. 3 and 4). Its advantages, briefly stated, are the
 
 GENERAL CONSIDERATIONS. 
 
 following : It allows a free admission of air from above, which becomes 
 saturated with ether ; the evaporating surface is great, causing thereby 
 a rapid vaporization, which hastens anaesthesia and saves ether ; the 
 ether can be replenished through the top, 
 which obviates the necessity of removing 
 the inhaler and interrupting the adminis- 
 tration. The cloth partitions can be read- 
 ily changed whenever propriety and clean- 
 liness demand it. 
 
 The inhalers of Lente, Squibb, Noyes, 
 and others, are all serviceable, and whoever 
 possesses either of them can, so far as the 
 apparatus is concerned, administer ether 
 with safety. It is not necessary to the safe- 
 ty of the patient that any one of them be 
 employed. It is, however, necessary to the 
 safety of the patient, no matter which one Fl - 5Lente's modified inhaler, 
 be used, that the administrator of the anaesthetic shall rely more upon 
 his knowledge of the principles governing its administration than upon 
 the mechanism of the apparatus. With a proper knowledge of these prin- 
 ciples, it matters but little whether one or another form of inhaler be used. 
 Lents' s Modified Inhaler (Fig. 5). When this is to be used, either 
 a piece of old muslin, lint, or a suitable amount of cotton batting can 
 
 be confined in 
 position at the 
 top by a wire or 
 whalebone fas- 
 tening. The 
 amount of air 
 admitted can be 
 easily regulated 
 by the adjust- 
 ment of the stopper at the top, and the 
 ether can be poured in at this situation if it 
 be undesirable to remove the apparatus from 
 the face. 
 
 Clover's Inhaler (Fig. 6) consists of a re- 
 ceptacle holding two ounces of ether a 
 mouth-piece cushioned with inflated rubber 
 fitting closely over the patient's nose and 
 mouth, and connected with the ether recep- 
 tacle in such a manner that the amount of 
 ether inhaled may be increased or diminished 
 at will, and a rubber bag which receives the expired air charged with 
 ether vapor. 
 
 FIG. 6. Clover's inhaler.
 
 10 OPERATIVE SURGERY. 
 
 The advantages claimed for this inhaler are : the patient can be 
 anaesthetized in a very short time ; the depression of the system is not 
 so great ; the patient recovers consciousness more quickly and does not 
 feel the effects of ether so long as with the plain ether inhalers. The 
 amount of ether to be inhaled is graduated by turning the receptacle : 
 when turned on 0, no ether is inhaled ; when at 1, f the usual 
 amount ; at 2, the usual amount ; at 3f, and at F the full amount is 
 inhaled. Thus the quantity of ether administered can be increased or 
 diminished during the operation. 
 
 Another important point is, that there is so little ether consumed 
 
 that the inhaler is 
 very valuable for use 
 in hospitals and in 
 the field. 
 
 Squill's Inhaler 
 (Fig. 7). This con- 
 sists of an hour-glass- 
 shaped muslin bag, 
 
 one end of which is 
 TIG. 7. Squibb s inhaler. 
 
 cut off to fit the face 
 
 of the patient. The narrow portion is made to receive a tin tube sev- 
 eral inches in length and two in diameter ; the round end serves the 
 purpose of an air-chamber. When the bag is to be used, it should be 
 wetted with water and thoroughly squeezed, to render it only partially 
 pervious to the passage of air or other vapor. Into the tin tube a 
 piece of flannel and blotting-paper rolled together, each about six 
 inches wide and eighteen inches long, are thrust, after which they are 
 saturated with ether ; or it may be done before their introduction. 
 The open end of the apparatus is then placed over the mouth and 
 nose of the patient, and the administration commences.. One to two 
 and a half ounces is quite enough to properly anaesthetize the patient. 
 
 Noyes 1 Inhaler (Fig. 8). This apparatus is simple of construction. 
 It consists of a flexible air-chamber at one end and a face-piece at the 
 other. Between the two is a small tin chamber to contain the ether. 
 The bag or air-chamber is perforated by a small hole, that allows the 
 entrance of a sufficient amount of air, which enters the lungs together 
 with the ether at each effort of inspiration. The amount of ether 
 used with this, is about the same as with the preceding. 
 
 The amount of ether required to produce insensibility depends upon 
 several conditions, the most important of which are, the susceptibility 
 of the patient, the manner of administering, and the purity of the 
 anaesthetic. Some persons can be completely anaesthetized by an ounce, 
 and even less, if it be not wasted ; on the other hand, those are occa- 
 sionally met with who " take ether badly," and can not be rendered 
 quiet unless a large amount be given ; rarely, a case is encountered
 
 GENERAL CONSIDERATIONS. 
 
 which will not yield to its influence, and the surgeon is forced to 
 desist, from fear of killing the patient. It is not prudent to deter- 
 mine in advance the definite amount that will be used, except pos- 
 
 \ 
 
 FIG. 8. Noyes' inhaler. 
 
 sibly in some peculiar cases. Anaesthesia is never to be attempted 
 unless the surgeon can be certain he has a sufficient amount to com- 
 plete the operation, for nothing can be more humiliating than to be 
 obliged to discontinue an operation for the purpose of procuring ad- 
 ditional ether. It is not prudent to begin an operation that requires 
 much time and care, unless at least one pound of ether be at hand. 
 
 Purity of the Ancesthetic. It is important that the anaesthetic be 
 pure, in order that the amount taken may be suitably judged, and a 
 proper interpretation placed upon the effect produced. The anaes- 
 thetics of Squibb, of Brooklyn, are generally considered to be of a 
 superior quality. 
 
 Dangers from the Use of Ether. The dangers attending the use 
 of an anaesthetic may be reduced to a minimum, provided proper at- 
 tention be given to the physical conditions recognized as contra-indi- 
 cating or requiring caution in their use, together with a display of 
 ordinary care in administering. Before administering it, the condition 
 of the heart, lungs, brain, kidneys, vessels, etc., should be ascertained, 
 even though there be no apparent evidences of disease. If they have 
 undergone organic changes, or, if the patient have laryngeal obstruc- 
 tion from any cause, be suffering from bronchitis, or be pregnant, the 
 greatest caution must be employed in the administration, even if it 
 be administered at all. The degree of the disease, and the condition of 
 the patient dependent thereon, together with the necessity of an im- 
 mediate operation, and its severity, must determine the advisability 
 of an anaesthetic. If the patient have advanced heart and kidney 
 disease, phthisis, or aneurism, it is better to use nitrous oxide ; 
 chloroform, even, has been used under such circumstances instead 
 of ether, on account of its causing less excitement and vomiting.
 
 12 OPERATIVE SURGERY. 
 
 The danger from a full stomach is great, especially if the ingesta be 
 solid ; since, if vomiting occur, the food may be sucked into the 
 larynx and trachea, causing death by suffocation ; moreover, nausea 
 and vomiting are more frequent and persistent when the stomach is 
 partially filled with food. It is impracticable to lay down all the 
 important relations existing between the use of an anaesthetic and 
 the various complications that may exist as centra-indications. The 
 surgeon must be largely controlled by the circumstances surrounding 
 each individual case. If it be determined to administer ether or chloro- 
 form to a patient suffering from a debilitated heart, the latter's action 
 must be strengthened by the administration of digitalis some days 
 prior to, as well as by stimulants during the operation. If the pa- 
 tient have laryngeal obstruction, from spasm of the glottis or other 
 causes, the pungency of the ether, and spasm of the respiratory mus- 
 cles, when added to the already lessened area of the respiratory chink, 
 and the diminished aeration of the blood resulting therefrom, may be 
 often sufficient to produce rapid unconsciousness and impending death 
 from asphyxia. In my opinion, chloroform is the better anaesthetic 
 under such circumstances. 
 
 How to Prepare a Patient for Anaesthesia. First. Inform your- 
 self of the state of the brain, heart, lungs, kidneys, vessels, etc. ; if 
 disease be found, inform the patient or the friends of the additional 
 dangers incurred. 
 
 Second. Count the pulse and respiration, noting the character of 
 each, and making due allowance for the excitement dependent upon 
 surrounding circumstances. These observations will be far more valu- 
 able if they have been taken some time prior to the immediate opera- 
 tion. 
 
 Third. See that no solid food has been taken for at least six to 
 eight hours before ; if so, evacuate the stomach by means of a simple 
 and rapid emetic. The practical way of having the stomach in a 
 proper condition is to omit the meal preceding the operation. If the 
 time be too long for this, a glass or two of milk five or six hours before 
 will meet the indications. 
 
 Fourth. Remove all false teeth from the mouth, or whatever else 
 might fall into the larynx. 
 
 Fifth. Loosen all constricting bands which surround the abdomen, 
 chest, and throat. 
 
 Sixth. Cause the evacuation of the contents of the bladder and 
 rectum ; this will often prevent the soiling of the clothes and the 
 patient. 
 
 Seventh. Place the patient upon the back, with the head and 
 shoulders slightly raised ; neck not bent. 
 
 Eighth. If the patient have a beard, wet it to prevent the rapid 
 escape of the ether through it.
 
 GENERAL CONSIDERATIONS. 
 
 13 
 
 Ninth. Adjust windows and doors to admit fresh air, without ex- 
 posing the patient to a draught. 
 
 Tenth. Disarm the patient of all fears of danger attending the use 
 of the anaesthetic. 
 
 The assistant who is to administer the anaesthetic should have at 
 his convenience a basin, a towel, and a tenaculum or forceps. The 
 first for the reception of the dejections from the stomach ; the towel 
 to remove the saliva, etc., from the mouth and face ; the tenaculum 
 or forceps, to pull forward the tongue if it fall backward over the 
 glottis (Fig. 9). 
 
 It is recommended, and with much force, to administer, hypo- 
 
 FIG. 9. Drawing the tongue forward. 
 
 dermically or otherwise, a dose of morphia an hour or so before anaes- 
 thesia is to be commenced. It quiets the nervous excitement of the 
 patient, reduces the amount of ether otherwise necessary, and prolongs 
 its effect, lessens the tendency to nausea and vomiting, and diminishes 
 shock. Moderate inebriation has been produced immediately in ad- 
 vance of an operation by giving brandy or whisky, and for substan- 
 tially the same reasons. 
 
 Method of Administering Ether. This will depend somewhat upon 
 the variety of inhaler used ; if it be of ordinary construction, com- 
 mence by pouring a small amount (an ounce or so) into or upon the 
 inhaler, and adjust it so that a good volume of air shall mingle with 
 the ether for the first few moments of the administration. After the 
 sense of pungency has somewhat subsided, the patient should be told 
 to "cough," "breathe deeply," at the same time the fresh air is to 
 be quite rapidly excluded. The patient soon becomes oblivious, and 
 may be fully anaesthetized without further trouble. This is recog- 
 nized by the insensibility of the conjunctiva, or, what is better, a re- 
 laxed muscular system, which is ascertained by noting the absence of 
 any resistance to flexing or extending the extremities. If an extremity
 
 OPERATIVE SURGERY. 
 
 be raised from the bed, it will fall directly downward and lie motion- 
 less. Stertorous breathing is likewise a concomitant of complete anses- 
 thcsia. More often, however, the patient will be seen to pass through 
 the three distinct stages of anassthesia, which will vary in their length 
 and manifestations, according to his peculiarities. The attention of the 
 administrator of the anaesthetic should always be directed to the char- 
 acter of the respiration and pulse, the color of the surface and its tem- 
 perature. The respiration is often temporarily arrested or impeded by 
 the tonic stage, causing marked cyanosis. This is quite readily relieved 
 by making sudden and forcible pressure in the epigastrium, or slap- 
 ping the chest with the naked hand or a wet towel. The respiration 
 may be obstructed or prevented, at any period of anaesthesia, by for- 
 eign bodies in the larynx and trachea, such as false teeth, vomited 
 matter, etc. In complications of this character, the obstructing agent 
 must be removed immediately or death will ensue, unless tracheotomy 
 be performed. The glottis may become stopped by the falling back- 
 ward of the tongue ; this usually occurs during the stage of complete 
 anaesthesia, and is to be instantly remedied by drawing the tongue 
 forward by the aid of a tenaculum, or dry towel, or forceps. 
 
 If the jaw be pressed forward during the administration of the 
 anaesthetic by the administrator (Fig. 10), the muscular attachments 
 
 of the base of the 
 tongue are sepa- 
 rated, and its 
 base depressed 
 and drawn for- 
 ward. 
 
 The treat- 
 ment for the re- 
 lief of poison- 
 ing, due either 
 to an overdose 
 of ether or 
 chloroform, is 
 substantially 
 the same. Suc- 
 cessful treat- 
 ment will depend not only upon the presence of mind of the sur- 
 geon, but upon the precautionary preparations which have been made 
 for such a contingency, as well as the rapidity and force with which 
 the remedies are applied. 
 
 The anaesthetic must be stopped at once ; the head lowered and 
 the tongue pulled forward ; windows and doors opened to admit fresh 
 air ; artificial respiration (Figs. 11 and 12) ; flagellation of the face and 
 chest by towels wet with cold water ; hypodermic injections of brandy, 
 
 FIG. 10. Pressing the jaw forward.
 
 GENERAL CONSIDERATIONS. 15 
 
 whisky, or ammonia ; inhalation of nitrite of amyl, and the use of elec- 
 tricity employed. It is not intended that these remedies shall be used 
 in the order mentioned; but the surgeon and his assistants will find 
 their time and thoughts occupied in carrying them into execution 
 s'ach of them as may admit of instant application. Under no con^ 
 
 FIG. 11. Artificial respiration first movement. 
 
 sideration must the efforts of resuscitation be allowed to flag, or 
 be stopped, until every hope of saving the life has some time since 
 passed.* 
 
 Intestinal Etherization. Since the appearance in the " Lyon medi- 
 cal" of March 30, 1884, of M. Molliere's article, calling the attention 
 of the profession to the feasibility of etherization by the rectum and 
 setting forth the advantages to be gained thereby, not a few promi- 
 nent members of the profession have made trial of it. This mode 
 of administration is a simple one. The ether is put into a bottle of 
 suitable size holding four or five ounces with which a rubber tube 
 of convenient length, terminating in a nozzle, is connected. The bot- 
 tle containing the ether is placed in water of a temperature of 120 to 
 
 * In performing artificial respiration the movements should be done slowly and with a 
 regularity similar to the normal act of breathing. To move the arms upward and down- 
 'vard with the rapidity of a pump-handle is irrational and inoperative ; yet, under the in- 
 fluence of exciting surroundings, such attempts at resuscitation are not infrequently 
 made.
 
 16 
 
 OPERATIVE SURGERY. 
 
 140 Fahr., and the nozzle inserted into the rectum of the patient. 
 The ether vapor resulting from the ebullition passes through the tube 
 into the rectum and is absorbed by the intestinal mucous membrane. 
 An apparatus that is especially devised for the rectal administration 
 (Fig. 13) simplifies the procedure some"what. The advantages claimed 
 for this method by Mollie're are not, as yet, verified by American sur- 
 geons. At the present time, therefore, this method can not be said to 
 equal the older one, except, pe.rhaps, for operations about the face, or 
 when ether is contra-indicated on account of the irritation it causes 
 the mucous membranes of the respiratory apparatus, especially if they 
 be diseased. And, even under these conditions, the number of fatal 
 cases already reported as due to its use are evidence, as yet, of the 
 greater safety of the old plan. 
 
 It is not unlikely that it may prove serviceable in intestinal obstruc- 
 
 FIG. 12. Artificial respiration second movement. 
 
 tion due to invagination, inasmuch as the distention and relaxation of 
 the intestinal walls which it causes may overcome their abnormal rela- 
 tions. 
 
 Local Anaesthesia. Although there are numerous agents in use 
 for this purpose, ether possesses the greatest number of practical ad- 
 vantages. The following instrument (Fig. 14) is the one commonly 
 used for purposes of local anassthesia, and is employed in those minor
 
 GENERAL CONSIDERATIONS. 
 
 17 
 
 operations which can be quickly done. The pain that follows the re- 
 turn of sensibility to the benumbed parts is often more severe and pro- 
 longed than the imme- 
 diate suffering from the 
 operation without its 
 use. The tissues should 
 not be frozen, but be- 
 numbed ; since to freeze 
 them increases the pain 
 and retards repair. 
 
 Cocaine. Solutions 
 of this important drug 
 can be employed both 
 hypodermically and en- 
 dermically in many mi- 
 nor surgical operations. 
 Ten to twenty drops of 
 a five-per-cent. solution 
 injected at the site of 
 the operation will usual- 
 ly, in a few minutes, 
 render the part insensi- 
 ble to pain. It can be 
 applied to mucous sur- 
 faces, like those of the 
 nose and pharynx, by 
 
 means of a spray. It is sometimes employed in the urethra to obvi- 
 ate the pain and irritation incident to the passage of instruments 
 into this canal. It is proper for me to state in this connection, how- 
 ever, that it 
 should never be 
 employed in 
 any instance 
 when the sen- 
 sations of the 
 patient are nec- 
 essary to guide 
 the operator in 
 his action. 
 
 There is reason to believe that even a small dose may. in rare in- 
 stances, cause alarming symptoms of depression ; still, it seems to 
 be proved that its unfavorable constitutional effect may be obviated, 
 while its local effect is increased and prolonged, by obstructing the 
 return circulation from the part to which it has been applied. 
 2 
 
 FIG. 13. Apparatus for intestinal etherization. 
 
 FIG. 14. Richardson's atomizer.
 
 18 
 
 OPERATIVE SURGERY. 
 
 FIG. 
 
 15. Scalpels 
 touries. 
 
 INSTRUMENTS NECESSARY FOR THE PERFORMANCE OF OPERATIONS. 
 
 The instruments necessary for the performance of an operation 
 must, of necessity, be regulated by its magnitude and nature. They 
 can, however, for the sake of brevity, be di- 
 vided into those in general use, and, those for 
 special purposes. The ones in general use in- 
 clude scalpels and bistouries of various forms 
 (Fig. 15), thumb-forceps, grooved directors, 
 and scissors. Those for special purposes are 
 used in performing the operations which, in 
 most instances, caused their creation. These 
 will be considered in connection with the 
 operation to which they are particularly 
 adapted. 
 
 Method of Holding the Scalpel. Three po- 
 sitions are commonly recommended, each of 
 which is subdivided into two. The basis of 
 the positions rests upon the manner of hold- 
 ing the ordinary table-knife, the pen, and the 
 
 and Bis- yiolill-bow. 
 
 Figs. 16 and 17 represent the subdivisions 
 of the first position ; they indicate that force or firmness are desired. 
 Figs. 18 and 19 represent the subdivisions of the second position. These 
 are taken when quick, delicate, and precise movements are required. 
 Figs. 20 and 21 are the subdivisions of the third position, and are em- 
 ployed when caution is used in conjunction with delicacy in cutting. 
 
 These positions are more essential to graceful than to successful 
 operating. 
 
 Thumb - Forceps (Fig. 22) are 
 used in connection with the scalpel 
 or scissors. They are employed to 
 pick up tissues like the fascia, etc., 
 which are to be incised at the point 
 grasped for the purpose of inserting 
 the grooved director. The scalpel 
 or bistoury should be held at near- 
 ly a right angle to the forceps when 
 the incision is made, especially when 
 important structures lie immediate- 
 ly beneath (Fig. 23). 
 
 The Grooved Director (Fig. 24) is used to raise the tissues which 
 are to be divided with caution. It should be five or six inches in 
 length, depending upon the length of the incision and the depth of 
 the wound into which it is to be inserted ; flexible, with a broad ex- 
 
 FIG. 16.
 
 GENERAL CONSIDERATIONS. 
 
 19 
 
 tremity to grasp, and a pocket at the end of the groove to arrest the 
 point of the knife or scissors. It should not be pushed beyond the 
 
 FIG. 17. 
 
 extremities of the external incision, because of the danger of making 
 pockets in the soft parts, which will impede drainage. The tissues 
 
 ^ : tt i^r 
 
 ^^^|ii!. : : : iS \ 
 
 FIG. 18. 
 
 FIG. 19. 
 
 raised upon the director must not be divided beyond the angles of the 
 external incision. Care should be taken when the director is passed 
 between a serous membrane and its superimposed fascia that the mem- 
 
 Fio. 20. 
 
 FIG. 21.
 
 20 
 
 OPERATIVE SURGERY. 
 
 brane does not fold over the advancing extremity, thereby causing it 
 to be punctured or divided by the knife or scissors. 
 
 The Scissors. They are used as a substitute for the scalpel in in- 
 cisions of great depth, combined with limited space and a necessity 
 
 FIG. 22. Thumb forceps. 
 
 for caution. Less hemorrhage follows their use than from the scalpel, 
 owing to the crushing nature of their force. They should be more or 
 
 FIG. 23. Nicking fascia. 
 
 less angular, to accommodate them to the depth of the operation- 
 wound (Figs. 25 and 26). 
 
 Incisions. The varieties of incisions are numerous, and are named 
 from the shape which they take. The outlines of incisions 1 are con- 
 trolled very largely by the underlying anatomy, the desire to secure 
 good drainage, and to avoid disfiguring the patient. There is a 
 greater danger of making an incision too short than too long ; and 
 of the two, the former is the greater evil. A long, deep, clean-cut 
 
 FIG. 24. Grooved director. 
 
 incision will drain better and heal more quickly than a short deep one 
 bounded by tissues which have been disturbed by the efforts to accom- 
 plish a definite purpose within a too limited space. The various 
 forms of incisions will appear in connection with the operations to 
 which they are applicable.
 
 GENERAL CONSIDERATIONS. 
 
 21 
 
 FIG. 25. Curved scissors. 
 
 Instruments should be Plain. All instruments associated with 
 surgery should, when practicable, be constructed in a plain and sub- 
 stantial manner. The handles and shanks of the knives should be 
 smooth and closely 
 fitted, or, what is bet- 
 ter, the entire instru- 
 ment should be made 
 of metal and be highly 
 polished. The inequal- 
 ities of instruments FlQ 2 6. Straight probe-pointed scissors, 
 tend to catch impuri- 
 ties, and should never be tolerated when they but serve to embellish 
 the implement. 
 
 Receptacle for Instruments. It is better that all instruments be 
 made aseptic before they are employed ; for this purpose, a shallow 
 tray of suitable dimensions should be filled with an antiseptic fluid, 
 and the instruments immersed therein for an hour or two before 
 they are used. This tray, with the contents, should be placed at a 
 convenient distance, in order that the instruments may be taken di- 
 rectly from it when needed. If they are to be again required, they 
 should be returned to the tray as soon as used. 
 
 Operating-Table. The patient should always be placed upon a 
 regular operating-table, or an ordinary table of sufficient height to suit 
 the convenience of the surgeon. To operate upon a bed or lounge, as 
 is often done, not only cripples the resources of the surgeon, but robs 
 him, too often, of a suitable light, to say nothing of the soiling of the 
 bedding. There are numerous styles of operating-tables, many of which 
 are of very ingenious construction ; they are, however, much better 
 suited for hospital than private practice. The ordinary table, covered 
 by an old quilt and rubber cloth, will meet all common indications. 
 
 Empty Vessels. There should always be a good supply of empty 
 pails and basins to receive the waste- water, soiled linen, amputated 
 parts, etc. At least one empty basin should be provided to receive the 
 soiled sponges, otherwise they may fall upon the floor or table, and be 
 stepped upon or lost. Two pails of antiseptic water, one hot and one
 
 22 OPERATIVE SURGERY. 
 
 cold, should be provided to wash the sponges during, and the hands 
 and instruments after the operation ; for the latter purpose hot water 
 is better. 
 
 Clean Towels and Old Linen. An abundance of these should be at 
 hand, and for obvious reasons. However, if the operation is being con- 
 ducted on strict antiseptic principles, they must not be used until 
 after the wound is dressed ; unless they be, at first, saturated with 
 an antiseptic solution. 
 
 Antiseptic Solutions must be abundantly provided and used in 
 the place of water, by all who are obliged to handle the undressed 
 wound or the instruments which are to be brought in contact with it. 
 Carbolic acid is more often used than all the others combined. It is 
 cheap, efficient, and easily obtained. Two solutions are commonly 
 employed : one called the weaker, and the other the stronger solution. 
 The latter can be made in the following manner : 
 
 Carbolic-acid crystals 1 part. 
 
 Alcohol 1 " 
 
 Water 20 parts. 
 
 This is employed to wash the wound before and subsequent to an 
 operation. It is used for the spray, and to purify all the instruments ; 
 it may be used to wash the hands prior to operating, but this strength 
 is objectionable, since it often benumbs the keen sense of touch and 
 otherwise causes them to feel disagreeable. The weaker solution is 
 made by taking 
 
 Carbolic-acid crystals 1 part. 
 
 Alcohol . 1 " 
 
 Water 40 parts. 
 
 This is employed for the general purpose of cleanliness, and has, 
 therefore, a somewhat more extended range of usefulness. 
 
 Carbolic acid is often combined with oleaginous substances in the 
 proportions of one of the acid to five or ten of the substance, although 
 it is thought that the antiseptic power of the acid is lessened if not 
 entirely prevented, by all such combinations. Ligatures may be soaked 
 in these preparations, and lint be saturated with them and applied 
 directly to the raw surfaces. The objections- to carbolic acid are its 
 offensive odor, and liability to produce poisoning. The former can be 
 tolerated, while the latter can be prevented in nearly all instances by 
 not allowing the strong solution to become confined within the tis- 
 sues. Solutions of the chloride of zinc (1-15), iodine (1-500), sulpho- 
 carbolate of zinc (1-80), bichloride of mercury (1-2,000 to 1-10,000), 
 biniodide of mercury (1-2,000), a saturated solution of boracic acid, 
 sulphurous acid, pure or diluted (1-2), or a saturated solution of 
 iodoform and ether, are employed as washes, or modified applications 
 for wounded surfaces. The objectionable odor of iodoform may be 
 masked by adding to it one tenth of its weight of thymol, Tonka
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 23 
 
 bean, or balsam of Peru. The solutions of the bichloride of mercury 
 (1-2,000 to 1-10,000) are deserving of especial consideration, inasmuch 
 as they bid fair to supplant the carbolic-acid solutions as antiseptic 
 agents ; like the former, they are cheap, accessible, and efficient ; un- 
 like carbolic-acid solutions, however, they are inoffensive, more in- 
 nocuous, and do not benumb the sensations of the operator. They 
 should be freshly prepared before using, and their tendency to chemi- 
 cal transformation into the chloride, by exposure, counteracted by the 
 addition of a small amount of common salt. The liability of mercurial 
 poisoning from their use during an operation is of little practical im- 
 portance. It is not advisable, however, to employ them for the pur- 
 pose of the daily cleansing of wounds of larger size, since their con- 
 stitutional effects may be produced. For this purpose they should not 
 be used of tener than twice per week, and then they should be carefully 
 drained from the wound cavity and the patient be rigidly scrutinized 
 to detect the first manifestation of their constitutional effects. Peroxide 
 of hydrogen is an efficient fluid for antiseptic purposes, but its use is 
 not practicable on account of the difficulty of obtaining it. 
 
 Sponges. The variety known as " surgeons' sponges " are the best, 
 although expensive. The larger sponges of a proper texture can be 
 cut into pieces of a suitable size, thoroughly cleansed and disinfected, 
 when they will answer all purposes. No sponge of whatever quality 
 should be used till it has been thoroughly deprived of all foreign mat- 
 ters and disinfected. It is a good practice to select and cleanse a num- 
 ber of sponges, and keep them in a closed jar containing a strong solu- 
 tion of carbolic acid or other disinfectant until needed. They should 
 not be repeatedly used ; it is far more consistent with careful surgery 
 to get a new supply in each individual case than to use them, even a 
 second time, under the most favorable circumstances. 
 
 CHAPTER II. 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 The agents that arrest hemorrhage are multifarious and suited to 
 all of its phases. They may be divided into the natural and artificial, 
 each of which may be subdivided into the temporary and permanent. 
 A natural agent is one interposed by nature ; one which results as a 
 natural consequence from an interference with the inherent tenden- 
 cies or endowments of the vessels and blood. The principal tempo- 
 rary natural hemostatics consist of the contraction and retraction of
 
 24 OPERATIVE SURGERY. 
 
 the inner coat of a divided or ligatured vessel, accompanied by the for- 
 mation of a blood-clot within it. The contraction and retraction, to be 
 perfect, require that the coats of the vessels be not diseased, and that 
 they be properly constricted by the ligature or other force. The forma- 
 tion of the internal clot requires that a suitable distance, depending up- 
 on the size of the vessel, shall exist between the ligature and the collat- 
 eral branches ; also, that the coats of the vessel be not greatly diseased. 
 These points are of importance in determining the site and feasi- 
 bility of an operation. The permanent natural agent is the organiza- 
 tion and contraction of the clot, thereby completely occluding the 
 artery ; this result will depend largely upon the condition of the coats 
 of the vessel, and has a very important bearing upon the possibility of 
 that much to be dreaded sequel to an operation, secondary hemorrhage. 
 Artificial Hemostatics. This class is always temporary. The fol- 
 lowing are the well-recognized ones in constant use : Cold, styptics, 
 posture of the injured part, bandages of various forms, digital and in- 
 strumental pressure ; also, pressure by a simple, or a graduated com- 
 press, acupressure, torsion, forceps, serrefines, compressors, cautery, 
 etc. ; finally, and best of all, the ligature. 
 
 Styptics, such as liquor ferri subsulphatis, tannin, etc., are fre- 
 quently employed to check oozing ; hot water is especially indicated 
 when the patient is debilitated or suffering from severe shocks. 
 Liquor ferri subsulphatis is decidedly objectionable where union by 
 first intention is desired, but is very serviceable when an antiseptic 
 styptic is required. 
 
 Position. Elevation or flexion of a limb serves to impede its cir- 
 culation, and thereby lessens the tendency to hemorrhage. The reverse 
 
 of this principle directs us 
 to lower the head in pros- 
 tration from loss of blood. 
 Bandages. These 
 may be divided into two 
 distinct classes, the ine- 
 lastic and elastic. The 
 inelastic, or ordinary 
 roller, is used to check 
 capillary and venous ooz- 
 ing by applying it firmly 
 over the bleeding part. 
 
 FIG. 27,-Eiastic bandage. The Elastic Bandage- 
 
 of which Esmarch is the 
 projector is made of elastic webbing the width of an ordinary roller, 
 and of sufficient length to meet the requirements (Fig. 27). It is to 
 be applied firmly in a spiral manner to the limb, from the distal ex- 
 tremity upward (Fig. 28) to a good distance above the point to be oper-
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 25 
 
 FIG. 28. Elastic bandage 
 applied. 
 
 ated upon, where it is supplemented by a rub- 
 ber cord, or strap, passed firmly around the 
 limb at this point, and fastened by a clasp or 
 hook adapted to that special purpose (Figs. 29, 
 30, and 31). The bandage is then removed by 
 unwinding it from above downward. The 
 clamp devised by Langenbeck (Fig. 32) can 
 be applied to the upper turns of the bandage, 
 or, the upper turns can be tied together by a 
 piece of an ordinary roller bandage, after 
 which the rubber bandage is removed from be- 
 low upward. The independent cord or strap 
 can be fastened in a similar manner. After 
 the removal of the bandages the limb will have 
 a cadaverous aspect, being entirely devoid of 
 blood, and the necessary operation can be per- 
 formed and the wound dressed even without 
 the least hemorrhage. This, like 
 many other useful agents, has objec- 
 tionable features. Its removal is often 
 
 followed by a large amount of persistent oozing ; its applica- 
 tion may force into the circulation deleterious elements which 
 
 will form the basis of disease ; 
 it has temporarily paralyzed 
 the part to which it was ap- 
 plied, and caused transient dis- 
 turbances of the general circu- 
 lation. These latter are not, 
 however, sufficiently import- 
 ant to centra-indicate its use. 
 The tendency to severe oozing 
 is an objection which must 
 stand against it ; but its power 
 to force improper products 
 from diseased or injured parts 
 into the general circulation can 
 be obviated by omitting its ap- 
 plication to those parts ; that 
 is, by raising the limb and 
 holding it till well depleted by 
 the force of gravity, then ap- 
 plying it to the sound parts, 
 above the seat of injury or dis- 
 ease, and using the rubber band 
 FIG. 29. Nicaise's compression band. as before. The elastic ban-
 
 OPERATIVE SURGERY. 
 
 FIG. 30. Foulis* fastening 
 position. 
 
 dages can be made to serve another and very important purpose, that 
 of forcing into the circulation of the trunk the blood in the extremi- 
 ties in cases of extreme 
 prostration from hemor- 
 rhage. Martin's bandage 
 (Fig. 33) is simply a rub- 
 ber roller, and is used to 
 meet the same indications 
 as the former. It can 
 be, however, more readily 
 cleaned than a webbed 
 one, and in this particular 
 is preferable to it. Solid 
 rubber rings of a suitable 
 size to pass firmly over 
 an extremity have been 
 used as a substitute for 
 the rubber bandage. In 
 connection with the dig- 
 its, and even the foot, 
 hand, and wrist, they act 
 
 quite well, but have not as yet gained the support of 
 the profession. 
 
 Compresses. Two kinds of compresses are in com- 
 mon use the simple and the graduated. The former 
 consists of several thicknesses of cloth, or other suita- 
 ble material, folded into small dimensions and placed 
 over the vessel, or upon the part which it is desired to 
 compress, and held in position by a tightly drawn 
 bandage or strip of adhesive plaster. 
 
 The graduated compress may be of the form of an inverted pyramid 
 or cone, and oblong (Figs. 34, 35, and 36). Its apex should be firm 
 
 and unyielding, to 
 give an equal and 
 constant pressure. 
 The whole arrange- 
 ment can be made of 
 superimposed layers 
 of cloth, antiseptic 
 gauze, or adhesive 
 plaster, of a size and 
 shape to symmetri- 
 
 FIG. 32. Langenbeck's clamp. Cally form its struc- 
 
 ture. It is employed 
 to press upon the deep-seated vessels of the soft parts, and to arrest 
 
 FIG. 31. Foulis' 
 fastening with 
 rubber cord.
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 27 
 
 hemorrhage from within a deep wound or cavity. Care must be em- 
 ployed in properly adjusting it, else it may impede venous return, or 
 cause pain by pressing upon large nervous trunks. 
 
 Digital pressure is the most available of all the pressure hemo- 
 
 FIG. 33. Martin's bandasrc. 
 
 FIG. 34. Pyramidal compress. 
 
 statics. It is constantly at hand, and often intuitively seeks to arrest 
 
 the flow of blood. It is necessary only to add to a sensitive finger and 
 
 a sensible brain, a knowledge of where and how to apply the force, to 
 
 render this form of pressure of inestimable value. The vessel should 
 
 be pressed against some resisting part ; as, where it lies in contact 
 
 with a bone. If the bone be 
 
 deeply seated, the vessel must 
 
 always be pressed toward it (Fig. 
 
 37), unless, as is done in many 
 
 cases, the limb be grasped so as 
 
 to bring the ends of the fingers 
 
 against the vessel (Fig. 38). If 
 
 blood flows from an open wound, 
 
 direct pressure must be made 
 
 FIG. 35. Oblong compress. 
 
 upon the bleeding points with one hand, while the other hastens to 
 compress the main artery above the point of hemorrhage. It is not 
 necessary to use great force to interrupt the blood current ; moreover, 
 
 FIG. 36. Conical compress. 
 
 to do so tires the arm and hand, and causes the patient much pain ; 
 use just force enough to interrupt all blood flow. The thumb of 
 the right hand is the best digit to apply at first ; afterward, it may 
 be relieved in various ways by the aid of the fingers and thumbs of 
 those in attendance. If secondary hemorrhage be anticipated, or have
 
 OPERATIVE SURGERY. 
 
 occurred, the proper point for pressure on the body or limb must be 
 indicated by some indelible substance, so that, in case of a sudden flow, 
 
 FIG. 37. Digital compression of femoral. FIG. 38. Digital compression of brachial. 
 
 any attendant can arrest it ; with this object in view, all the attendants 
 must be instructed in the details of making pressure, and be thor- 
 oughly impressed with the ne- 
 cessity of constant vigilance and 
 instant action. 
 
 Vessels that are inaccessible 
 to digital compression can be 
 controlled often by the handle 
 of a key, or by a short crutch ; 
 the applied extremity of either 
 should always be covered by 
 some soft material to prevent 
 injuring the vessel. 
 
 Instrumental Pressure. Un- 
 der this heading are included 
 the various forms of tourniquets 
 and such other devices as are not 
 directly connected with the ad- 
 justment of ligatures to bleeding 
 vessels. The tourniquet in com- 
 Fio. 39. Petit's tourniquet. mon use was devised by Petit,
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 29 
 
 and is no doubt familiar to all (Fig. 39). It should be cautiously ap- 
 plied, and so directed that the pressure will compress the vessel against 
 
 FIG. 40. Tourniquet applied to femoral. FIG. 41. Tourniquet applied to brachiaL 
 
 the bone, when possible. A simple and effective tourniquet can be 
 
 extemporized by placing a roller bandage over the site of the vessel, 
 
 confining it in position by a 
 
 handkerchief passed around 
 
 the arm. If the handkerchief 
 
 be then tied and twisted by 
 
 a stick, the circulation will 
 
 be effectually stopped (Fig. 
 
 42). 
 
 Davy's Lever is an imple- 
 ment devised by the surgeon 
 whose name it bears. It is 
 employed for the especial pur- 
 pose of controlling hemorrhage 
 in amputations at the hip- 
 joint. It is passed up the rec- 
 tum in the direction of that 
 canal a sufficient distance to 
 make pressure on the common 
 iliac artery on the side from 
 which the limb is to be re- 
 moved. The upper extremity FIG. 42. Knebel's improvised tourniquet.
 
 30 OPERATIVE SURGERY. 
 
 is then carried to the right or left sufficiently to lie between the bodies 
 of the lumbar vertebrae and the psoas-magnus muscle. The lower 
 extremity must then be raised, to bring the requisite pressure upon 
 the vessel (Fig. 43). 
 
 It has been employed by its designer and other surgeons with sig- 
 
 FIG. 43. Davy's lever applied. 
 
 nal success. It can be more safely applied to the left than to the right 
 side, on account of the left iliac artery being nearer to the rectum 
 than the right. Its introduction must be preceded by an injection of 
 sweet-oil, after which it must be cautiously introduced, and held in 
 position by a gentle, though firm, pressure. If unnecessary force be 
 used, it may tear or perforate the gut. The instrument in question is 
 round, turned from ebony, and from eighteen to twenty inches in 
 length. The surface is smooth, and its extremities rounded ; its
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 31 
 
 largest diameter is about five eighths of an inch. It can be graduated 
 so that the surgeon will be able to estimate the exact extent of its 
 entrance to the bowel. Its shape has been variously modified to meet 
 the requirements suggested by its more extended use. 
 
 Trendelenbury's Rod. This is likewise used 
 for the same purpose, but in an entirely differ- 
 ent manner (Fig. 44). It is passed through the 
 soft parts at such a depth as to include the whole 
 thickness of the proposed flap. A strong rubber 
 cord is then passed over its extremities with 
 sufficient force to compress the vessels in the 
 tissues above it. The flap can then be made and 
 the vessels ligatured without loss of blood, after 
 which the rod is withdrawn and the remaining 
 flap made in a similar manner. The principle is 
 a feasible one, but it has not yet been enough 
 practiced to become an established method. 
 
 Acupressure. This plan, as a means of con- 
 trolling hemorrhage, was devised by Sir James 
 Y. Simpson, and is used much less in this than 
 in foreign countries. Acupressure is applied in 
 many modified ways ; the modifications may, 
 however, be reduced practically to two in num- 
 ber : one, where the pin is carried through the 
 soft parts under the vessel, and the point ele- 
 vated and pushed through at an angle sufficient 
 to cause it to tightly close the lumen of the 
 artery. 
 
 If this be not effective, additional pressure 
 can be made by passing beneath each extremity 
 of the pin several turns of cotton yarn or of the 
 ordinary silk ligature. This method is often 
 employed to arrest hemorrhage from small 
 branches in the palm of the hand and other 
 similar situations, and should be supplemented 
 by Buck's pin-conductor (Fig. 48), which is 
 passed beneath the vessel and out through the FlG 44 _ Trendelen- 
 integumeut ; then the pin is inserted into its burg's rod. 
 
 open extremity and carried through by withdrawing the needle. The 
 second method is the reverse of the first, the pin resting upon and 
 pressing the vessel downward upon the deep-seated tissue, instead of 
 upward against the superficial. The distance from the end of the ves- 
 sel at which the pressure is applied depends upon its size ; if large, 
 within one-half inch ; if smaller, the distance can be lessened propor- 
 tionately to its size.
 
 32 
 
 OPERATIVE SURGERY. 
 
 FIG. 45. Pin above 
 vessel. 
 
 FIG. 46. Oblique in- 
 sertion of pin. 
 
 FIG. 47. Pin be- 
 neath vessel. 
 
 Circumchision, torsoclusion, and retroclusion are variations of the 
 method of pin-pressure produced either by twisting or compressing the 
 
 caliber of the ves- 
 sel. These vari- 
 ous methods seem 
 to possess but one 
 distinct practical 
 advantage over 
 the occlusion of 
 the same chan- 
 nels by catgut lig- 
 ature ; they can 
 be more safely ap- 
 plied to vessels with brittle coats due to atheromatous and other 
 changes. The minute description of the various modifications of 
 acupressure can be found in the text-books of the day. The pins, 
 which are made of gold, silver, steel, and iron, are of various lengths ; 
 they have glass heads and differently shaped points. A further de- 
 scription or an illustration is not necessary, since they can be satisfac- 
 torily ordered. Shawl-pins, ordinary pins and needles, can be substi- 
 tuted, if the exigencies of the case require it. 
 
 Torsion. - - Tor- 
 sion is not as modern 
 a procedure as its 
 limited employment 
 would warrant the 
 belief. It consists in 
 thoroughly isolating 
 and drawing down 
 the vessel, seizing it 
 firmly with a pair of 
 forceps, about one- 
 half inch above its 
 extremity, and twist- 
 ing the end several 
 times till its resist- FIG. 48. Buck's needle conductor. 
 
 ance is overcome (Fig. 49) ; care being taken not to twist it off. 
 The blood is then allowed to impinge upon the twisted portion be- 
 fore the vessel is released, to test the completeness of the occlusion. 
 The twisting produces a mutilation and breaking up of the coats 
 of the vessel, which occlude its caliber, and cause a rapid forma- 
 tion of the internal clot. It is evident, if the coats be diseased 
 and brittle, that much caution is necessary in twisting them, else a 
 good basis for the occurrence of secondary hemorrhage will be estab- 
 lished. Torsion-forceps, which combine in one instrument the hold-
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 33 
 
 ing and twisting forceps, are far more convenient (Fig. 50). Torsion 
 as a substitute for the ligature is not considered with much favor in 
 this country, except in individual 
 instances. It is commonly em- 
 ployed, however, to check the 
 small bleeding points seen on the 
 surface of freshly cut wounds. 
 
 Forceps, Serreftnes, and Tenac- 
 ula. Since these instruments are 
 closely associated in common use- 
 fulness, they can be spoken of in 
 connection with each other. The 
 spring-catch fenestrated forceps are 
 the best. There are two patterns 
 of these : Liston's (Fig. 51), and 
 those devised by Prof. Hamilton 
 (Fig. 52).* 
 
 The expansion of the fenes- 
 trated extremity carries the liga- 
 ture around the vessel, rendering 
 
 it practically impossible to tie the ^ 49 ._ Torsion of an artery . 
 
 end of the instrument, as in the 
 case of the simple Liston forceps (Fig. 53). 
 
 Liston's mouse-tooth forceps, while they are not suitable for the 
 common purpose of catching bleeding vessels, are nevertheless of great 
 
 FIG. 50. Hewson's torsion forceps. 
 
 service in securing bleeding points on flat surfaces, especially when 
 
 surrounded by dense tissues. 
 
 The serrefine-forceps are of great utility to control bleeding points 
 
 during an operation. 
 They can be easily and 
 quickly adjusted, and, 
 by their pressure on the 
 coats of the small ves- 
 sels, the necessity of 
 
 FIG. 51. Liston's spring-catch fenestrated artery forceps, afterward using a liga- 
 ture may be obviated. 
 
 They can be used to catch and control bleeding points to which the 
 
 * The slide-catch arterial forceps of Esmarch are strong and serviceable, although 
 they can not be so quickly applied as the snap-catch varieties. 
 3
 
 OPERATIVE SURGERY. 
 
 application of a ligature is impossible, and even be allowed to remain 
 upon the vessel till all danger of bleeding has subsided. There are 
 
 several varieties of these 
 instruments. The for- 
 cep - serrefine, which is 
 the largest (Fig. 54) ; the 
 angular and straight, and 
 those of Langenbeck 
 (Fig. 55). The first are 
 admirably adapted to con- 
 
 FIG. 52. Hamilton's (F. H.) artery forceps. 
 
 trolling large vessels, and, 
 by their grasping and 
 self-retaining forces, can be employed in connection with other tissues. 
 Dr. J. L. Little, of this city, devised a forcep-serrefine having a 
 fenestrated biting extremity, re- 
 sembling in all practical respects 
 the extremity of the fenestrated 
 
 FIG. 53. Listen's mouse-tooth forceps. 
 
 artery forceps. The one devised 
 by Gross (Fig. 57) can be at- 
 tached to the bleeding point, the handle unscrewed, and the blades per- 
 mitted to remain until all danger of bleeding has ceased. The smaller 
 
 ones (Figs. 55 and 56) 
 are employed to catch 
 small bleeding points. 
 
 Milne's compressing 
 forceps (Fig. 58) are 
 closely allied in princi- 
 ple to the serrefine ; 
 they are likewise useful 
 for compressing the 
 smaller arteries in their course through the soft tissues, as the coro- 
 nary arteries in the operation for hare-lip. Langenbeck's are also ad- 
 mirable for a similar purpose. 
 Tenaculum (Fig. 59). 
 This is used to pick up and 
 draw vessels from the soft FIG. 55. Langenbeck's FIG. 56. Wire serre- 
 parts. If the extremity of a 
 vessel be too short to be ligatured by the aid of forceps, it can be trans- 
 
 \l JJ FIG. 54. Serrefine forceps. 
 
 FIG. 57. Gross' artery compressor.
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 35 
 
 FIG. 58. Milne's artery 
 compressor. 
 
 fixed along with a small portion of the contiguous soft parts by the 
 tenaculum, and a ligature thrown around the combined tissues (Fig. 
 60). If a nick be made 
 on either side of the tis- 
 sues raised by the tenac- 
 ulum, the ligature can 
 be more securely applied 
 and the vessel more firm- 
 ly grasped. 
 
 Prince's tenaculum 
 forceps combine the 
 principles of both in- 
 struments, and can be 
 used with advantage 
 (Fig. 62). 
 
 The arterial com- 
 pressor of Speir, of 
 Brooklyn (Fig. 61), is 
 an instrument of un- 
 doubted efficacy, but the 
 advantages which it is 
 said to possess over the 
 ordinary ligatures are 
 not of enough impor- 
 tance to commend it to 
 general use. A small 
 portion of the vessel is 
 isolated and its hook- 
 like extremity passed 
 around it ; the handle 
 is then turned until the 
 coats are compressed suf- 
 ficiently to divide the 
 
 innermost, as is accom- 
 
 w 
 
 EJ 
 
 plished in the tightening FIG 59. ' 6 o._ App i icat ; on of Fio 61. -Spelr'a 
 Of the ordinary ligature. -Tenac- tenaculum p vessels- artery compres- 
 
 _ mi_ ulum. sor. 
 
 Cautery. This rem- 
 edy, once a universal means of controlling hemorrhage, has now but 
 
 a limited applica- 
 tion. There are 
 three varieties of 
 cautery in com- 
 
 FIG. 62. Prince's Tenaculum forceps. 
 
 and galvano-cauteries. 
 
 mon use : the ac- 
 tual, the thermo- 
 The actual cautery requires the cautery irons
 
 36 
 
 OPERATIVE SURGERY. 
 
 FIG. 63. Cautery irons. 
 
 (Fig. 63), which should be accompanied by the blow-pipe (Fig. 64), 
 although they can be heated by ordinary means. The blow-pipe is by far 
 
 the best, since during the 
 ' summer months, or in un- 
 favorable situations, when 
 great haste is necessary, the 
 domestic means of heating 
 them will be inadequate. 
 The irons can be made in- 
 candescent, or of a dull red 
 color ; the latter is the bet- 
 ter, since it burns more 
 deeply and is less liable to 
 be followed by secondary 
 hemorrhage. 
 
 Tliermo-cautery. The 
 instrument designed by M. 
 Paquelin for this purpose 
 is exceedingly ingenious. 
 
 FIG. 64. Blow-pipe. 
 
 It consists of a thorough- 
 ly isolated hollow handle, 
 provided with three movable platinum cauteries, into which, after they 
 have been heated in the flame of a spirit lamp, a continuous stream 
 of benzine vapor is introduced by the means of a double spray bulb 
 connected by a tube with the bottle containing it (Fig. 65) ; this 
 
 FIG. 65. Paquelin's thermo-cautery.
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 37 
 
 brings the cauteries quickly to the required temperature, which can 
 be maintained for an indefinite length of time by squeezing the rubber 
 bulb. The range of the usefulness of this instrument is more extended 
 than the former. It is used, not only for the same purposes, but can 
 be employed as a cutting implement for the removal of morbid 
 growths, etc., when union by first intention becomes a lesser consid- 
 eration than the annoyance from primary hemorrhage. 
 
 Galvano-cautery. This method is chiefly employed in connection 
 with uterine surgery, although it is a proper expedient in connection 
 with all operations where the use of the ecraseur is admissible. 
 
 Ligatures. The ligature is by far the best general agent for con- 
 
 FIG. 66. Tying a ligature. 
 
 trolling hemorrhage. It can be readily applied, is easily portable, and 
 can always be obtained in some form. Ligatures may be classified 
 according to their nature into organic and inorganic. The latter are 
 very infrequently used, and then in the form of fine silver or iron 
 wire, which is looped rather than tied around the vessel. The organic 
 comprise the hemp, silk, and catgut varieties, which should be made 
 at least from twelve to sixteen inches in length, depending on the 
 depth of the wound in which they are to be applied. They must be 
 of sufficient strength to withstand the traction necessary to cause 
 complete occlusion of the vessel. Their size must depend somewhat 
 upon the force to be employed in tying. The requisite force to prop- 
 erly occlude a vessel can not be estimated by ounces or pounds, but is 
 largely a matter of experience. The traction should be made steadily, 
 and over the ends of the forefingers or thumbs, without disturbing 
 the relations of the vessel to its surrounding parts (Fig. 66). The 
 giving away of the inner coat of a vessel indicates that the ligature is 
 drawn sufficiently tight. This can not be felt, however, except in con- 
 nection with the larger vessels. Great caution is to be exercised to 
 prevent any tissues other than the walls of the vessel being included in 
 the grasp of the ligature. If a nerve be included the patient will be 
 tormented by constant pain, which may not cease even with the dis- 
 appearance of the constricting agent. All tissues, other than the coats
 
 38 
 
 OPERATIVE SURGERY. 
 
 of the vessel, not only cause additional irritation, but delay the sepa- 
 ration of the ligature. 
 
 Knots. The security of the ligature depends very much on the 
 kind of knot tied. The surgeon's knot is tied by making two turns 
 
 of the ligature at first instead of one 
 (Fig. 67) ; it will not slip when drawn 
 tightly, and should always be em- 
 ployed when the knot is to be made 
 beyond the sight of the surgeon, 
 otherwise the first half of it may slip 
 without his knowledge, thereby re- 
 sulting in an imperfect ligaturing of 
 
 the vessel. It sometimes happens, owing to the ligature becoming 
 soaked, that this knot can not be drawn as tightly as one with a 
 
 FIG. 67. Surgeon's knot. 
 
 FIG. 68. Reef-knot. 
 
 FIG. 69. Granny knot 
 
 single turn. If it binds in this manner, the tying of the second part 
 will leave the whole very insecure. 
 
 The Reef or Square Knot. Either this, or the preceding, must 
 always be employed in .tying a vessel. The reef-knot (Fig. 68) is easily 
 confounded with the " granny knot " (Fig. 69), which is insecure. The 
 following description of 
 the method of tying the 
 reef - knot, taken from 
 Heath, is too graphic to 
 be substituted by any 
 other : " The ligature is 
 to be held in the palm of 
 the right hand between 
 the thumb and finger ; 
 the end is then' to be 
 thrown around the for- FIG. 70. First step in tying reef-knot, 
 
 ceps closely and caught 
 
 with the left hand, and carried across the right thumb and inserted be- 
 tween the third and fourth fingers of the right hand (Fig. 70). The left 
 at the same moment seizes the other end, and the ends of the threads are 
 drawn out as is being done in Fig. 71. There will now be no difficul-
 
 AGENTS FOR CONTROLLING HEMORRHAGE. 
 
 39 
 
 FIG. 71. Second step. 
 
 ty in drawing the knot thus formed tight with the forefingers, or, if 
 preferred, with the thumbs (Fig. 72). To complete the knot by mak- 
 ing another tie, the same 
 manosuvre is to be effected, 
 taking care always to begin 
 with the opposite hand to 
 that which began before. It 
 is quite immaterial which 
 hand begins the first part of 
 the knot, so long as the op- 
 posite one always begins the 
 second part ; in this way, 
 with a little practice, the 
 reef-knot may be unerringly 
 tied with the greatest rapid- 
 ity." When the knot is 
 completed, it will be seen 
 
 that the ends of the ligatures lie parallel with and in contact with the 
 portion of the ligature which surrounds the vessel (Fig. 68). 
 
 The silk and hemp ligatures must be well puri- 
 fied before they are applied by being placed in a 
 suitable disinfecting solution. A solution of bi- 
 chloride of mercury (1-1,500), or the strong solu- 
 tion of carbolic acid, may be employed, although 
 the latter diminishes the strength of the ligature by 
 impairing the integrity of 
 its fiber. If the ligatures 
 be wound on small glass 
 bobbins and placed in suit- 
 ably sized large-mouthed 
 bottles containing the anti- 
 septic fluid for a week or 
 ten days, then transferred 
 to similar bottles contain- 
 ing absolute alcohol, their 
 ends escaping through a 
 
 narrow groove in the side of the cork, they can be unwound as re- 
 quired without exposing the remaining portions to external influ- 
 ences. If uncarbolized, they should be freshly waxed. After tying, 
 one end may be cut short and the other allowed to hang from the 
 wound. 
 
 The iron-dyed silk ligature recommended by Paneoast is credited 
 by some with the attributes of the aseptic ones. 
 
 Catgut ligatures are now in established use in surgery ; they, like 
 other ligatures, vary in size and strength, and a selection must be 
 
 Fia. 72. Third step.
 
 40 OPERATIVE SURGERY. 
 
 made in accordance with the purposes in view. If properly chosen 
 they can be relied upon to fulfill the ordinary indications of the silk 
 ligature. Crude catgut of assorted sizes can be purchased of dealers 
 in surgical supplies and be asepticized to suit the fancy of the surgeon, 
 or it may be procured already prepared for use after the methods in 
 common practice. Catgut can be tied by the surgeon's or the reef- 
 knot, but is less secure than silk. A third tie should always be 
 added to whichever of the two is employed. The ends are cut close 
 to the point of tying, and the wound closed irrespective of the pres- 
 ence of the ligature. Aseptic kangaroo tendon, silkworm gut,. aortic 
 tissue, whalebone tissue, etc., are also commended for special purposes, 
 but they possess a greater novelty than practical utility. 
 
 The crude material is variously prepared to conform to the de- 
 mands of asepsis, ready absorption, and non-irritation. It can be 
 placed in a bichloride solution 1 to 100 of water for ten minutes, 
 then into a weaker one 1 to 1,000 for twelve or fourteen hours, and 
 afterward wound on bobbins and kept for ready use in absolute alcohol 
 in the manner before described ; or it may be prepared after the 
 method of Kocher, of Berne, by first putting it into the oil of juniper 
 for twenty-four hours, and afterward into absolute alcohol. Ligatures 
 prepared by these methods meet all of the indications admirably, and 
 are devoid of the slipping tendencies of those kept in acid and oil 
 after the manner of Mr. Lister. The following method of preparing 
 ligatures was recommended by Lister, in his inaugural address of June 
 28, 1881 : 
 
 "Dissolve one part of chromic acid in 4,000 parts of distilled 
 water, and add to the solution 200 parts of pure carbolic acid ; into 
 this liquid immediately put catgut equal in weight to the carbolic acid. 
 At the end of forty-eight hours it is sufficiently prepared. Then it is 
 to be removed from the solution, dried, and placed in one-to-five car- 
 bolized oil. It is then fit for use." The dry chromacized catgut is not 
 satisfactory, owing to its hardness and power of resisting absorption. 
 
 Assistants. The number of efficient assistants necessary to con- 
 duct an operation with ease is modified by its character. 
 
 To one must be intrusted the administering of the anaesthetic, and 
 watching the pulse, respiration, and circulation of the patient. By com- 
 bining these duties the administrator of the anaesthetic becomes the im- 
 mediate observer of its effects, and he must always be prepared to carry 
 into execution the various expedients that are recommended in the com- 
 plications attending anaesthesia. If the temporal and radial pulsations 
 be compared before its administration, the assistant will be able to 
 judge of one from the character of the other. He can then give the 
 anaesthetic, hold forward the lower jaw to prevent swallowing the 
 tongue (Fig. 10), and, with the finger on the temporal artery, he will be 
 able to attend to the necessities of the case without any interruption.
 
 TREATMENT OF OPERATION-WOUNDS. 41 
 
 To a second should be assigned the care of the instruments ; hand- 
 ing them to the surgeon when asked for, and returning them to a 
 place of safety after being used. 
 
 To a third may be intrusted the care of the sponges ; he must 
 always see to it that a suitable number be well squeezed and placed at 
 the convenience of the operator. 
 
 To a fourth the ligatures should be given. He can first hold the 
 limb, when necessary, after which he may either sponge or ligature 
 the vessels, as best suits the circumstances of the case or the fancy of 
 the operator. The securing of the bleeding points and the necessary 
 sponging are best done by the operating surgeon ; however, these are 
 matters which will become self-regulating as the operation progresses. 
 All assistants must be proficient, especially the one who ligatures the 
 vessel, and the one who administers the anaesthetic. When the sur- 
 geon is not able to avail himself of a suitable number of assistants, he 
 must then draw upon his own resources. This can be done by placing 
 the sponges and instruments where they can be conveniently reached, 
 when he can sponge, secure, and tie the vessels. If the circumstances 
 demand it, he can at the same time control the administration of the 
 anaesthetic. If the operation is to be antiseptic, the entire charge of 
 the douching should be given to one assistant. 
 
 The patient should always be prepared for the operation. The 
 physical, legal, and spiritual aspects of a preparation have been here- 
 tofore considered under various headings, consequently little remains 
 to be advised other than to properly cleanse and shave the part to be 
 operated upon. 
 
 CHAPTER III. 
 
 TREATMENT OF OPERATION-WOUNDS. 
 
 It is absolutely necessary to have the proper materials for uniting 
 and dressing wounds, together with a knowledge of their use. 
 
 As soon as the operation is completed the wound should be washed 
 thoroughly with the strong solution of carbolic acid, or other anti- 
 septic, which not only purifies it, but serves to check the capillary 
 oozing of the incised surfaces. The proper securing of the incised sur- 
 faces and the dressing of the wound involve three important considera- 
 tions : 1, the retentive coaptation of the divided tissues ; 2, perfect 
 drainage ; 3, the application of some suitable protective dressing. If 
 union by first intention be a desideratum, the incised surfaces must be 
 kept in perfect coaptation. For this purpose there are numerous 
 means employed. The part bearing the wound should be so placed as
 
 42 OPERATIVE SURGERY. 
 
 to avoid all muscular contraction, or undue tension of the soft parts. 
 Strips of adhesive plaster with or without roller bandages, or simple 
 compresses may meet the indications. These agents constitute the 
 common dressings of a less recent date, and are at the present time 
 open to the objection of interfering with union by first intention, ex- 
 cept they be of an antiseptic nature. 
 
 Sutures may be classified with reference to their composition or 
 method of arrangement. They are of either organic or inorganic nature. 
 
 Those of an organic nature are most commonly used ; but which 
 of these is the best is more a matter of personal preference than a 
 surgical requirement. The silk, hemp, catgut, and horse-hair sutures 
 belong to this class, and are respectively employed as best suits the 
 preference of the surgeon. The silk and the hemp varieties are con- 
 stantly employed, and if carbolized they cause but little irritation, 
 may become absorbed, and, when present, can be removed without pain. 
 
 The proper introduction of sutures under all conditions requires 
 needles of various shapes and sizes : the curved and straight ; those 
 with round and edged extremities. These are too familiar to all to 
 require other than a passing mention. The curved are used in cavi- 
 ties and depressions ; the straight on plane surfaces. Those with an 
 edged extremity cut the tissues they pass through, while the smoother 
 separate the tissues and avoid the hemorrhage that so often follows 
 the track of the former. The latter are, however, inserted with 
 greater difficulty. 
 
 Needle forceps, or holders (Figs. 73, 74, 75), should always be at 
 
 FIG. 73. Stimson's ncedlo forceps. 
 
 FIG. 74. Prout's needle forceps. 
 
 FIG. 75. Sands' needle forceps.
 
 TREATMENT OF OPERATION-WOUNDS. 
 
 hand to aid in conducting the needles steadily through the tissues. 
 The instrument bearing the artery forceps at one end and the needle- 
 holder at the other (Fig. 76) is an admirable and compact implement. 
 
 FIG. 76. Combined forceps and needle-holder. 
 
 Horse-hair. When carbolized, this causes but slight irritation, 
 and is well adapted to those cases requiring but little force to maintain 
 coaptation and where scarring from sutures is to be avoided. 
 
 Catgut as a suture possesses the same special advantages that be- 
 long to it as a ligature. It rarely produces irritation, and if allowed 
 to remain will become absorbed without ulceratiou. If, however, 
 much force is required to unite the wound, catgut is less reliable than 
 silk. 
 
 Inorganic or Metallic Sutures. Those in common use are the 
 silver and iron wire. They can be retained in situ longer than the 
 uncarbolized silk or hemp, with less danger from ulceration. Their 
 application and removal, however, are attended with more pain than 
 either of the others. The silver wire is more expensive than the iron ; 
 aside from this, it matters little which be used. The depth to which 
 sutures should be passed, the distance between them, and their ten- 
 sion, depend upon the depth of the wound, and the tendency of its 
 lips to separate. The object of all sutures is to hold the surfaces of 
 wounds in close contact until union occurs. To accomplish this they 
 must be carried to such depth, and be 
 placed at such distances from each other, 
 as will best accomplish the purpose. 
 They can, if necessary, be supplemented 
 by strips of adhesive plaster passed be- 
 tween them that have been heated by 
 immersion in a hot solution of bichloride 
 of mercury (1-500) (Fig. 77). Sutures 
 must never be drawn too tightly (Fig. 
 79), or the tissues within their grasp will 
 be strangulated, causing ulceration and 
 disfigurement. 
 
 If the integument within the grasp 
 of a suture remain white after it is tightened, the suture must be 
 loosened before the final dressing is completed. The length of time 
 sutures should remain is to be governed by the danger of ulcera- 
 
 FIG. 7T. Antiseptic adhesive plas- 
 ter between sutures.
 
 44: 
 
 OPERATIVE SURGERY. 
 
 FIG. 78. Interrupted su- 
 ture. 
 
 tion and disfigurement, also the tendency of the wound to open. 
 In exposed portions of the body, they should be removed as soon 
 as notable irritation is observed. The rapidity and extent of the 
 ulcerative process can be lessened, by relieving any undue traction 
 upon them, by strips of adhesive plaster or by other supporting 
 means. 
 
 Different Forms of Sutures. The interrupted, continuous, quilled, 
 hare-lip, etc., are the forms in common use. The special varieties for 
 intestinal sewing will be shown in connection 
 with operations upon the intestines. 
 
 The interrupted suture is the one in every- 
 day use, and has a more general application than 
 the other forms (Fig. 
 78). It is made by 
 
 passing a needle armed with a well-pre- 
 pared suture through the integument, 
 from a line to a third of an inch or more 
 from the borders of the wound, depend- 
 ing upon its size, depth, and retractive 
 force. The ends are then united by a 
 reef-knot, drawn with sufficient force to 
 oppose the surfaces without puckering the 
 skin (Fig. 79). The ends of the suture 
 can be united at alternate sides of the 
 wound, or at one of its points of exit alone. 
 
 The latter is the better, since, if the dress- 
 ings cling to the extremities, their remov- 
 al is less liable to interfere with the line 
 of coaptation. 
 
 TJie continuous suture, sometimes 
 called the glover's suture (Fig. 80), is used 
 to unite superficial wounds, and such oth- 
 ers as require little force to secure a 
 FIG. SO.-Continuous, or glover's proper adjustment of the divided sur . 
 
 How to do it. 
 
 How not to do it. 
 
 FIG. 79. Tension of sutures. 
 
 FIG. 81. Quilled suture.
 
 TREATMENT OF OPERATION-WOUNDS. 
 
 45 
 
 faces. This is made by passing the needle diagonally from one side of 
 the wound over to the other. 
 
 Tlie Quilled Suture. This is made by passing several strong double 
 threads through the lips of the wound, half an inch 
 or so apart, and tying them over quills, wood, etc., 
 while they lie parallel with the cut (Fig. 81). It is 
 used about the vagina, perineum, etc., when deep 
 gaps are to be closed. 
 
 The Twisted or Hare-lip Suture (Figs. 82 and 
 83). This is made by pushing a pin through the 
 edges of the wound, and passing cotton yarn around 
 it to confine it in position (Fig. 83). The yarn 
 should be changed as often as it becomes soiled. If 
 it be properly carbolized before application, it lessens 
 its tendency to cause irritation. An ordinary pin or 
 needle can be used, although those specially adapted FlG - 
 for the purpose are preferable (Fig. 84). They can 
 be, if not spear-pointed, pushed or drawn through the tissues by aid 
 of Post's (Fig. 85) or Buck's pin-carrier, after which the points should 
 be nipped off and separated from the skin by a small strip of adhesive 
 
 82. Hare-lip 
 suture. 
 
 FIG. 83. Hare-lip suture.
 
 OPERATIVE SURGERY. 
 
 I 
 
 plaster. Pins with adjustable spear-shaped points can be employed 
 and carried into position by the fingers of the operator (Fig. 86). 
 
 There are various other special forms 
 of sutures which will be considered under 
 their proper headings. 
 
 Drainage. This is not only of the 
 greatest importance in securing successful 
 union of the divided surfaces, but also to 
 the safety of the patient. Good drainage 
 to a wound is as potent to its cleanliness, as 
 is the good drainage of a dwelling to the 
 healthfulness of its occupants. No one lo- 
 cal condition will interfere so materially 
 with the process of healing, or expose the 
 patient to- greater constitutional danger, 
 than the collection and decomposition of 
 fluids in a wound. Drainage may be se- 
 cured through dependent incisions, or, bet- 
 ter still, by the introduction into the wound 
 of a drainage-tube. Horse-hairs or threads 
 introduced into the wound in some cases 
 FIG. 84. FIG. 85. FIG. 86. answer quite well. The long extremities 
 FIG. 84.llare-lip pins FIG. 85. O f t h e s iik or linen ligatures, if allowed to 
 
 Post s pin-carrier. IIG. 86. , . .. , , , 
 
 Adjustable pointed pin. extend from its most dependent portion, 
 
 will drain it, though somewhat imperfectly. 
 
 Ellis' Drainage Spiral (Fig. 87), or that which is still more practi- 
 cable, the rubber drainage-tube (Fig. 88), will fulfill the indications more 
 perfectly. An ordinary piece of black or white rubber tubing, of about 
 one fourth of an inch in diameter, with 
 holes in the sides at irregular intervals, 
 can be inserted into the bottom of the 
 wound cavity through its most depend- 
 ent portion. Another can be introduced into the upper portion of the 
 cavity through the uppermost angle of the wound. The size should 
 
 vary with the dimen- 
 sions of the wound. 
 They are more often 
 too small than too 
 large. They must 
 be fastened in posi- 
 tion, or they may slip into the wound ; this can be done by passing a 
 thread through the projecting extremity and tying it around the limb. 
 If a single tube be passed so as to protrude from both sides of the 
 wound, it can be securely fastened by passing an ordinary safety pin 
 through each extremity. However, it is better to use two short tubes 
 
 FIG. 87. Ellis' drainage spiral. 
 
 FIG. 88. Rubber drainage tube.
 
 TREATMENT OF OPERATION-WOUNDS. 47 
 
 than one long one ; the use of the latter introduces into the wound a 
 superfluous amount of rubber, which does not perform a duty com- 
 mensurate with its presence. In either case it is necessary to allow for 
 the swelling of the parts, else the pins or threads may cause constric- 
 tion of the injured tissues. The outer extremities should then be cut 
 oif flush with the soft tissues. The wound can be washed though the 
 upper tube, while all discharges will pass from the lower one. The length 
 of time they should remain must depend upon the character and amount 
 of the discharge. When the amount is small and of inoffensive nature, 
 they can be removed. It must not be forgotten that the tubes, as foreign 
 bodies, may excite the discharge which they are introduced to carry off. 
 
 TJie decalcified tubes of Neuber are admirable, although not suffi- 
 ciently accessible to supplant the rubber ones ; moreover, they not 
 infrequently become absorbed before the wound is sufficiently healed 
 to properly dispense with their use. Several strands of the ordinary 
 antiseptic catgut can be introduced together and retained in the 
 wound ; they drain satisfactorily, and are easily absorbed. Chicken- 
 bones, decalcified by a weak solution of hydrochloric acid, may be ex- 
 temporized, and, while they are suitable substitutes for the rubber 
 tubes, they are too hard to be absorbed, and consequently do not add 
 materially to the surgeon's equipment. A drainage-tube can be pushed 
 into position often, although it is better if it be aided by a director or 
 probe inserted within it, either as a propelling agent or a guide. It 
 may be pushed or drawn into place by the ordinary thumb-forceps ; 
 the latter is the better if the wound be open. 
 
 Canalization. This term is applied by Neuber to a method of 
 establishing good drainage to a wound without the use of tubes. Shal- 
 low and deep canalization comprise its varieties. The former is the 
 draining of shallow subcutaneous cavities by oval-shaped punctures a 
 fourth of an inch or so in width through the integumentary laps at 
 the most dependent portion of the wound. These punctures vary in 
 number and situation to meet the demands of the case, and are made 
 by a punch, in construction not unlike the leather-punch ; in fact, the 
 latter may be employed as a suitable substitute. Deep canalization is 
 directed to the drainage of deep wound cavities, such as are formed 
 by the removal of the female breast, of the connective tissue from the 
 axilla, and other deep wounds, which, when united by granulation, 
 produce an objectionable amount of cicatricial tissue. The integu- 
 ment at either border of the wound is loosened from its deep connec- 
 tions to an extent sufficient to permit its borders to be easily drawn 
 or slid into apposition with each other and carried to the bottom of 
 the wound cavity, to which they are connected by sutures. The sur- 
 face then appears concave or trough-like, and is covered by the de- 
 pressed integument, which it is intended shall become united to the 
 walls and floor of the cavity by first intention.
 
 48 OPERATIVE SURGERY. 
 
 Protective Dressings. These include the ordinary dressings, such 
 as one who is a long way from the base of supplies, or not a believer in 
 the modern methods, would employ : as covering the wound with a 
 linen cloth kept moist with a weak solution of carbolic acid, or water ; 
 the application of adhesive plaster, and covering it with medicated 
 cloths held in position by bandages or plasters. Of the modern meth- 
 ods, the one bearing the name of Lister, its designer, is deserving of 
 especial mention, not only on account of its acknowledged worth, but 
 also from the fact, that other measures involving similar principles 
 are advocated, the same result being sought by the aid of different 
 agents. 
 
 The requirements for the Lister treatment are the atomizer or 
 spray, carbolic -acid solution, drainage-tube, protective, antiseptic 
 gauze, Mackintosh, antiseptic catgut ligatures, and that everything to 
 be brought in contact with the wound be made aseptic by a strong 
 solution of carbolic acid or other proper fluid. 
 
 The Antiseptic Spray Apparatus consists of a kettle, lamp, spray- 
 tube, and a bottle to contain the solution of a strong carbolic acid 
 (Fig. 89). The spray is produced and directed upon the site of the 
 operation before the first incision is made. It should be continued 
 
 FIG. 89. Weir's spray apparatus. 
 
 through the whole operation, and until the wound is surrounded by 
 the protective dressing. It is always to be used when the wound is 
 redressed. 
 
 The Protective, which somewhat resembles oiled-silk, is placed over 
 the wound and extended an inch or so from its border, with openings 
 through it for the mouths of the drainage-tubes. A small piece of the 
 antiseptic gauze wet in the strong solution of carbolic acid can be laid 
 over and beyond the protective. Numerous layers eight or ten of 
 the antiseptic gauze are then made to cover the part, their borders 
 extending a good distance beyond the edge of the wound. Around
 
 TREATMENT OF OPERATION-WOUNDS. 49 
 
 the whole is wrapped the Mackintosh, which is confined in position by 
 bandages made of the antiseptic gauze. 
 
 This dressing can be removed on the second or third day, the 
 wound washed out, protective and Mackintosh purified, and clean 
 gauze substituted, after which it need not be examined again other 
 things being equal within a week or ten days, unless the discharges 
 soak through it. 
 
 At the present time the spray is less often employed than for- 
 merly. In place of it, the surface to be operated upon should be 
 thoroughly scrubbed for three minutes with a brush and soap and 
 water, and afterward washed with a strong solution (1-20) of carbolic 
 acid (Kummell) and some other suitable disinfectant, as aq. chlorinii 
 or a solution of thymol, and the surfaces contiguous to it should be 
 covered by towels saturated with the same disinfecting solution, which 
 should be kept thoroughly wet by it during the operation. The opera- 
 tion-wound should be likewise thoroughly douched with some disin- 
 fecting fluid during the entire course of the procedure. In all other 
 respects, however, the details are substantially similar to the preceding. 
 
 The Douching apparatus is easily made by siphoning the anti- 
 septic solution from a receptacle through a long, small rubber tube, to 
 the end of which is attached a metallic one that discharges the fluid 
 upon the wound through a number of coarse openings at its extremity. 
 The flow can be regulated by pinching the tube, or by the attachment 
 of a regulator constructed to meet the indication. 
 
 The part to be operated upon should be isolated by means of rub- 
 ber cloths, to prevent the patient's clothing becoming saturated by 
 the antiseptic fluid, and by towels saturated by strong antiseptic solu- 
 tions. If the operating table be tilted sidewise it will facilitate the 
 escape of the fluid upon the floor, or into receptacles provided for the 
 purpose. 
 
 Cotton-batting Dressing. Cotton batting, or that which is better, 
 borated, or salicylated cotton, is frequently employed as a protective 
 dressing in place of the antiseptic gauze. The results obtained, war- 
 rant the belief that it is entitled to be considered worthy of an ex- 
 tended application. It exerts a very desirable uniform pressure upon 
 the parts to which it is applied, thereby aiding coaptation and foster- 
 ing union. 
 
 Combined Dressing. Combined dressing is made by placing sev- 
 eral thicknesses of borated or other variety of antiseptic batting be- 
 tween two layers of antiseptic gauze. This is shaped to suit the 
 circumstances of the case and applied over the gauze that is placed in 
 immediate contact with the wound and confined in position by anti- 
 septic bandages (Fig. 90). 
 
 lodoform Dressing. lodoform can be dissolved in ether, and after 
 the operation thrown upon the incised surface by means of an ordinary 
 4
 
 50 
 
 OPERATIVE SURGERY. 
 
 atomizer. The ether will evaporate and leave the iodoform evenly 
 deposited over the incised surfaces. 
 
 It can be better applied, if pulverized, and blown into the wound 
 by an insufflator. The wound is then closed by antiseptic sutures, 
 
 FIG. 90. Antiseptic dressings in position. 
 
 drainage-tubes introduced, iodoform sprinkled upon the integument 
 in the vicinity of the wound, and the other antiseptic dressings ap- 
 plied, which are bandaged in place and allowed to remain until they 
 become soiled, when the wound is redressed as before. It is a common 
 practice to sprinkle pulverized iodoform upon the immediate and con- 
 tiguous surface of parts operated on, after the closure of the wound, 
 as soon as the douche is stopped. The dressings are then applied as 
 before. 
 
 The odor of iodoform, and its occasional deleterious effects upon 
 the nervous system of the patient, should make its free use upon large 
 surfaces infrequent and cautious, especially if the wound be one of the 
 scalp. 
 
 Iodoform gauze is made use of in many instances. It can be made 
 extemporaneously, by rubbing iodoform into sterilized gauze, or by 
 saturating sterilized gauze with an ethereal solution of iodoform. This 
 variety of gauze seems, at the present time, to be indispensable in the 
 treatment of deep wounds associated with the rectum, vagina, etc. 
 
 Peat Dressing. Into a small carbolized gauze bag light peat or 
 turf is introduced, combined with 2^ per cent of iodoform ; over this 
 a large bag filled with carbolized peat is applied, and the whole band- 
 aged firmly in position. The fine peat serves admirably to make 
 equable pressure and absorb the discharges, and need not be re-applied 
 until it has become soiled. 
 
 Coarse and fine jute, wood-wool, wood-pulp, moss, peat, saw-dust, 
 etc., can each be made antiseptic if it be steeped six or eight hours in 
 a solution of bichloride of mercury (1-1,000), with 5 per cent of glycer- 
 in, then wrung out and allowed to dry, when suitably sized pads or 
 bags can be made, one inch or two thick, by aid of some variety of 
 antiseptic gauze.
 
 TREATMENT OF OPERATION-WOUNDS. 51 
 
 Gauze and cotton batting can each be made antiseptic, after the 
 removal of the oily matters contained in their texture, if they be 
 placed into a solution of bichloride of mercury 10 parts, water 2,240 
 parts, glycerin 250 parts, and allowed to stand for ten or twelve 
 hours, then wrung out and dried. 
 
 It should not be forgotten that the bichloride of mercury is thought 
 to be a somewhat unstable component, and it therefore becomes neces- 
 sary to use the freshly prepared combinations of it. If a small amount 
 of common salt be added to the solution, its stability is said to be 
 better maintained. 
 
 Bichloride of Mercury Dressing. By this method, the dangers 
 attending the use of carbolic acid and iodoform are avoided, at the 
 same time, a cheap and inoffensive substance is utilized. It is used 
 with the spray (1-1,200) or as a wash for a wound (1-2,000-10,000). 
 Sponges, ligatures, and sutures are soaked in solutions of it, varying 
 in strength from 10 to 75 grains to the pint of water or alcohol, the 
 latter being used for the ligatures and sutures, in which they are kept 
 for three or four hours, thence removed to a much weaker one. Cat- 
 gut can be treated in substantially the same manner, by allowing it to 
 remain ten or twelve hours in the alcoholic solution, from which it is 
 to be taken and introduced into a weaker one (one half of 1 per cent), 
 containing a drachm or so of glycerin. 
 
 The protective dressing can be saturated with a strong solution 
 (50 grains to the pint), and applied in the same manner as before. It 
 is well to remember that if this variety of protective be applied 
 directly to the skin, especially of a child, it is very liable to cause an 
 erythematous irritation. 
 
 Instruments can be purified with it, although it lessens their cut- 
 ting power. This dressing is recommended as one possessing efficiency 
 and safety. The soluble compressed tablets containing a definite 
 amount of bichloride of mercury are very convenient for the minor 
 requirements of general practice. They should not, however, become 
 in any way associated with the compressed tablets employed for inter- 
 nal medication, for obvious reasons. 
 
 Thiersch's Fluid, composed of one grain of salicylic acid and six 
 of boracic acid to an ounce of water, is a good antiseptic solution. It 
 does not produce the catheretic influence upon the tissues, so charac- 
 teristic of the strong carbolic and bichloride of mercury solutions, and 
 therefore the tissues to which it is applied retain their normal appear- 
 ance. 
 
 Alcohol, thymol, eucalyptol, and the essential oils have been recom- 
 mended for their antiseptic virtues, but with insufficient testimony to 
 warrant their employment in place of the other well-established 
 agents. 
 
 The Patient should he kept Quiet. Absolute quiet of the patient.
 
 52 OPERATIVE SURGERY. 
 
 and of the part bearing the wound, is not the least of the elements 
 necessary to secure a satisfactory result. A careful record of the pulse, 
 temperature, and respiration should be kept. If the temperature 
 rises to 102 F., and remains thus longer than two or three days, the 
 dressing should be removed, the drainage carefully examined, and the 
 parts inspected, after which, if no contra-indications exist, it is again 
 dressed as before. The same antiseptic precautions should be employed 
 with the redressing of the wound as with the operative procedure it- 
 self. 
 
 The Common Preparations for an Antiseptic Operation. Operat- 
 ing-Table. The table .should be well covered with blankets and by a 
 rubber cloth, so arranged that if the table be slightly tilted all the 
 fluids employed will be quickly discharged into a suitable-sized recep- 
 tacle placed on the floor. 
 
 The Patient. All portions of the body not to be operated upon 
 should be carefully excluded from draughts of air, and also from con- 
 tact Avith antiseptic fluids, by wrapping them around and isolating 
 them from the immediate field of operation by suitably arranged rub- 
 ber cloths. 
 
 The parts to be operated upon, together with their contiguous 
 surroundings, must be made entirely aseptic by shaving, and by scrub- 
 bing them with a stiff brush and soap and water, after which they 
 should be rinsed in the strong solution of carbolic acid or chlorine 
 water, and wrapped in towels saturated by a strong antiseptic fluid. A 
 saturated ethereal solution of iodoform may be poured over the imme- 
 diate site of the operation, and the antiseptic wraps omitted if the op- 
 eration is to be commenced in a few moments. 
 
 The surroundings, for a foot or two outside the immediate field of 
 the operation, should be isolated from it by towels, saturated by strong 
 antiseptic fluid, with which they are kept thoroughly wet, and, when 
 soiled, they should be replaced by clean ones. 
 
 The forearms, hands, and nails of the operator, and of others who 
 are brought in contact with the wound or with the instruments, to- 
 gether with the instruments, must be made as thoroughly aseptic as 
 the parts to be operated upon. 
 
 Douching. An. attentive assistant should have the care of the 
 douching fluid, discharging it more or less constantly on the cut sur- 
 faces during the entire operation. This fluid may be used either hot 
 or cold, according to the requirements of the individual cases. If, for 
 any reason, the fluid becomes exhausted, or the operation be tempo- 
 rarily suspended, the incised surfaces must be at once enveloped by 
 towels saturated by an antiseptic fluid. 
 
 The Wound. All bleeding points requiring a ligature should be 
 tied with catgut, the wound itself closed with catgut, when prac- 
 ticable, and thoroughly drained. Iodoform can be dusted on and
 
 TREATMENT OP OPERATION-WOUNDS. 53 
 
 around the seat of the wound, after which the kind of dressings are 
 applied that have been selected to complete the antiseptic treatment. 
 These dressings should be removed as soon as the discharges from the 
 wound have soiled their external surface. Furthermore, care must be 
 taken that the external dressings be kept closely in contact with the 
 surface of the patient for a considerable distance from the operation- 
 wound ; otherwise, unfavorable atmospheric influences may be ad- 
 mitted to the wound. 
 
 Open Dressing, The so-called open dressing consists in washing 
 the wound cavity with the strong carbolic-acid solution at the com- 
 pletion of the operation, after which it is placed upon a suitable 
 cushion of oakum, and over it is laid a thin piece of gauze, which is 
 kept moistened with a solution of carbolic acid. The wound is washed 
 two or three times daily by gentle irrigation with a carbolic solution, 
 after which balsam of Peru is poured into it. All the dressings are to 
 be kept clean. If antero-posterior coaptation be desired, the anterior 
 angle of the wound is drawn together by two or three stitches to pre- 
 vent exposure of the bone, otherwise no mechanical agents are applied 
 to the wound. 
 
 The success which is said to have attended this method in the hands 
 of the late Prof. James B. Wood, can but cause the skeptical surgeon to 
 wonder at the necessity of the details of the Lister and other methods. 
 
 PKECAUTIONAKY REQUIREMENTS. 
 
 These requirements, and their importance, were stated some time 
 previously. 
 
 Stimulants, of which brandy, whisky, champagne, ammonia, nitrite 
 of amyl, digitalis, etc., are examples, enter into common use. Some 
 one or more of these should be at hand during an operation, irre- 
 spective of its length or requirements. 
 
 For purposes of administration, the hypodermic and Davidson's 
 syringes are most convenient. Under no circumstances must fluids 
 be administered by the mouth, if the patient be unconscious, except 
 by the medium of a stomach-tube. 
 
 Tenaculum. Its use has been sufficiently emphasized to render 
 the importance of its presence evident. 
 
 Electric Battery. This must always be thought of when the na- 
 ture of the operation, or condition of the patient, may give rise to the 
 subsequent failure of the circulatory or respiratory powers. 
 
 Tracheotomy Tube. Although this is not necessary to the per- 
 formance of tracheotomy or laryngotomy, when indications suddenly 
 arise calling for either, yet it is better to be provided with one. The 
 surgeon must not overlook the fact that the death of a patient due to 
 the absence of a tube, or to the loss of time consumed in seeking for 
 one, is unpardonable.
 
 54: OPERATIVE SURGERY. 
 
 Elastic Bandages. These are not only important in preventing 
 the loss of blood, but, as heretofore stated, doubly important, when 
 applied to the limbs, in forcing the blood contained in them into the 
 center of circulation, as in cases of impending death from shock 
 due to the loss of blood. They are, in my opinion, of greater prac- 
 tical utility for immediate use, than the more elaborate instruments 
 employed in transfusion. They will certainly bridge over, better than 
 any other expedient, the interval of time necessary to prepare for the 
 use of the transfusion apparatus. 
 
 Artificial Respiration. No one can be safely intrusted to admin- 
 ister an anaesthetic, or to attempt any operative procedure, who is not 
 familiar with the manipulations necessary to the proper performance 
 of this means of resuscitation. It is, in fact, the only one of the re- 
 quirements which can, and should, be continuously employed until 
 the safety of the patient is assured, or until death is an established 
 fact. 
 
 Transfusion. If the operation be of such a nature that a great 
 loss of blood is assured, arrangements should be perfected for the rapid 
 performance of this measure. 
 
 Finally, a surgeon should not begin an operation, be it of greater 
 or lesser magnitude, without having carefully rehearsed its various 
 steps in his mind, together with the possible complications that may 
 arise, and the best means of combating them. 
 
 Precautions of this kind serve to distinguish the careful and con- 
 scientious surgeon, who places a proper value upon human life and a 
 just professional reputation, from the one who operates only because 
 the opportunity is offered, and considers the details tedious or worth- 
 less, because he has not had sufficient patience or faith to practice 
 them. He trusts to luck, and often attributes his results to an in- 
 scrutable Providence ; more especially when the patient succumbs. 
 
 SPECIAL EMEEGESTCIES. 
 
 While the scope of this work will not admit of an extended con- 
 sideration of these emergencies, still it is the author's earnest desire to 
 sufficiently emphasize their importance, that those desiring more ex- 
 tended information will seek it from other and more extended sources. 
 Unexpected emergencies not infrequently occur during the course of an 
 operation, even though it be of a minor character. The anaesthetic 
 given to relieve pain may, from unknown reasons, prove a treacherous 
 ally, and, by its unexpected depressing influence, surround the case 
 with greater gravity than that of the condition demanding the opera- 
 tion. This emergency, together with the suffocation that may be 
 caused by the solid contents of an incautiously fed stomach finding 
 their way into the air-passages, has been quite fully considered in the 
 preceding pages.
 
 TREATMENT OF OPERATION-WOUNDS. 55 
 
 SJiock. The symptoms of this important nervous state especially 
 demand a careful study on the part of those who contemplate prac- 
 ticing surgery. It may exist before, occur during, or follow an 
 operation ; and, in either instance, may depend on loss of blood, or 
 be the result of a physical injury, or both combined. Shock may be 
 slight in degree, or be characterized by syncope, which maybe fol- 
 lowed by collapse. Shock due to the loss of blood has characteristics 
 somewhat distinctive from that dependent on mutilation of the soft 
 parts. In the former, the cold, clammy surface, feeble, fluttering 
 pulse, extreme pallor of the mucous surfaces, great restlessnesss, and 
 sighing respiration are especially prominent. 
 
 Treatment of Shock. The severity as well as the cause will very 
 much modify the treatment. If the shock be slight, lower the head, 
 admit fresh air, and administer a stimulant. If collapse be impending, 
 to the preceding should be added hot stimulating enemata, heat to the 
 body by means of bottles filled with hot water, or hot plates placed 
 upon the abdomen and chest, hypodermic injections of brandy or ether, 
 and inhalation of amyl nitrite. Small doses of opium can be cau- 
 tiously administered if nervous irritation be marked, or the shock be 
 due to loss of blood. Transfusion, either sanguineous or saline, and 
 the application of Esmarch's bandage to the extremities, comprise the 
 additional means to be employed when the collapse depends on the 
 loss of blood. 
 
 Air in the Veins. This accident is associated with operations upon 
 the portions of the body where the venous circulation is markedly in- 
 fluenced' by the force of aspiration, as, in the regions of the neck, 
 chest, and axillae, where, if a vein connected with a morbid growth, 
 be nicked while on the stretch, or otherwise divided, it may remain 
 open sufficiently to admit the sucking in of air, by reason of the ten- 
 sion of its walls. 
 
 Symptoms. The local symptoms are a bubbling or hissing sound 
 at the seat of hemorrhage, sometimes attended with air-bubbles. The 
 patient suddenly utters a cry, becomes pallid with anxious facies, 
 labored breathing, and livid lips. Eapid insensibility or convulsions 
 may be the principal features. Sudden death not infrequently oc- 
 curs. 
 
 Treatment. The treatment must be quick, decisive, and persist- 
 ent. Close the opening at once with the finger and tie the vessel. 
 Artificial respiration and stimulation as applied to shock must be 
 thoroughly employed. 
 
 Preventive Treatment. This consists in taking such measures as 
 shall tend to prevent the entrance of air. 1. Pressure upon the vein 
 by the fingers at its proximal portion during an operation. 2. Avoid 
 incisions during inspiration, especially when in the vicinity of large 
 veins, and when the veins may be held open by disease of their coats
 
 56 OPERATIVE SURGERY. 
 
 or of the surrounding tissues. 3. If a vein be cut, compress it at 
 once, and then apply a ligature to it. 
 
 If the means here given be carefully applied, the danger of this 
 complication need not annoy the surgeon. 
 
 CHAPTER IV. 
 
 LIGATURE OF ARTERIES. GENERAL CONSIDERATIONS. 
 
 AETEEIES are ligatured in their continuity or at their divided ex- 
 tremities. Under this heading, however, will be considered the liga- 
 turing in their continuity only. Nearly all arteries to which ligatures 
 are thus applied can, from their association with the soft and hard 
 parts, be said to possess certain guides, which, when carefully adhered 
 to, indicate with precision their position beneath the surface. 
 
 The guides to ligaturing arteries in the living subject are practi- 
 cally four in number : 1. The linear guide. 2. The muscular guide. 
 3. The contiguous anatomical guide. 4. The pulsation and color of 
 the vessel. 
 
 The linear guide to an artery is a line drawn upon the external sur- 
 face so as to correspond with the established course of the vessel be- 
 neath. Its extremities are usually indicated by the relations which 
 the vessel bears to fixed bony prominences. 
 
 The muscular guide is based upon the relation which the vessel 
 bears to some portion of a well-developed superficial or deep muscle, 
 the outline of which can be quite readily traced if the muscle be 
 placed upon the stretch. If the border of a muscle be given as the 
 guide, it must not be forgotten that, in case it be unusually developed, 
 or have a broader origin and insertion than common, it will overlap 
 the vessel, and thus may lead the surgeon astray. Under these cir- 
 cumstances he must direct his attention unerringly to the contiguous 
 anatomical guides, which include the relations that a vessel bears to 
 its immediate surrounding parts, and, when taken in connection with 
 its pulsation, lead directly to it.. The contiguous guides may be mus- 
 cular, if a muscle be ascertained to bear an established relation to it ; 
 or bony, when a bony prominence is in close contact with it ; or nerv- 
 ous, when a certain nerve is known to lie in a definite relation with 
 it; or' vascular, when vessels of an established arrangement exist. 
 And, finally, the sheath of the vessel itself becomes a valuable guide 
 when it is present and considered in connection with the others. Some 
 of the large vessels, of which the common carotid and femoral arteries 
 are the most striking examples, possess well-developed sheaths, while
 
 LIGATURE OF ARTERIES. GENERAL CONSIDERATIONS. 
 
 57 
 
 the smaller arteries are surrounded by a greater or lesser amount of 
 areolar tissue. The larger arteries, as the popliteal, femoral, and sub- 
 clavian, are each accompanied by a single vein which commonly runs 
 in a definite relation with them. The smaller ones, those of the ex- 
 tremities, etc., are attended by satellite veins, known as the vena3 
 comites, usually two in number ; however, that is not invariable, since 
 three or more are often seen. The vessels are distinguished from each 
 other by the darker color of the veins and the lighter or pinkish color 
 of the artery. If three vessels are seen, the middle one is almost cer- 
 tain to be the artery ; if more than three exist, the third vein usually 
 rests upon the artery ; if pressure be made upon them, the veins are 
 distended, and the artery is collapsed on the distal side of pressure. 
 If to these facts be now added the pulsation of the artery, its location 
 is assured. The operator who relies exclusively upon the arterial im- 
 pulse as a guide may be led astray by the transmitted pulsations of 
 other vessels, or by the functional movements of parts in which the 
 artery is located. 
 
 Having determined the anatomical details, the portion of the body 
 in which the vessel is situated, is placed in position to afford all 
 available room and the best possible light ; the part of the vessel is 
 then selected, at which the surgeon feels best assured of the absence 
 of a branch of sufficient size to interfere with formation of an internal 
 clot. The primary incision is made, the center of which should, if 
 possible, correspond to the portion of the vessel to which the ligature is 
 to be applied. The length of the incision will depend upon the depth 
 of the vessel, and should always be of sufficient extent to afford easy 
 access to it. If the thumb and finger be employed to make tense and 
 to steady the integument, great care must be taken to make the trac- 
 tion equal on .the 
 respective sides 
 (Fig. 91). Other- 
 wise, after the tis- 
 sues are released, 
 the incision will be 
 outside the line of 
 the vessel, which, 
 if not noticed, will 
 lead the surgeon 
 astray ; besides, its 
 irregularity will in- 
 
 Fio. 91. Primary incision. 
 
 terfere with the necessary space and light, as well as the subsequent 
 drainage. The external incision should be made with one sweep of 
 the knife, rather than by repeated incisions, which tend to chop the 
 tissues, increasing the danger of suppuration, and correspondingly 
 lessening the prospects of union by first intention.
 
 58 
 
 OPERATIVE SURGERY. 
 
 The fascia is pinched up by the thumb-forceps, or tenaculum, care- 
 fully nicked with a scalpel, after which a grooved director is cautiously 
 passed beneath it, upon which it is then divided. The fascia should 
 not be incised the full length of the integumentary cut. The nearer 
 the approach to the vessel, the shorter should be the line of the sepa- 
 ration of the tissues, so that when the vessel is reached, the bottom 
 of the wound will somewhat resemble an inverted triangle, with its 
 apex corresponding to the artery. 
 
 The tissues beneath the fascia are to be gently separated by the 
 
 fingers, handle of the scal- 
 pel, or director ; using the 
 knife only when necessary, 
 until the sheath of the ves- 
 sel is reached, when a 
 small opening is made into 
 it about one fourth of an 
 inch being ample of suffi- 
 cient size to pass the nee- 
 dle with ease. This open- 
 ing is made by picking up 
 the sheath or condensed 
 tissue with the thumb-for- 
 ceps, and with the scalpel 
 at, or nearly at, right an- 
 gles with the forceps, care- 
 fully cutting out a button- 
 hole-shaped piece of a suit- 
 able size (Fig. 92). 
 
 The borders of the opening in the sheath are then to be separately 
 raised, to inform the operator if deeper tissues still surround the ves- 
 sel ; if so, they should be incised in a similar manner. When the pe- 
 
 FIG. 92. Opening sheath of vessel. 
 
 FIG. 93. Passing aneurism needle. 
 
 FIG. 94. Passing probe. 
 
 culiar pinkish white appearance of its coats are seen, the side of the 
 cut in the sheath nearest to the contiguous vein should be grasped and 
 raised by the forceps, and the aneurism needle, or probe, armed with
 
 LIGATURE OF ARTERIES. GENERAL CONSIDERATIONS. 
 
 59 
 
 a ligature, carefully passed around the vessel, being carried from the 
 contiguous vein (Fig. 94). When the advancing end of the ligature 
 appears at the opposite side of the vessel, it may be seized and brought 
 through by forceps, and the aneurism needle withdrawn. If the ves- 
 sel be sufficiently superficial, the ligature can be passed through the 
 eye of the needle after its passage beneath the artery (Fig. 93). If now 
 all doubts be settled as to the identity of the vessel, the ligature is tied 
 by making either the surgeon's, or the reef-knot. If it be of catgut, 
 cut both ends short and dress the wound ; if silk, cut one extremity 
 short and allow the other to hang from its most dependent part. This 
 extremity should be secured, so that it will not be unnecessarily drawn 
 upon when the wound is dressed. The length of time the ligatures 
 are to remain depends upon the size of the vessel. If tied with cat- 
 gut, this element of the operation is eliminated. 
 
 Instruments required to Ligature Arteries. An ordinary scalpel, 
 a flexible grooved director, thumb- forceps, tenacula, retractors, and an 
 aneurism needle armed with a ligature are required. 
 
 Retractors vary in size and shape. The ones recommended by 
 Profs. Mott (Fig. 
 
 95) and Parker (Fig. 
 
 96) are appropriate 
 for all practical pur- 
 poses. If neither be 
 at hand, one can be 
 devised by bending 
 the handle of the 
 
 common tablespoon to the necessary angle. 
 
 Aneurism Needle. These differ in size, shape, and arrangement. 
 
 The simplest form is combined with a director (Fig. 97) ; another in 
 
 common use has a 
 broader extremity 
 with a suitable handle 
 (Fig. 98) ; still an- 
 other with adjustable 
 
 points for the pur- 
 FIG. 96. Parker's retractor. . A 
 
 pose of securing deep- 
 seated vessels. The points must be securely screwed into position, 
 else the turning and twisting often necessary to pass it may loosen 
 them, causing it to become a source of annoyance instead of an advan- 
 
 Fio. 95. Mott's retractor. 
 
 FIG. 97. Combined director and aneurism needle.
 
 60 
 
 OPERATIVE SURGERY. 
 
 tage (Fig. 99). Also one with a lateral curvature may be employed. 
 
 Fig. 100 is a representation of the safest needle with movable points 
 
 now in use. It is 
 known as the " Mov- 
 able Immovable An- 
 eurism Needle," 
 and also as the 
 " Student's Aneu- 
 rism Needle." It 
 was devised by 
 Dr. S. W. Fletch- 
 er, of Pepperell, 
 Mass., while a stu- 
 dent ; hence the 
 name sometimes 
 given to it. 
 
 OPERATIONS OH" 
 SPECIAL ARTERIES. 
 
 Ligature of the 
 Abdominal Aorta, 
 This vessel can be 
 ligatured at its 
 lower two inches 
 that is, below the 
 origin of the inferior mesenteric by 
 two or three methods. 
 
 Contiguous Anatomy. The omen- 
 turn, intestines, peritoneum, sympa- 
 thetic nerves, and mesentery lie in 
 front ; the left lumbar veins, receptac- 
 ulum chyli, thoracic duct, and ver- 
 tebral column behind ; on the right 
 FIG. 99. Mott's f^e inferior vena cava, vena azygos, 
 
 aneurism J 
 
 needle. and thoracic duct. At the left no 
 
 structures are liable to be injured. 
 The Linear guide to the vessel is the linea alba. 
 Operation. First Method (Cooper). With the 
 patient on the back and the legs flexed, make an 
 incision, three or four inches in length straight or 
 curved to the left of the umbilicus, to which the 
 center of the incision may correspond (Fig. 102, a, 
 a], downward through the various tissues comprising 
 the abdominal wall at this point, to the peritoneum, dividing each on 
 a director. Check all oozing and carefully incise the peritoneum, se- 
 
 FIG. 100. 
 Student's needle. 
 
 Byrne's needle
 
 LIGATURE OF ARTERIES. 
 
 61 
 
 curing its borders to prevent them from retreating outward behind 
 the abdominal walls. 
 
 Turn the patient toward the right side, or tilt the table in that 
 direction, to aid the displacement of the in- 
 testines to one side ; scratch through the 
 peritoneum covering the vessel carefully at 
 its left side, pass the needle from the vena 
 cava from behind forward, closely hugging 
 the vessel and carefully avoiding the sym- 
 pathetic nerves and inferior vena cava. 
 This operation should be done with strict 
 antiseptic precautions. If it be possible, 
 the temperature of the operation - room 
 should be 85 F. at least, and the room 
 should have been thoroughly disinfected. 
 If it be necessary to remove the intestines 
 from their cavity, they must be kept 
 wrapped in antiseptic gauze wet with warm 
 water. Linen cloths wet with a warm, 
 though weak, solution of carbolic acid, or bichloride of mercury 
 (1-10,000), may be substituted for the antiseptic gauze. 
 
 Second Method (Murray). This leads to the vessel without open- 
 ing into the abdominal cavity. 
 
 Linear Guide to the Operation. A line drawn from the apex of 
 
 FIG. 101. Inferior vena cava 
 and abdominal aorta. 
 
 Left. 
 
 FIG. 102. Linear guides to iliac arteries. 
 
 Riffht. 
 
 the tenth rib downward and forward, to within about one inch of the 
 anterior superior spine of the ilium (Fig. 102, i, right). 
 
 Contiguous Anatomy. The ureter lies to the outer side. In other 
 respects the relations of the vessel are similar in both methods.
 
 62 OPERATIVE SURGERY. 
 
 Operation. Divide the various tissues on a grooved director down 
 to the peritoneum ; the hand is then inserted into the wound, and 
 the peritoneum, intestines, and ureter are raised carefully upward and 
 inward, readily exposing the vessel to view. The artery is then raised 
 with the finger and the ligature passed as before. It can be reached 
 through an incision extending from the end of the last rib to the an- 
 terior superior spinous process of the ilium. 
 
 Results. It has been ligatured ten times, and in every instance 
 has proved fatal, death occurring from within three or four hours to 
 ten days. 
 
 Ligature of the Common Iliac Arteries. These vessels average 
 about two inches in length, and should be ligatured at a point near- 
 est to their middle. They commonly begin at the left of the mid- 
 dle of the body of the fourth lumbar vertebra, and pass downward 
 and outward to the sacro-iliac synchondroses. 
 
 Linear Guide to the Vessels. A line drawn between the highest 
 portions of the iliac crests corresponds very nearly to their point of 
 origin. Two lines drawn a little to the left of the center of this one, 
 and carried downward and outward between, but a little nearer the 
 pubes, than to the anterior spinous process of the ilium, mark the 
 course of the vessels downward (Fig. 102, left). 
 
 There are two general methods of access to them ; one by entering 
 the abdominal cavity in front, the other by raising the peritoneum 
 through an incision made at the side of the abdomen. 
 
 . First Method. At this time this method is not generally accept- 
 ed as a substitute for the latter, except in cases where the latter is of 
 doubtful expediency. If the surgeon be able to command complete 
 
 asepsis, the advisability of the latter ope- 
 ration is greatly enhanced ; if otherwise, 
 it should not be attempted unless the 
 situation of the disease calling for it ren- 
 ders the former impracticable. The outer 
 border of the rectus muscle, or more prop- 
 erly the linea semilunaris, is the best su- 
 perficial guide to the vessel in this meth- 
 od. The linea semilunaris extends from 
 the lower portion of the seventh rib in 
 
 a slightly outward arched direction 
 FIG. 103. Venous relations of .. ; . 
 
 iliac arteries. downward to the spme of the pubes. In 
 
 a normal abdomen these lines are about 
 
 three inches from the umbilicus. An incision through the linea alba 
 below and even extending a little above the umbilicus, may be em- 
 ployed likewise (Fig. 102, , right). The relations of the common iliac 
 arteries and veins are intricate and dissimilar (Fig. 103), and should 
 be carefully memorized.
 
 LIGATURE OF ARTERIES. 
 
 63 
 
 PLAN OF THE RELATIONS 
 In front. 
 
 Peritoneum. 
 
 Small intestines. 
 Sympathetic nerves. 
 Ureter. 
 
 OF THE COMMON ILIAC ARTERIES. (GRAY.) 
 
 In front. 
 Peritoneum. 
 Sympathetic nerves. 
 Rectum. 
 
 Superior hsemorrhoidal artery. 
 Ureter. 
 
 
 Outer side. 
 
 Inner side. 
 
 {Bight ~] 
 
 Vena cava. 
 
 Left common 
 
 common I 
 
 Right common 
 
 iliac vein. 
 
 iliac j 
 
 iliac vein. 
 
 
 artery. J 
 
 Psoas muscle. 
 
 
 Behind. 
 
 Right and left common 
 iliac veins. 
 
 Left ^ 
 common I 
 
 iliac 
 . artery. J 
 
 Behind. 
 
 Left common 
 
 iliac vein. 
 
 Outer side. 
 Psoas muscle. 
 
 Operation. An incision, five inches in length, and three inches to 
 the left of the median line, is carefully made into the abdominal cav- 
 ity ; the intestines are pushed aside, a small opening is scratched 
 through the peritoneum, and the vessel ligatured by passing the nee- 
 dle from without inward on the right and from within outward on the 
 left side. That is to say, pass it from, the vein nearest the vessel. 
 The external wound is then closed as in ovariotomy. 
 
 FIG. 104. Incision for ligaturing common iliac artery, a. Peritoneum, b. Ureter. 
 c. Common iliac artery, d. Common iliac vein. /. Psoas muscle. 
 
 If it be necessary to remove the intestines from the abdominal 
 cavity, they should be protected the same as in the ligaturing of the
 
 OPERATIVE SURGERY. 
 
 abdominal aorta, and under all circumstances the most rigid antisep- 
 tic care must be enforced. 
 
 Results. They are, thus far, sufficiently satisfactory to warrant 
 the employment of this method when other methods are of a question- 
 able utility. 
 
 Second Method. Without opening into the abdominal cavity. 
 Linear Guide to Operation. First (Crampton). A line drawn 
 from the apex of the last rib, downward and a little forward nearly to 
 the crest of the ilium, then carried forward parallel with it to a 
 little below the anterior superior spine (Figs. 102, c, left, and 104). 
 
 Second (McKce). A line drawn downward from the tip of the 
 eleventh rib to one and a half inches within the anterior superior 
 
 spine, then carried down- 
 ward and forward and 
 curved upward, abruptly 
 terminating above the in- 
 ternal abdominal ring 
 (Figs. 102, b, left, and 105). 
 Muscular Guide. 
 There is no superficial mus- 
 cular guide to the common 
 iliac artery except the rec- 
 tus in the median opera- 
 tion. The inner border 
 of the psoas magnus is, 
 however, an undeviating 
 and markedly prominent 
 deep muscular guide. The 
 contiguous anatomy is in- 
 dicated by the plan of the 
 preceding method. 
 
 Operation. Place the 
 patient on the back, the 
 body inclined to the opposite side, and with the thighs flexed suffi- 
 ciently to relax the abdominal walls. By repeated divisions on the 
 grooved director, the various layers of the tissues composing the ab- 
 dominal walls are divided down to the fascia transversalis, which is 
 cautiously raised from the peritoneum at the upper end of the wound, 
 where it is less dense and less firmly attached, and a small opening 
 made into it, through which the finger or a large grooved director can 
 be passed, and upon which the fascia is divided to the full extent of 
 the wound. The hand of an assistant, who should stand on the op- 
 posite side of the body, should then be introduced into the wound and 
 the peritoneum raised gently upward and inward, while the operator, 
 by the aid of the finger or handle of the scalpel, separates it carefully 
 
 FIG. 105. Ligature of primitive iliac artery.
 
 LIGATURE OF ARTERIES. 65 
 
 from the tissues beneath. When the psoas magnus is reached, the 
 surgeon will then know the exact location of the artery. If the exter- 
 nal iliac artery be first felt, it is to be followed upward to the common 
 iliac ; when the common iliac is reached, the areolar tissue surround- 
 ing it is scratched aside by the finger or a director, and the needle 
 passed, the one with the adjustable end being preferable. 
 
 Dangers. The dangers attending this operation are of consider- 
 able magnitude. The peritoneum may be lacerated, the ureter in- 
 cluded in the ligature, or the veins punctured by the needle. The 
 assistant who raises the peritoneum should keep the fingers closely 
 approximated, using both hands, if necessary, and being careful that 
 the fingers do not become too much flexed, else they may lacerate it. 
 If the patient struggle, vomit, or cough, the peritoneum should be 
 permitted to return to its normal site until quiet is again restored. 
 The traction necessary to separate and elevate it can not be made too 
 carefully, and it is better if it be done during the acts of expiration, 
 since at this time less downward pressure will be made by the abdom- 
 inal contents. Large, broad retractors are sometimes employed for 
 this purpose, but they are much less reliable than the hands of an in- 
 telligent assistant. 
 
 The ureter crosses the artery at its point of bifurcation ; but it is 
 in little danger, since it is usually raised together with the peritoneum 
 and its subjacent tissue. The veins can be avoided by always remem- 
 bering to pass the needle from them. This will be somewhat difficult 
 on the right side, owing to the large venous trunks in close contact 
 with it. If the vein obscures the arterial trunk, pressure upon it 
 below the point to be ligatured will diminish its size, by obstructing 
 the venous return, which will permit the easy exposure of the artery. 
 
 Fallacies. The external iliac artery may be mistaken for the com- 
 mon iliac artery. The relation of the sacro-vertebral prominence to 
 the external iliac artery should settle this doubt. The ligature may 
 be applied too near the bifurcation, owing to the difficulty of finding 
 it, on account of obscure light and the intimate relation of the vessels. 
 Care only will prevent this with certainty. 
 
 Results. This vessel has been ligatured sixty-eight times, with 
 sixteen recoveries, giving a rate of mortality of about seventy-seven 
 per cent. 
 
 Ligature of Internal Iliac Artery. This vessel is about an inch 
 and a half in length, extending from the bifurcation of the common 
 iliac downward and forward to near the upper border of the great 
 sacro-sciatic foramen. 
 
 Methods of Operating. Two or three incisions are given with a 
 
 view of reaching this vessel. Either of the incisions employed in the 
 
 ligature of the common iliac will easily lead to it ; or, an incision five 
 
 inches in length, parallel with the epigastric artery ; or, a semicircular 
 
 5
 
 66 
 
 OPERATIVE SURGERY. 
 
 Outer side. 
 Psoas magnug. 
 
 incision about seven inches in length, two inches to the left of the 
 umbilicus, with its convexity outward, and ending just to the outer 
 side of the external abdominal ring. It can be easily tied through an 
 incision made into the abdominal cavity in the median line below the 
 umbilicus. 
 
 This vessel possesses no practical linear or muscular guide other 
 than it lies to the inner side of the psoas magnus. 
 
 PLAN OF THE RELATIONS OF THE INTERNAL ILIAC ARTERY. (GRAY.) 
 
 In front. 
 Peritoneum. 
 Fascia. 
 Ureter. 
 
 ( Internal } 
 s iliac > 
 
 ( artery. ; 
 
 
 
 Behind. 
 
 Internal iliac vein. 
 Lum bo-sacral nerve. 
 Pyriformis muscle. 
 
 Operation. The tissues are successively divided in the line selected 
 for the primary incision, as in the operation for ligaturing the primi- 
 tive iliac ; the peritoneum is elevated in the same cautious manner, the 
 connective tissue scratched away, and the ligature carried from within 
 outward, taking care to avoid the ureter, and the external iliac vein 
 as it lies at the angle of bifurcation of the primitive iliac artery. 
 
 Fallacies. The internal might be mistaken for the external iliac 
 
 artery ; this doubt, however, can be 
 quickly settled if the course of the 
 latter vessel be considered. 
 
 Results. Of twenty-six cases, 
 eighteen terminated fatally, mak- 
 ing a rate of mortality of about 
 seventy per cent. 
 
 Ligature of the Gluteal Artery. 
 This vessel passes out of the pel- 
 vis at the upper border of the great 
 ischiatic notch, above the pyrifor- 
 mis muscle. 
 
 The Linear guide is a line ex- 
 tending from the posterior superior 
 spinous process of the ilium, to the 
 trochanter major, when rotated in- 
 ward. The artery is beneath the 
 and j unc ^ on f tne upper and middle 
 thirds of this line (Fig. 106, a) 
 
 FIG. 
 
 106. Linear guides to 
 sciatic arteries.
 
 LIGATURE OF ARTERIES. 
 
 67 
 
 107. A. Gluteus 
 maximus. B. Gluteal ar- 
 tery. C. Gluteal veins. 
 
 Anatomically it lies in the upper border of the notch, which is a 
 guide to it ; it is accompanied by its vense comites, and is covered by 
 the glutens maximus muscle. 
 
 Operation. Place the patient on the abdomen, with the thigh 
 extended and rotated inward ; make an incision 
 five inches in length in the course of the line in- 
 dicated. The direction of the incision will cor- 
 respond to the course of the fibers of the glute- 
 ns maximus, which can be separated with the 
 handle of the scalpel ; liberate the artery from 
 its accompanying veins and pass the ligature in 
 the most convenient manner (Fig. 107). 
 
 Fallacies. It may be mistaken for either of | 
 its venae comites ; otherwise no fallacy will occur. \ 
 Results. The operation itself implies but | 
 little danger to the patient. 
 
 Ligature of the Sciatic Artery. This vessel i 
 escapes from the pelvis below the pyriformis 
 muscle, and passes downward in the interval 
 between the tuberosity of the ischium and the 
 trochanter major. 
 
 The Linear guides to the vessel are two in 
 number, one of which is drawn parallel with the 
 
 linear guide to the gluteal artery, only about an inch and a half lower 
 down. A second extends from just below the posterior superior spinous 
 
 process of the ilium to the outer side of 
 the tuberosity of the ischium (b, Fig. 106). 
 Its deep muscular guide is the lower 
 border of the pyriformis, beneath which 
 it descends from the pelvis. 
 
 Contiguous Anatomy. It is covered 
 by the gluteus maximus ; the sciatic 
 nerve accompanies it, and it is posterior 
 to the pudic artery. 
 
 Operation. An incision is made 
 FIG. 108. Ligature of sciatic artery, three or four inches in length on one of 
 
 the lines indicated, the fibers of the 
 
 gluteus maximus separated, the nerves and veins are pushed aside, 
 and the ligature is carried around the vessel, care being taken to avoid 
 the vein which lies to its outer -side (Fig. 108). 
 
 Fallacies. This artery might be mistaken for the pudic artery, 
 which lies internal to it ; however, the direction taken by the respect- 
 ive vessels should make the distinction easy. 
 
 Results. The prognosis to life is always good so far as the opera- 
 tion itself is concerned.
 
 68 
 
 OPERATIVE SURGERY. 
 
 Ligature of the Internal Pudic Artery. This vessel escapes from 
 the pelvis through the greater sacro-sciatic foramen below the pyri- 
 formis muscle, lying internal to the sciatic artery ; it then enters the 
 pelvis through the lesser sacro-sciatic foramen, and runs along the 
 inner surface of the ramus of the ischium and pubes, till it divides 
 into its terminal branches. 
 
 It may be ligatured in two situations : 1. At the greater sacro- 
 sciatic foramen. 2. In the perineum. In the first situation, the in- 
 
 FIG. 109. Linear guide to pudic artery in perineum. 
 
 cision for ligaturing the sciatic artery is sufficient, the pudic being 
 found internal to that artery, and lower down, accompanied by its 
 
 veins and the pudic nerve. In the peri- 
 neum, the linear guide to the operation ex- 
 tends from the arch of the pubes to the 
 inner border of the tuber ischii (Fig. 109). 
 The artery is situated about an inch and a 
 quarter above the margin of the tuber ischii. 
 Contiguous Anatomy. It runs along 
 the outer side of the ischio-rectal fossa, rest- 
 ing upon the obturator internus muscle, 
 covered by the obturator fascia, and accom- 
 panied by the pudic veins and the internal 
 pudic nerve. 
 
 Operation. The patient is placed in the 
 lithotomy position, and an incision is made 
 about four inches in length in the course of 
 the line indicated ; the tissues are carefully 
 divided down to the vessel, which is then isolated from its veins and 
 nerves and tied (Fig. 110). If care be not taken the cms penis will 
 
 FIG. 110. Passing needle 
 around pudic artery.
 
 LIGATURE OF ARTERIES. 69 
 
 be cut. The introduction of a sound into the urethra will so posi- 
 tively define its outlines, that the danger of wounding the parts unne- 
 cessarily will be obviated. 
 
 Ligature of the Dorsalis Penis Artery. This artery may be tied on 
 the dorsurn of the penis by making an incision an inch in length at 
 either side of the dorsum of the penis, and on a line parallel to the cen- 
 ter of its long axis. It is superficial, and is attended by its veins and 
 nerves, which should be carefully avoided in passing the needle. 
 
 Ligature of the External Iliac Artery. This vessel is about four 
 inches long, and passes obliquely downward and outward, nearly cor- 
 responding to a line drawn from the left side of the umbilicus to mid- 
 way between the anterior superior spinous process of the ilium and 
 the symphysis pubis. It is ligatured at about the middle of its course. 
 It has no superficial muscular guide ; however, the psoas magnus, at the 
 inner border of which it lies, is a most important deep muscular guide. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE EXTERNAL ILIAC ARTERY. (GRAY.) 
 
 In front. 
 
 Peritoneum, intestines, and iliac fascia. 
 I Spermatic vessels. 
 
 Genital branch of genito-cmral nerve. 
 Poupart's -< ,, ... . 
 _ . ' Circumflex iliac vein. 
 
 I Lymphatic vessels and glands. 
 
 Outer side. Inner side. 
 
 Psoas magnus. \ * ^rnal J External iliac vein and vas 
 
 Iliac fascia. 1 ac ( deferens at femoral arch. 
 
 (. artery. ; 
 
 Behind. 
 
 External iliac vein. 
 Psoas magnus. 
 Iliac fascia. 
 
 Operation. Before beginning the operation evacuate the contents 
 of the bladder and rectum of the patient, place him in a recumbent 
 position, with the thigh slightly flexed, and the body inclined to the 
 opposite side. A curvilinear incision is then made, with the convexity 
 downward, beginning about an inch above Poupart's ligament, and 
 immediately to the outer side of the external abdominal ring, and 
 terminating on a level with, but about two inches internal to, the 
 anterior superior spinous process of the ilium (Fig. Ill, c). The 
 superficial fascia, aponeurosis of the external oblique, the muscular 
 fibers of the internal oblique, and the transversalis are separately divided 
 upon a grooved director. The fascia transversalis is now carefully 
 picked up with the thumb-forceps, and a small opening made through 
 it, into which the director is inserted and the fascia divided. The 
 peritoneum and its subserous tissue are then carefully raised from the 
 iliac fascia, and pressed upward and inward until the outer border of
 
 70 
 
 OPERATIVE SURGERY. 
 
 the psoas magnus is ascertained, when, after a little further separation, 
 the vessel is felt pulsating at its inner margin. 
 
 FIG. 1 11. Linear guide to external iliac, 
 epigastric, and femoral arteries. 
 
 FIG. 112. Ligature of external iliac. 
 
 The condensed areolar tissue constituting its sheath is then opened, 
 and the needle carefully inserted between the vein and artery, from 
 within outward (Figs. 112 and 113). If the incision be made only 
 
 about a third of an 
 inch above Pou- 
 part's ligament 
 (Fig. 102, Bright), 
 it will come upon 
 the iliac fascia 
 without coming 
 in contact with 
 the peritoneum, 
 since the latter is 
 
 FIG. 113. Ligature of external iliac, a. Aponeurosis of exter- reflected upward 
 nal oblique muscle, b. Internal oblique and transversalis -, , , -i , 
 
 fibers, c. Ganglion sometimes found on artery, d. Borders ana oaCKWard 
 of sheath of vessels, e. Iliac artery. /. Iliac vein. g. Psoas- the pelvis a little 
 magnus muscle, h. Deep circumflex artery, i. Deep epigas- a Vv OV p fhi<s noint 
 trie artery, j. Superficial branches. 
 
 Fallacies. The 
 
 external oblique aponeurosis may be mistaken for the deep layer of 
 fascia. The muscular fibers of the internal oblique will then be 
 mistaken for those of the external oblique. If, however, the direc- 
 tion of the fibers of the respective muscles be recalled, and, further- 
 more, that the external oblique has no muscular fibers in this situa- 
 tion, the mistake will be quickly rectified. The fascia transver- 
 salis may be mistaken for the peritoneum ; this fallacy is easily de- 
 tected by following it downward, when, if it be attached to Poupart's 
 ligament, or pass beneath it, it can not be the peritoneum, and must
 
 LIGATURE OF ARTERIES. 71 
 
 therefore be the transversalis fascia. If its relations to the previously 
 divided tissues be taken into account, together with its density and 
 opacity, this mistake can hardly occur. 
 
 The iliac fascia may be mistaken for the subserous tissue, and be 
 raised together with the peritoneum. Under such circumstances the 
 vessel will be raised upward together with the peritoneum and iliac fas- 
 cia, and will be felt pulsating in the roof rather than the floor of the 
 operation wound. This mistake can be avoided by remembering that 
 the iliac and psoas muscles are covered by a dense fascia, which passes 
 out of the pelvis beneath Poupart's ligament to which it is attached, 
 and that the artery does not lie beneath it. 
 
 If an irreducible inguinal hernia exist, or the vein be adherent to 
 the artery, then much difficulty may be experienced in properly de- 
 positing the ligature without injury to the intestines or the vein. 
 After ligaturing, the wound must be thoroughly closed by carrying the 
 sutures deeply down and close to the peritoneum, the superficial tissues 
 (integument and fascia) being united separately. If this be not done, 
 the patient will be exposed to the danger of the occurrence of a hernial 
 protrusion due to the weakening of the abdominal walls. . This is a 
 precaution which should always be taken in operations involving the 
 separation of the peritoneum. 
 
 Results. This vessel has been ligatured one hundred and seventy- 
 one times, with sixty-one deaths ; which have arisen from various 
 causes connected either with the operation itself, or the conditions 
 calling for it. 
 
 Ligature of the Epigastric Artery. This vessel is ligatured in one 
 situation only. It arises from the lower portion of the external iliac 
 (i, Fig. 113) and runs upward toward the umbilicus, between the peri- 
 toneum and the fascia transversalis. It lies at the inner border of the 
 internal abdominal ring. 
 
 Linear Guide. A line extending from the umbilicus to the mid- 
 dle of Poupart's ligament corresponds to the course of the vessel. 
 The guide to the first incision is the upper border of the middle of 
 Poupart's ligament (a, Fig. 111). 
 
 Operation. An incision is made, about three inches in length, 
 parallel with and about one inch above Poupart's ligament. The va- 
 rious layers of the abdominal wall are then divided separately upon a 
 grooved director until the fascia transversalis is reached, which is 
 opened over the artery, the veins separated from it, and the ligature 
 properly placed. 
 
 The wound should then be carefully closed, and the patient kept 
 quiet in a recumbent posture until the tissues are firmly united, else a 
 weak point in the abdominal walls may follow. 
 
 Ligature of the Deep Circumflex Iliac Artery. This vessel maybe 
 secured in two situations : 1, at the internal abdominal ring ; 2, near
 
 72 OPERATIVE SURGERY. 
 
 the anterior superior spinous process of the ilium. In the first situa- 
 tion it may be tied through the same incision as for the epigastric 
 artery (a, Fig. 111). In the second it may be secured through an in- 
 cision made parallel to Poupart's ligament and just above it to the 
 outer side of the course of the epigastric artery, through the various 
 tissues anterior to the transversalis fascia, which is then opened, the 
 artery isolated and tied. 
 
 Ligature of the Femoral Artery. The femoral artery extends from 
 Poupart's ligament to the lower extremity of Hunter's canal, at the 
 junction of the middle and lower thirds of the thigh, where it termi- 
 nates in the popliteal. It is ligatured in three situations : 1, Just be- 
 low Poupart's ligament ; 2, at the apex of Scarpa's triangle or about 
 four inches below the ligament ; 3, at its lower third or in Hunter's 
 canal. The most favorable situations are at the apex of Scarpa's tri- 
 angle and in Hunter's canal. However, circumstances often arise 
 which necessitate its being tied, irrespective of the stereotyped situ- 
 ations. 
 
 The linear guide to the artery, throughout its whole course, is a 
 line drawn from midway between the anterior superior spinous pro- 
 cess of the ilium and the symphysis pubis to the inner condyle of the 
 femur (Fig. 114). 
 
 A line drawn from the origin of the adductor longus to the inser- 
 tion of the adductor magnus tendon into the internal condyle of the 
 femur also corresponds to the femoral artery at its lower third (Fig. 
 114, a). 
 
 FIG. 1 14. Linear guides to femoral artery. 
 
 The Muscular Guide. The sartorius is given as its muscular 
 guide ; the artery is at its inner border in the upper third, behind it 
 in its middle, and at its outer side in its lower third. The better 
 guide to the lower third is the inner border of the tendon of the ad- 
 ductor magnus. This tendon can be quite easily felt, but care must 
 be taken, otherwise it will be mistaken for one of the ham-string 
 tendons.
 
 LIGATURE OF ARTERIES. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE FEMORAL ARTERY. (GRAY.) 
 
 In front. 
 Fascia lata. 
 
 Branch of anterior crural nerve. 
 Sartorius (middle part). 
 Long saphenous nerve. 
 Aponeurotic covering of Hunter's canal (lower part). 
 
 Inner side. 
 
 Femoral vein (at upper part). 
 Adductor longus. 
 Sartorius. 
 
 Outer side. 
 
 ( Femoral ) Vastus internus. 
 i artery, > Femoral vein (at lower part). 
 
 Behind. 
 Psoas muscle. 
 Profunda vein. 
 Pectineus muscle. 
 Adductor longus. 
 Femoral vein (middle part). 
 Adductor magnus. 
 
 Operation First Situation, Common Femoral (Fig. 115). The 
 vessel can be ligatured immediately below Poupart's ligament through 
 
 FIG. 115. Relations of femoral artery. 
 
 FIG. 116. Ligature of upper third of femoral 
 artery. 
 
 two incisions : one made in the long axis of the vessel, the other paral- 
 lel with the lower border of the ligament (I, Fig. 111). The former 
 is, however, the better method. The patient is placed upon his back.
 
 OPERATIVE SURGERY. 
 
 and the thigh flexed and rotated outward. The pulsation of the ar- 
 tery is noted by the finger, then an incision about three inches in 
 
 FIG. 117. Relation of femoral vessels. 
 
 length is made through the integument and subcutaneous tissues ; the 
 fascia lata is divided on a director in the usual manner, and the arte- 
 rial sheath, which is very dense, is opened and the needle passed from 
 within outward (Fig. 116). The vein will be noticed at its inner side, 
 inclosed in a common sheath with it, but separated from the artery 
 by a fibrous partition (Fig. 117). The attention of the surgeon should 
 be directed to the pinkish-white pulsating vessel rather than to seek- 
 ing for the vein. If the attention and manipulations be directed toward 
 the artery, the vein will remain uninjured within its compartment. 
 The lymphatic glands which are encountered should be drawn aside. 
 
 Second Situation. This is at the apex of Scarpa's triangle, or about 
 four inches below Poupart's ligament. The saphenous vein runs along 
 the inner side of this region ; its location can be determined by press- 
 ing it above, which will cause it to be distended. Place the limb as in 
 the preceding operation, and make an incision about four inches in
 
 LIGATURE OF ARTERIES. 
 
 75 
 
 length along the inner border of the sartorius muscle ; divide the tis- 
 sues down to the fascia lata, draw the sartorius to the outer side, and 
 the pulsations of the vessel will be seen beneath the fascia ; cautiously 
 open the fascia lata and the sheath of the vessel, and pass the needle 
 from within outward. The vein lies to the inner side, somewhat more 
 posteriorly than above (Figs. 118 and 119). 
 
 Third Situation or in Hunter's Canal. Flex the thigh on the 
 pelvis and the leg on the thigh, 
 with the thigh rotated outward; 
 an incision is then made along 
 
 the outer border of the tendon 
 of the adductor magnus, begin- 
 ning at a point a little below the 
 junction of the middle and lower 
 thirds of the thigh, and extend- 
 ing upward (Fig. 114, a], about 
 four inches in length, through 
 the integument and fascia, when 
 the tendon will be readily felt. 
 If the sartorius be in the way, it 
 should be drawn to the inner 
 side. Any intervening soft parts 
 are pushed aside, and the fibrous 
 canal in which the artery is con- 
 tained will be exposed, formed 
 by the tendon of -the adductor ,-, , 1Q T . 
 
 J IIG. 118. Ligature of femoral artery at 
 
 magnus with the inner border of apex of Scarpa's triangle. 
 
 the vastus internus and the fi- 
 brous reflections extending between them. The canal is cautiously 
 
 opened, and the long 
 saphenous nerve is 
 seen resting upon the 
 vessel ; this is drawn 
 aside and the needle 
 passed from without 
 inward, the vein now 
 being located poste- 
 riorly and externally 
 (Figs. 120 and 121). 
 The vessel can be lig- 
 atured in this situa- 
 
 FIG. 119. Ligature of femoral artery at apex of Scarpa's tri- * ion . ^ making an 
 
 angle, a. Superficial aponeurosis. b. Inner border of sar- incision of a similar 
 
 torius. c. Sheath of artery, d. Femoral artery. /. Long l en g t h on the linear 
 saphenous nerve, g. Internal saphenous vein, h, I em- 
 
 oral vein. guide before repre-
 
 76 
 
 OPERATIVE SURGERY. 
 
 sented (Fig. 114, i). It is not so easily secured, however, as by the 
 
 method just stated. 
 
 Fallacies. The sartorius may be mistaken for the other muscles 
 
 lying in its course. If, how- 
 ever, it be recollected that no 
 other muscles run in the same 
 direction on the anterior sur- 
 face of the thigh, and that it 
 is superficial throughout its 
 whole course, no great confu- 
 sion can arise from this falla- 
 
 (' II "% cy. The lymphatic glands 
 
 that lie over the. sheath of the 
 vessel in the upper portion of 
 
 its course may be mistaken for 
 
 FIG. 120.-Ligature of femoral artery in Hunter's tfa vegsel itgelf QWm to their 
 canal. 
 
 color and to the transmitted 
 
 pulsation. Those are irregular, movable, and can be raised upward, 
 when their apparent pulsation will cease ; moreover, the artery is be- 
 neath the fascia 
 lata, and they 
 are above it. 
 
 The tendon 
 of the adductor 
 magnus may be 
 mistaken for the 
 tendon of the 
 se mi mem bran o- 
 sus or semiten- 
 
 \s 
 
 dinosus. This 
 
 mistake Will be FIG. 121. Ligature of femoral artery in Hunter's canal, a. Sartorius 
 avoided if the muscle, pushed outward, b. Aponeurosis of Hunter's canal, c. 
 , -, i , Femoral artery, d. Long saphenous nerve pushed backward and 
 
 tenaon DC traced outward, e, Anastomotica magna. f. Femoral vein, 
 by palpation 
 
 downward ; the two latter will pass behind the internal condyle, while 
 the former will be found inserted into it. Care must be taken in liga- 
 turing the artery at the apex of Scarpa's triangle not to make the in- 
 cision too low down. The width of the hand below Poupart's liga- 
 ment is a good practical guide to its apex. In ligaturing the artery in 
 Hunter's canal, it should be remembered that the canal is located but 
 a little below the middle third of the thigh, otherwise the incision 
 will be made too low down, and the upper portion of the popliteal 
 artery secured instead. 
 
 In a very small number of cases (four) the femoral has been double ; 
 in a like number it passed behind instead of in front of the thigh. If
 
 LIGATURE OF ARTERIES. 
 
 77 
 
 it be double, the portion found will be smaller than normal, and the 
 object for which the ligature is applied will not be accomplished. If 
 the vessel be not found in its 
 common location it will be 
 necessary to seek for it else- 
 where. Deep pressure may 
 enable one to detect the site 
 of its anomalous situation. 
 
 Results. The common 
 femoral has been ligatured 
 eight times for aneurism, with 
 a rate of mortality of twenty- 
 five per cent. The superficial 
 femoral has been tied two hun- 
 dred and four times, with a 
 mortality of fifty cases. 
 
 Ligature of the Deep Fem- 
 oral Artery, or the Profunda. 
 This vessel usually comes off 
 from the common trunk one 
 or two inches below Poupart's 
 ligament. It may arise above 
 or even four inches below this 
 ligament. There is no known 
 manner of determining its site 
 prior to an operation. It arises 
 from the outer side of the com- 
 mon femoral, running slightly 
 outward, then downward and inward, passing behind the superficial 
 femoral, accompanied by its vein, which lies in front of it (Fig. 122). 
 
 Operation. This vessel can be tied through the incision for the 
 ligation of the common femoral, and is to be sought for at its outer 
 side. When found it should be carefully isolated, in order that the 
 ligature may be applied a proper distance from where the profunda 
 gives off its circumflex branches. 
 
 Fallacies. It may arise from the inner, or back portions of the 
 common femoral. If not found in the usual place, it should be sought 
 after in these latter-mentioned situations. 
 
 Ligature of the Popliteal Artery. This vessel may be ligatured 
 in two situations : at its upper and lower portions. It is continuous 
 with the femoral, beginning at the junction of the middle and lower 
 thirds of the thigh, at the termination of Hunter's canal, and passes 
 with a slight obliquity downward and outward to the lower border of 
 the popliteus muscle. 
 
 Linear Guide. The linear guide begins a little to the inner side 
 
 FIG. 122. Relation oi' the deep to the superfi- 
 cial femoral.
 
 78 OPERATIVE SURGERY. 
 
 of the middle of the upper portion of the popliteal space, and termi- 
 nates below between the heads of the gastrocnemius muscle, passing 
 midway between the condyles of the femur 
 (Fig. 123). 
 
 Muscular Guide. The artery in its upper 
 third lies to the inner border of the semi- 
 membranosus ; at its lower, midway between 
 the heads of the gastrocnemius. 
 
 Contiguous Anatomy. In the upper third 
 the internal popliteal nerve is more superfi- 
 cial than the vein and artery. The vein lies 
 in close contact with the artery, and between 
 it and the nerve. The artery is the inner- 
 most of the three ; and is the most deeply sit- 
 uated, resting on the posterior surface of the 
 femur. In the lower third, the nerve is still 
 the most superficial, but lies upon and to its 
 inner side. The vein in this situation is to 
 its inner side, and more superficial than the 
 artery, which rests upon the popliteus mus- 
 cle. This vessel should not be tied at its 
 middle third, on account of the large number 
 of branches given off at this point, together 
 with its contiguity with the knee-joint. 
 
 Operation in the Upper Portion (Fig. 
 
 123, b). The patient can be placed upon the 
 
 FIG. 123. Linear guides to J . , r 
 
 popliteal artery and great face, or, while on the back, the thigh can be 
 sciatic nerve. wc u flexed and rotated outward. The former 
 
 position is more convenient for the surgeon, but is objectionable on 
 
 account of danger to the patient. The pa- 
 tient may be placed on the side corresponding 
 
 to the limb to be operated upon, with that 
 
 thigh extended and the opposite one flexed 
 
 on the pelvis, when the safety and comfort 
 
 of both will be consulted. 
 
 An incision is made, about four inches in 
 
 length, along the inner border of the semi- 
 
 membranosus through the integument and 
 
 fascia, and is deepened by separating the are- 
 
 olar tissue with the handle of the scalpel or 
 
 the fingers. The nerve will no doubt be first 
 
 seen, and, when drawn outward, the vein will 
 
 be found lying more deeply and internal to FlG - 124. Ligation of pop- 
 
 it ; if this be now carefully isolated and drawn 
 
 in the same direction, the artery will be seen at its inner side, which
 
 LIGATURE OF ARTERIES. 
 
 79 
 
 must be separated from the surrounding tissues, and the needle carried 
 from* without inward (Fig. 124). 
 
 Operation in the Lower Portion (Fig. 123, c). Make an incis- 
 ion midway between the 
 heads of the gastrocnemius, 
 carefully avoiding the exter- 
 nal saphenous vein and nerve, 
 as they escape between the 
 heads of that muscle ; sepa- 
 rate the connective tissues 
 with the handle of the scal- 
 pel, draw the vein and nerve 
 
 to the inner side, and pass 
 ,i T, f .... FIG. 125. Ligation of popliteal, lower third, 
 
 the needle from within out- 
 ward. Its lower third may be tied below the inner 
 \ \ I tuberosity of the tibia. 
 
 The linear guide in this situation is continuous 
 with that of the posterior tibial (Fig. 132), and the 
 limb should be placed in a similar position as for lig- 
 aturing the posterior tibial. 
 
 Fallacies. The tendon of the semitendinosus 
 may be mistaken for the tendon of the semimembra- 
 nosus. At this situation the semimembranosus has 
 a large fleshy belly, which extends much nearer to 
 the median line of the popliteal space than the semi- 
 la- / tendinosus. Sometimes there are two popliteal veins, 
 \ / one on either side of the vessel. 
 
 Results. It is seldom ligatured unless it be rup- 
 tured, when both ends must' be tied. Of the three 
 or four cases thus reported, all terminated unfavora- 
 bly, due, however, to the nature of the injury. 
 
 Ligature of the Anterior Tibial Artery. It arises 
 from the popliteal, just below the lower border of 
 the popliteus muscle, passes forward between the 
 bones of the leg, above the interosseous membrane, 
 then downward on its anterior suface to the ankle- 
 joint, where it becomes thedorsalis pedis. This ves- 
 sel can be tied in three situations : at its upper, mid- 
 dle, and lower thirds ; but, two : the middle and lower, 
 FIG. 126. Linear are m ore than sufficient for all practical purposes. 
 tibSlwridonS The linear guide of the vessel is drawn on ante- 
 pedis arteries. rior surface of leg from the inner border of the head 
 of the fibula to midway between the malleoli (Fig. 126). 
 
 The muscular guide is the outer border of the tibialis anticus mus- 
 cle (Figs. 127 and 128).
 
 80 
 
 OPERATIVE SURGERY. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE ANTERIOR TIBIAL ARTERY. (GRAY.) 
 
 In front. 
 
 Integument, superficial and deep fasciae. 
 Tibialis anticus (overlaps it in the upper part of leg). 
 Extensor longus digitorum ) (oyer , - t 
 Extensor proprius polhcis l 
 Anterior tibial nerve. 
 
 Inner side. 
 Tibialis anticus. 
 Extensor proprius pollicis 
 
 (crosses it at its lower 
 
 part). 
 
 j Anterior 
 1 tibial artery. 
 
 Behind. 
 
 Interosseous membrane. 
 Tibia. 
 Anterior ligament of ankle-joint. 
 
 Outer side. 
 Anterior tibial nerve. 
 Extensor longus digitorum. 
 Extensor proprius pollicis. 
 
 FIG. 1 27. Transverse section, upper third. 
 1. Popliteus. 2, 3. Gastrocnemius. 4. 
 Soleus. 5. Peroneus longus. 6. Exten- 
 sor longus digitorum. 7. Tibialis anti- 
 cus. 8. Tibialis posticus. 9. Posterior 
 tibial artery and venae comites. 10. 
 Posterior tibial nerve. 11. Anterior tib- 
 ial artery and venae comites. 12. An- 
 terior tibial nerve. 
 
 FIG. 128. Transverse section, middle third. 
 1. Soleus. 2, 3. Gastrocnemius. 4. Flexor 
 longus pollicis. 5. Peroneus longus and bre- 
 vis. 6. Extensor longus pollicis. 7. Exten- 
 sor com. digitorum. 8. Tibialis anticus. 9. 
 Tibialis posticus. 10. Flexor longus digi- 
 torum. 11. Anterior tibial artery and ve- 
 nse comites. 12. Anterior tibial nerve. 13. 
 Posterior tibial artery and venae comites. 
 14. Posterior tibial nerve. 15. Peroneal 
 artery and venag comites. 
 
 Operation. Upper Third (Fig. 126). The great depth of the 
 vessel in this situation renders the tying of it one of the most tedious 
 of operations. Unless circumstances demand it, the ligaturing in this 
 situation should not be attempted. Fig. 127 shows the deep relations 
 of the vessel. The linear and muscular guides are similar to those of 
 the middle third. 
 
 Middle Third (Fig. 126, a). The artery in this situation lies quite 
 deep, and a good light must be had to see the bottom of the operation
 
 LIGATURE OF ARTERIES. 
 
 81 
 
 wound. Place the patient on the back with the thighs extended, the leg 
 
 turned inward, and the foot forcibly extended 
 
 to mark the outlines of the tibialis anticus 
 
 muscle. Make an incision four or five inches 
 
 in length on the line indicating the course of 
 
 the artery, down to the fascia, which is then 
 
 divided on a director. The aponeurosis is then 
 
 divided along the line of apposition between 
 
 the tibialis anticus and the extensor longus 
 
 digitorum ; it should likewise be divided 
 
 transversely to admit of the wider separation 
 
 of these muscles. The foot is now flexed, and, 
 
 with the finger, or handle of the scalpel, the 
 
 line of separation is extended directly down 
 
 to the vessel ; separate the surfaces of the 
 
 wound with spatulas, when the artery, with 
 
 its nerve and veins, will be seen, the nerve 
 
 being in front and to the outer side ; sepa- 
 rate the veins from the artery, draw the nerve 
 
 aside, and pass the ligature from without in- 
 ward (Fig. 129). 
 
 Operation at the Lower Third (Fig. 126, 
 
 J). With the limb as in the preceding in- 
 stance, extend the foot to mark the course of 
 
 the tendon of the tibialis anticus ; make an 
 
 incision along the external border of the ten- 
 don on the linear guide about three inches in 
 length. Divide the fascia on a director, and seek 
 with the finger for the space between the tibialis 
 anticus and the extensor proprius pollicis which 
 has crossed to the inner side of the vessel ; flex the 
 foot, separate these muscles, and the artery will be 
 seen accompanied by its veins and nerve, the latter 
 lying in front and a little to the outer side ; iso- 
 late the artery, and place the ligature by passing it 
 from without inward. 
 
 Fallacies. The outer surface of the head of the 
 tibia may be mistaken for the head of the fibula, 
 which will bring the linear guide too far to the in- 
 ner side of the leg, and cause the incision to be 
 made over the belly of the tibialis anticus muscle. 
 To avoid this it must be remembered that the head 
 of the fibula is more posteriorly, and constitutes 
 - Dorsalis * ne mos ^ external bony prominence at this point, 
 pedis artery. The septum between the tibialis anticus and the 
 
 6 
 
 FIG. 129. Ligature of anterior 
 tibial, middle third. 
 
 FIG.
 
 82 
 
 OPERATIVE SURGERY. 
 
 extensor longus digitorum may be indistinct or absent ; then the outer 
 border of the tibialis anticus can be determined, 1, by forcible exten- 
 sion of the tarsus ; 2, by determining its limits by the resistance to 
 lateral pressure ; 3, the line indicating the interspace may be seen at 
 the lower extremity of the incision when not visible above. 
 
 The vessel may be rudimentary or absent ; it may run more super- 
 ficially than common. So long, however, as it keeps in the proper 
 line its pulsations will lead to its detection. 
 
 Ligature of the Dorsalis Pedis Artery. This vessel is a continu- 
 ation of the anterior tibial (Fig. 126, c), beginning at the ankle-joint 
 and passing downward between the metatarsal bones of the great and 
 second toes. It is tied in one situation, and on a line which is a direct 
 continuation of the linear guide to the anterior tibial. 
 
 The muscular guide is the outer border of the tendon of the ex- 
 tensor proprius pollicis (Fig. 130). 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE DORSALIS PEDIS ARTERY. (GRAY.) 
 
 In front. 
 
 Integument and fascia. 
 Innermost tendon of extensor brevis digitorum. 
 
 Tibial side. 
 Extensor proprius pollicis. 
 
 Fibular side. 
 
 Extensor longus digitorum. 
 Anterior tibial nerve. 
 
 FIG. 131. Ligature of dor- 
 salis pedis. 
 
 ( Dorsalis ) 
 ( pedis artery, f 
 
 Behind. 
 Astragalus. 
 Scaphoid. 
 
 Internal cuneiform, 
 and their ligaments. 
 
 Operation. Extend the tarsus and forcibly 
 flex the great toe to make prominent the ten- 
 don of the extensor proprius pollicis ; make an 
 incision about three inches in length along its 
 outer border, commencing from the bend of 
 the ankle ; divide the fascia on a director, when 
 the fleshy inner portion of the extensor brevis 
 digitorum will be seen ; this should be drawn 
 outward, when the artery and its satellite veins 
 will appear ; separate the artery from them, 
 and pass the needle as best suits the conven- 
 ience of the operator (Fig. 131). 
 
 Fallacy. It may pass outside of the line 
 indicating its proper course. 
 
 Ligature of the Posterior Tibial Artery. 
 This is an artery of considerable size which.
 
 LIGATURE OF ARTERIES. 
 
 83 
 
 comes from the popliteal at the lower border of the popliteus muscle ; 
 it passes obliquely to the tibial side of the leg, goes down between the 
 superficial and deep layers of muscles to a point midway between the 
 
 FIG. 182. Linear guide to posterior tibial. 
 
 internal malleolus and inner tuberosity of the os calcis, where it 
 terminates a little further on in the external and internal plantar ar- 
 teries. It may be ligatured in three situations : at its middle third, at 
 its lower third, and as it passes behind the inner malleolus. 
 
 The linear guide of this vessel is drawn from the middle of the 
 popliteal space to midway between the inner malleolus and tuberosity 
 of the os calcis. This guide is not a feasible one, since to reach the 
 artery by cutting upon it necessitates the division of the fibers of the 
 muscles of the calf of the leg. 
 
 The linear guide to the operation is made by drawing a line three 
 fourths of an inch behind the posterior border of the tibia in the 
 upper and lower thirds, and from its upper to its lower extremity 
 (Fig. 132). 
 
 The Muscular Guide. At its middle third it lies beneath the so- 
 leus ; at its lower third to the outer border of the flexor longus digi- 
 torum. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE POSTERIOR TIBIAL ARTERY. (GRAY.) 
 
 In front. 
 Tibialis posticus. 
 Flexor longus digitorum. 
 Tibia. 
 
 Ankle-joint. 
 Inner side. 
 
 Posterior tibial nerve, ( Posterior 
 
 upper third. ( tibial artery, 
 
 Behind. 
 
 Gastrocnemius. 
 Soleus. 
 Deep fascia and integument. 
 
 ,\ 
 
 Outer side. 
 
 Posterior tibial nerve, 
 lower two thirds.
 
 OPERATIVE SURGERY. 
 
 Operation at its Middle Tliird (Fig. 132, c). Place the patient on 
 the back, flex the leg on the thigh and the thigh on the pelvis, so that 
 
 Fio. 133 
 terior tibial 
 
 FIG. 134. Ligature of posterior tibial, middle third, a. Fascia 
 and fat. b. Gastrocnemius muscle, c. Cellular tissue, d. 
 Soleus muscle and its aponeurosis. e. Sheath of vessels. 
 /. Posterior tibial artery, g. Venae comites. A. Posterior 
 tibial nerve. 
 
 the leg will lie on the outer side. Make an incis- 
 ion on the linear guide to the operation, about 
 
 . Ligature of pos- , .. ., . , -,-., i T . 
 
 ibial, middle third. * our inches in length ; divide the deep fascia, rec- 
 ognize the inner border of the gastrocnemius, be- 
 neath which will be seen the fibers of the soleus, which should be di- 
 vided on a director, down to the pale yellow aponeurosis on its under 
 
 surface ; separate the fibers of the soleus 
 and make an opening through its apo- 
 neurosis, about one inch from the inner 
 border of the tibia, of sufficient size to 
 expose the artery, which is found be- 
 neath, attended by its veins and the pos- 
 terior tibial nerve (Fig. 133) ; draw the 
 nerve to the outer side, separate the ves- 
 sel from the veins, and pass the needle 
 from without inward (Fig. 134). 
 
 Operation at the Lower Third (Fig. 
 132, b). Place the limb as before ; make 
 an incision in the course of the linear 
 guide about three inches in length ; di- 
 vide the integument and fascia in the 
 usual manner ; separate the borders of 
 the wound, then divide the aponeurosis 
 (which binds down the deep layer of 
 
 Fio. 135. Ligature of posterior tib- 
 ial, lower third. 
 
 muscles) at about one inch from the pos- 
 terior border of the tibia, push aside the fat, and the vessel, with its
 
 LIGATURE OF ARTERIES. 85 
 
 nerve and veins, will be found at the outer border of the flexor longus 
 digitorum. Separate the vessel, push the nerve to the outer side, 
 and pass the needle from without inward (Fig. 135). 
 
 Operation between the Os Calcis and Internal Malleolus. Place 
 the foot on the outer surface and make a curved incision about three 
 inches in length, with the concavity uppermost, and its center at a 
 point midway between the malleolus and the inner tuberosity of the 
 os calcis (Fig. 132, a}. Divide the fascia and the internal annular 
 ligament on a director, using caution with the director, since the air- 
 tery lies beneath the ligament ; isolate the vessel from the veins and 
 pass the needle from without inward. In passing through the super- 
 ficial tissues, some small branches of the long saphenous vein may be 
 divided, unless caution be used. In old people both these and the 
 venae comites often become varicose, which increases the difficulty of 
 finding and isolating the artery. It is better not to attempt to liga- 
 ture it in this situation if evidences of varicosities exist. 
 
 Fallacies. The posterior tibial may be rudimentary or absent. In 
 either instance the peroneal is usually increased in size. 
 
 Ligature of the Peroneal Artery. It arises from the posterior tibial 
 about an inch below the popliteus muscle, passes obliquely outward to 
 the inner border of the fibula (Fig. 128), along which it descends 
 to the lower third of the leg, and is finally distributed to the outer . 
 side of the ankle. It may be ligatured at the middle third of the 
 leg. 
 
 The linear guide is a line drawn from the posterior border of the 
 head of the fibula to the external border of the tendo Achillis at its 
 insertion. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE PERONEAL ARTERY. (GRAY.) 
 
 In front. 
 Tibialis posticus. 
 Flexor longus pollicis. 
 Outer side. 
 
 Fibula. \ Peroneal ) 
 
 ( artery. ) 
 
 Behind. 
 Soleus. 
 Deep fascia. 
 Flexor lougus pollicis. 
 
 Operation. Extend the foot and make an incision about four 
 inches in length along the line indicated, parallel with the external 
 border of the fibula. Separate the attachments of the soleus and the 
 flexor longus pollicis from each other, when the artery will be found 
 at the inner side of the flexor longus pollicis close to the fibula.
 
 86 
 
 OPERATIVE SURGERY. 
 
 Fallacies. It may be absent ; this is, however, very rare. It may 
 be overlooked, and the posterior tibial found instead. If its close re- 
 lation to the fibula be remembered, this mistake will not occur. 
 
 Ligature of the Innominate Artery. The innominate artery arises 
 from the beginning of the transverse arch of the aorta in front of the 
 left common carotid, passes obliquely upward and outward to the up- 
 per border of the right sterno-clavicular articulation, where it divides 
 into the right common carotid and right subclavian. It has no prac- 
 tical linear or muscular guides. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE INNOMINATE ARTERY. (GRAY.) 
 
 In front. 
 Sternum. 
 
 Sterno-hyoid and sterno-thyroid muscles. 
 Remains of thymus gland. 
 
 Left innominate and right inferior thyroid veins. 
 Inferior cervical cardiac branch from right pneumogastric nerve. 
 
 Right side. 
 
 Right vena innominata. j Innominate ) 
 
 1 artery. ) 
 
 Right pneumogastric nerve. 
 Pleura. 
 
 I^eft side. 
 
 Remains of thymus. 
 Left carotid. 
 
 Behind. 
 Trachea. 
 
 Operation. Numerous incisions have been given for gaining ac- 
 cess to the vessel. The one which is best calculated to afford the 
 requisite amount of room was employed by the late Valentine Mott 
 
 (Fig. 136, d). Place 
 the patient on the 
 back, with the 
 shoulders somewhat 
 raised, and the head 
 turned to the oppo- 
 site side. An incis- 
 ion is then made 
 
 ^ three inches in 
 
 length, extending 
 along the upper bor- 
 / der of the clavicle 
 to opposite the cen- 
 ter of the episternal 
 notch. This is joined 
 
 FIG. 136. Linear guides to arteries of neck. hy another of a sim- 
 
 lar length directed 
 
 along the anterior portion of the sterno-mastoid muscle. This trian- 
 gular flap, consisting of the integument, superficial fascia, and pla-
 
 LIGATURE OF ARTERIES. 87 
 
 tysma, is turned upward and outward. The portions of the sterno- 
 cleido-mastoid, corresponding to the horizontal incision, and the ster- 
 no-hyoid and sterno-thyroid muscles, are divided on a director and 
 turned aside. The inferior thyroid veins, if they now come into 
 view, must be carefully drawn aside, the deep cervical fascia must be 
 carefully torn or cut through, when the sheath containing the com- 
 mon carotid artery, pneumogastric nerve, and internal jugular vein 
 is brought into view. Open the sheath, draw the vein and nerve to 
 the outer side, and follow the carotid down to the subclavian, the 
 origin of which should be exposed. The upper portion of the innom- 
 inata is then to be separated from its important connections by the 
 finger or a blunt director ; the left vena innominata is depressed, and 
 the right vena innominata, right internal jugular, and pneumogas- 
 tric nerve are carried to the right, and then the aneurism needle is 
 passed from below upward, and" from behind, forward and inward, in 
 close contact with the vessel. It is suggested to remove a sufficient 
 portion of the upper end of the sternum to admit of the direct open- 
 ing into the sheath of the innominata. It is thought that this mea- 
 sure will the better preserve the nutritive integrity of the coats of the 
 vessel by leaving its vascular connections with the sheath undisturbed 
 above. 
 
 Fallacies. If the innominata be shorter than usual, the lower 
 extremity of the common carotid may be tied instead. If the aorta 
 arches to the right side, the innominata will be on the left side, in- 
 stead of the right. 
 
 The necessity of treating all the veins and the pleura with most 
 judicious care is emphasized by the knowledge of the fact, that, nearly 
 all the fatal cases thus far have died from pleuritis or secondary 
 hemorrhage. 
 
 Results. This vessel has been ligatured seventeen times, with two 
 recoveries. 
 
 Ligature of the Subclavian Artery. The subclavian artery, on the 
 right side, arises from the arteria innominata, opposite the junction of 
 the right clavicle with the sternum ; on the left side it arises from the 
 arch of the aorta. These vessels must, therefore, differ in the first 
 part of their course in length, direction, and with relation to their 
 contiguous anatomical structures. This vessel can be ligatured in 
 three situations : between the inner border of the scalenus anticus and 
 its origin ; behind the scalenus ; between its termination at the lower 
 border of the first rib and the outer border of the scalenus anticus. 
 
 Ligature of the First Portion, Left Side. This portion has no 
 definite linear or muscular guide. The inner border of the scalenus 
 anticus is important as leading to and limiting its extent. Owing 
 to its origin from the arch of the aorta, it is of great depth, almost 
 beyond the reach of a ligature; while its close relation to very
 
 88 OPERATIVE SURGERY. 
 
 important structures injury to which, of itself, may be more 
 grave than the condition for which the vessel is to be tied ren- 
 der it exceedingly difficult to perform, and of questionable expedi- 
 ency. 
 
 Contiguous Anatomy. 
 
 PLAN OF RELATIONS OF FIRST PORTION OF LEFT SUBCLAVIAN ARTERY. (GRAY.) 
 
 In front. 
 
 Pleura and left lung. 
 
 Pneumogastric, cardiac, and phrenic nerves. 
 Left carotid artery. 
 
 Left internal jugular and innominate veins. 
 Sterno-thyroid, sterno-hyoid, and sterno-mastoid muscles. 
 
 Inner side. Outer side. 
 
 (Esophagus. ( Left subclavian artery, ) Pleura. 
 
 Trachea. 1 first portion. ) 
 
 Thoracic duct. 
 
 Behind. 
 
 (Esophagus and thoracic duct. 
 
 Inferior cervical ganglion of sympathetic. 
 
 Longus colli muscle and vertebral column. 
 
 Operation. Place the patient on the back with the head extended 
 and turned to the opposite side ; the left shoulder should be well de- 
 pressed ; make an incision three inches and a half in length along the 
 inner border of the sterno-cleido-mastoid down to the sternum ; another, 
 two inches and a half in length along the inner extremity of the clavi- 
 cle, meeting the former near the trachea. It is seen that this incision 
 is substantially the same as that for the ligaturing of the innomi- 
 nate artery (Fig. 136, d). The flap, consisting of the integument, 
 superficial fascia, and platysma, is turned aside ; one half of the cla- 
 vicular portion of the sterno-mastoid and its whole sternal portion are 
 then divided on a director, bringing into view the sterno-hyoid, steruo- 
 thyroid muscles, and, to the outer side, the omo-hyoid. The sterno- 
 thyroid and sterno-hyoid should be divided with great care, after be- 
 ing liberated from the fascia which covers them. The inner edge of 
 the scalenus anticus muscle is now sought for ; when found, it will 
 guide the finger directly to the vessel. The important contiguous 
 structures are now drawn inward and pressed away from the artery, 
 using great caution to avoid the thoracic duct, which will be in the line 
 of search, as it passes behind the jugular vein at its junction with 
 the left innominate vein. The needle is carefully passed from before 
 backward. The great depth of the vessel will make it exceedingly 
 difficult to pass the needle, which should be the one with the adjust- 
 able extremity. 
 
 Results. Tied by Dr. J. Kearney Rogers, 1845 ; patient died from 
 secondary hemorrhage on the fifteenth day.
 
 LIGATURE OF ARTERIES. 
 
 89 
 
 Ligature of First Portion, Right Side. The inner border of the 
 anterior scalenus leads to it upon this, as upon the left side. 
 Contiguous Anatomy. 
 
 RELATIONS OF FIRST PORTION OF RIGHT SUBCLAVIAN ARTERY. (GRAY.) 
 
 In front. 
 
 Clavicular origin of sterno-mastoid muscle. 
 Sterno-hyoid and sterno-thyroid muscles. 
 Internal jugular and vertebral veins. 
 Pneumogastric, cardiac, and phrenic nerves. 
 
 ( Bight subclavian artery, 
 
 Beneath. 
 Pleura. 
 
 first portion. 
 
 Behind. 
 
 Recurrent laryngeal nerve. 
 Sympathetic nerve. 
 Longus colli muscle. 
 Transverse process of seventh cervical or first dorsal vertebra. 
 
 Operation. The position of the patient, primary incisions, and 
 dissection are substantially the same as the preceding. The internal 
 jugular should be pressed aside and the needle passed from below up- 
 ward and from before back- 
 ward, carefully avoiding the 
 pleura, recurrent laryngeal 
 and phrenic nerves. The lig- 
 ature of the vertebral and in- 
 ternal mammary arteries at 
 the same time will lessen the 
 danger of secondary hemor- 
 rhage. 
 
 Fallacies. This vessel 
 may arise from the arch of 
 the aorta, when it will be 
 more deeply situated, often 
 passing behind the oesopha- 
 gus or between it and the 
 trachea. 
 
 Results. It has been lig- 
 atured thirteen times ; all the 
 cases proved fatal, of which 
 eight died of hemorrhage. 
 
 Ligature of the Second Fl ' 13/ 7. Linear guides to arteries of neck and face. 
 and Third Portions. The linear guide to the operation is drawn just 
 above the upper border of the clavicle, extending between the poste- 
 rior border of the sterno-cleido-mastoid and the anterior border of the 
 trapezius, and should be about four inches in length (Fig. 137, a}.
 
 90 
 
 OPERATIVE SURGERY. 
 
 Muscular Guides to the Artery. This vessel has no superficial 
 muscular guide. The deep muscular guide is the outer border of the 
 
 scalenus anticus. The 
 posterior belly of the 
 omo-hyoid, while not 
 in close contact with 
 it, serves an important 
 purpose in directing 
 the attention of the 
 surgeon toward it. 
 The situation of the 
 outer border of the 
 scalenus anticus is 
 well indicated by the 
 posterior border of the 
 stern o-cleido-mastoid, 
 provided the latter 
 FIG. 138. Surgical anatomy of subclavian. muscle be not uncom- 
 
 monly developed. The 
 
 junction of the inner two inches of the clavicle with its outer portion 
 is a far more unvarying indication of the approximate deep location 
 of the outer border of the scalenus anticus than is the former. 
 
 The tubercle on the first rib, into which the scalenus anticus is 
 inserted, is the guide to the vessel, the artery being directly behind it 
 (Fig. 138). 
 
 Contiguous Anatomy. 
 
 RELATIONS OF THIRD PORTION OF SCJBCLATIAN ARTERY. (GRAY.) 
 
 In front. 
 Cervical fascia. 
 
 External jugular, supra-scapular, and transverse cervical veins. 
 Descending branches of cervical plexus. 
 Subclavius muscle and supra-scapular artery and clavicle. 
 
 Above. Below. 
 
 Brachial plexus. j Subclavian artery, ) Fi rs t rib. 
 
 Omo-hyoid. 
 
 third portion. 
 
 Behind. 
 Scalenus medius. 
 
 Operation Third Portion. Place the patient on the back with 
 the shoulders elevated from the table, head ben t backward and turned 
 to the opposite side. Draw the shoulder of the corresponding side 
 firmly downward to the side of the patient, and retain it in that posi- 
 tion. Compress the external jugular vein above the clavicle, long 
 enough to cause its distention, thereby indicating its exact situation. 
 The integument is then drawn evenly downward and incised upon the
 
 LIGATURE OF ARTERIES. 
 
 91 
 
 clavicle, and will, when allowed to retract, carry the incision upward 
 to its proper situation one-half inch above the clavicle. The super- 
 ficial fascia and platysma are then divided upon a director, being care- 
 ful not to sever the external jugular, which can be either pulled aside 
 or divided between two ligatures. The supra-scapular and transverse 
 cervical veins should be treated in the same manner. The omo-hyoid 
 is now sought for and drawn upward, if necessary, and the supra- 
 scapular artery avoided. 
 The deep cervical fascia 
 is torn asunder by the 
 finger-nail or a director, 
 and the outer border of 
 the scalenus anticus felt 
 for on a line with the 
 outer margin of the ster- 
 no-cleido-mastoid, if the 
 latter have not been di- 
 vided ; if so, it should be 
 located as described un- 
 der the head of " Mus- FIG. 139. Ligature at third portion of subclavian. 
 cular Guides to the Ar- 
 tery." If the head be turned forcibly to the opposite side, the scale- 
 nus anticus will be made tense and more prominent. When found, 
 it should be followed downward to its insertion, when the finger will 
 
 rest upon the tubercle of 
 the first rib, immediately 
 behind which the pulsa- 
 tion of the artery will be 
 felt. The vessel is now 
 carefully exposed and the 
 needle passed from be- 
 fore backward (Fig. 139). 
 Great caution should be 
 taken not to interfere 
 
 roastoid muscle, c. Omo-hyoid muscle, d. Scalenus with the subclavian vein, 
 
 anticus muscle, e. Aponeurotic tissue. /. Subcla- which lies in front of, 
 vian vein, partly behind clavicle, q. Occasional ori- T . ^i^ , 4.u, 
 
 gin of the supra-scapular artery, h. External jugu- and on a lower P lane than 
 
 lar vein. i. Inner cords of the bracbial plexus, j. the artery (Fig. 140). 
 Superficial descending branches of brachial plexus. 3f/77//.a'/,o TVio efoV 
 
 I n i t r\ A* A B J- IvvvCvCr vt/t> ' J_ 11 1/ b Lfl ~ 
 
 K. Subclavian artery, t. Connective tissue. 
 
 no-cleido-mastoid may 
 
 have an unusual breadth of origin from the clavicle, thereby causing 
 the incision to be made too far posteriorly. The clavicular measure- 
 ment will prevent this error. The tubercle on the anterior surface of 
 a transverse process of one of the lower cervical vertebra? may be mis- 
 taken for the tubercle of the first rib. This, however, is easily recti- 
 
 J 
 
 Ji 
 
 FIG. 140. Ligature of subclavian artery, third portion, 
 a. Anterior border of trapezius muscle, b. Sterno-
 
 92 OPERATIVE SURGERY. 
 
 fied by remembering that the rib is located downward and backward, 
 that no contiguous pulsation is found, and that the outline of the 
 scalenus anticus is absent. The tubercle may be absent, and the 
 muscular insertion into the rib must then be relied upon. 
 
 The artery may be in front of the tubercle and the vein behind it. 
 The pulsation as well as the anatomical appearances will determine 
 the interchange of situations. The inner cord of the brachial plexus 
 may be mistaken for the artery. A little attention to the distinctive 
 physical characteristics between nerves and arteries will quickly settle 
 this doubt. 
 
 Results. Two hundred and fifty-one cases are tabulated, of which 
 one hundred and thirty-four, or fifty-three per cent, died. 
 
 Ligature of the Second Portion. All the muscular and linear 
 guides are practically similar to those of the preceding. 
 
 Contiguous Anatomy. 
 
 PLAN OF RELATIONS OF SECOND PORTION OF SUBCLAVIAN ARTERY. (GRAY.) 
 
 In front. 
 Scalenus anticus. 
 Phrenic nerve. 
 Subclavian vein. 
 
 Above - ( Subclavian artery, > Selow - 
 
 \ 
 
 Brachial plexus. ( second portion. ) Pleura. 
 
 Behind. 
 Pleura and middle scalenus. 
 
 Operation. The steps essential to arrive at the proper site in this 
 instance, are not varied from those given for the third portion, until 
 the outer border of the scalenus anticus is well determined ; the phre- 
 nic nerve and subclavian vein should then be pushed aside and the 
 muscle divided (Fig. 140, d), when the retraction of its fibers will ex- 
 pose the artery to view. The needle is then passed as before, closely 
 hugging the artery, to avoid the pleura below and posteriorly. 
 
 Fallacies. The vein and artery may be transposed. 
 
 Results. Thirteen cases are reported, of which nine, or sixty-nine 
 per cent, were fatal. 
 
 The subclavian should always be tied in the third portion when 
 possible ; if impossible, then the second should be selected. The liga- 
 ture of the first portion is unwarranted in view of the results here- 
 tofore obtained. 
 
 Ligature of the Vertebral Artery. This artery arises from the 
 upper and back part of the first portion of the subclavian, passes 
 directly upward along the anterior surface of the vertebral column, 
 and enters the foramen in the transverse process of the sixth cervi- 
 cal vertebra. It ascends through the foramina in the transverse pro-
 
 LIGATURE OP ARTERIES. 93 
 
 cess of all the vertebrae above this, inclining outward and upward be- 
 tween the transverse processes of the axis and atlas, and finally runs in 
 a deep groove on the upper surface of the posterior arch of the atlas 
 before it ascends to pierce the posterior occipito-atloid ligament. It 
 may be ligatured in three situations : 1, before entering the vertebral 
 canal ; 2, between the atlas and axis ; 3, between the atlas and the 
 occipital bone. 
 
 1. The linear guide to the artery in the first situation is drawn 
 from the junction of the inner fourth with the outer three fourths of 
 the clavicle, to the posterior border of the mastoid process. The deep 
 guides are the tubercle of the transverse process of the sixth cervical 
 vertebra, and the space between the borders of the longus colli and the 
 scale nus anticus. 
 
 Contiguous Anatomy. 
 
 In front. 
 
 Internal jugular vein and its sheath. 
 Inferior thyroid artery. 
 Thoracic duct (left side). 
 
 Aponeurosis between longus colli and the scalenus anticus. 
 Vertebral vein. 
 
 Outer side. ( Vertebral ) Inner side. 
 
 Scalenus anticus. (. artery. ) Longus colli. 
 
 Behind. 
 
 Cervical nerves. 
 Vertebral column. 
 
 Operation. 1. The head should be turned to the opposite side and 
 an incision about three inches and a half in length made along the 
 anterior border of the sterno-cleido-mastoid, terminating at the upper 
 border of the sternum. The fascia and the connections between the 
 sterno-mastoid and sterno-hyoid are divided and these muscles sepa- 
 rated, which exposes the common sheath of the internal jugular vein, 
 common carotid artery, and pneumogastric nerve. This sheath is now 
 carefully separated from its connections with the sterno-thyroid and 
 longus colli muscles and drawn outward. The parts are now relaxed 
 by raising the head, the inferior thyroid artery displaced, the tho- 
 racic duct avoided, and the aponeurosis covering the vessel torn 
 through, the vein pushed aside, and the ligature passed from within 
 outward. 
 
 Mr. Alexander, whose experience in tying these vessels on the 
 living subject is greater than that of any other surgeon, describes 
 his method of operating in the following language : "An incision 
 three or four inches long is made in an upward and outward direc- 
 tion along the hollow which exists between the scalenus anticus and 
 the sterno-mastoid muscles. The incision should begin just outside
 
 94 OPERATIVE SURGERY. 
 
 and on a level with the point where the external jugular vein dips 
 over the edge of the sterno-mastoid muscle, or, if the vein is invisible, 
 about half an inch above the clavicle. The external vein is drawn 
 inward with the sterno-mastoid muscle. The connective tissue now 
 appearing, the wound is opened by a blunt director, until the sca- 
 lenus anticus muscle, the phrenic nerve, and the transverse cervical 
 artery are seen. It can not be too well remembered that the pleura 
 is at the inner side of the wound, while below lies the subclavian ar- 
 tery. It is now only necessary to separate the edges of the scalenus 
 anticus and the longus colli muscles to see the vertebral artery lying 
 in the space between them. The artery is generally completely cov- 
 ered by the vein, which is drawn aside and the artery is then liga- 
 tured." 
 
 2. In this position the artery is in a triangular space formed by 
 the rectus posticus major and superior and inferior oblique muscles. 
 It is covered by the rectus posticus major and complexus. 
 
 Operation. "With the head turned to the opposite side and inclined 
 forward, make an incision three inches in length along the posterior 
 border of the sterno-masfcoid, beginning half an inch below the mas- 
 toid process. A second incision is then made, beginning at the upper 
 fourth of the first one and carried backward and downward one inch. 
 The splenius muscle appears in view as soon as the integument and 
 fascia are divided and pulled aside. The fibro-muscular structure of 
 the splenius is divided, its borders separated, the layer of fat that 
 now appears is pushed aside by the finger or handle of the scalpel, and 
 the vessel is seen ; its branches are drawn aside together with those of 
 the second cervical nerve, the artery isolated, and the needle passed 
 from without inward. 
 
 3. The incisions are the same as in the preceding, except that the 
 first one begins half an inch above the mastoid process. The skin, fascia, 
 and splenius are divided as before, the occipital artery appears at the 
 upper angle of the wound, and is held aside ; divide the aponeurosis 
 and cellular tissue, separate the borders, enter the triangle, separate 
 the fatty tissue, and the artery will be exposed. Pass the needle from 
 behind forward. 
 
 Fallacy. The vertebral arteries may enter the transverse processes 
 of the fifth cervical vertebra, instead of the sixth. 
 
 Results. These vessels have been ligatured forty- two times, in 
 thirty-six of which three died ; one each from hemorrhage, embolism, 
 and pleurisy. When done for the cure of epilepsy, about twenty per 
 cent were benefited, some of which ultimately recovered. The per- 
 manent benefit derived thus far in such cases has not been sufficiently 
 ample to warrant the general adoption of this measure for the treat- 
 ment of epilepsy. 
 
 Ligature of the Internal Mammary Artery. The internal mam-
 
 LIGATURE OF ARTERIES. 95 
 
 mary arises from the first portion of the subclavian. It descends be- 
 hind the internal jugular and subclavian veins to the inner surface of 
 the anterior wall of the chest, resting upon the costal cartilages about 
 half an inch from the margin of the sternum. It may be ligatured 
 in any of the five upper intercostal spaces. 
 
 Linear Guide. About one-half inch to the outer side of the 
 sternum is a fair indication of its locality. It has no muscular 
 guide. 
 
 Operation. Make an incision two inches in length along the up- 
 per border of the costal cartilage and rib. The integument, fascia, 
 and pectoralis major muscle are divided down to the intercostal mus- 
 cles. Beneath the internal intercostal muscle, surrounded by the 
 connective tissue, the artery, accompanied by the venae comites, will 
 be found. The vessel is isolated, and the needle carefully passed to 
 avoid penetrating the pleura. If the vessel be tied in the uppermost 
 intercostal space, a single vein will attend it. 
 
 Ligature of the Inferior Thyroid Artery. This vessel arises from 
 the thyroid axis, and passes in a somewhat irregular course upward 
 and inward behind the sheath of the common carotid and internal 
 jugular vein to the thyroid gland. 
 
 TJie linear guide to the operation is along the anterior border of 
 the sterno-mastoid, as in ligaturing the common carotid. The body 
 of the fifth cervical vertebra, opposite to which it enters the gland, is 
 an approximate bony guide to the vessel. 
 
 Contiguous Anatomy. In front, the common carotid sheath 
 and its contents, and the sympathetic nerve ; the recurrent lar- 
 yngeal and the oesophagus ; if low in the neck, carefully avoid 
 the thoracic duct. The respective tissues are pulled aside and 
 the needle passed. No dangers attend the ligaturing other than 
 those incurred by the manipulation necessary to arrive at the ves- 
 sel. 
 
 Ligature of the Axillary Artery. This vessel begins at the lower 
 border of the first rib and extends to the lower border of the tendon 
 of the latissimus dorsi. It may be tied in three situations : 1, above 
 the pectoralis minor ; 2, behind ; 3, below that muscle. The first 
 and last, however, are the only ones at which the vessel can be prac- 
 tically secured. 
 
 First Portion. There is no linear guide to the vessel. The linear 
 guide to the operation is located about one-half inch below the lower 
 border of the clavicle, extending from within an inch or so of the 
 sternal extremity, outward three or four inches. 
 
 The muscular guides are superficial and deep. The former is the 
 space between the border of the deltoid and pectoralis major muscles. 
 The latter is the pectoralis minor, its upper border corresponding to 
 the first portion, etc., as before stated.
 
 96 
 
 OPERATIVE SURGERY. 
 
 Outer side. 
 Brachial plexus. 
 
 Inner side. 
 Axillary vein. 
 
 Contiguous Anatomy. 
 
 RELATIONS OF THE FIRST PORTION OF THE AXILLARY ARTERY. (GRAY.) 
 
 In front. 
 Pectoral is major. 
 Costo-coracoid membrane. 
 Subclavius. 
 Cephalic vein. 
 
 ^ Axillary 
 
 artery, 
 ( first portion. 
 
 Behind. 
 
 First intercostal space, and intercostal muscle. 
 First serration of serratus magnus. 
 Posterior thoracic nerve. 
 
 In this situation the artery lies deeply, and it is better, if possible, 
 to ligature the third portion of the subclavian. 
 
 Operation (Fig. 141). Place the patient upon the back with the 
 head turned to the opposite side ; elevate the shoulder and carry the arm 
 a little distance from the side of the chest. Make an incision about four 
 
 inches in length on the 
 linear guide given above, 
 down through the integu- 
 ment, fascia, and platys- 
 ma : separate the fibers of 
 the pectoralis major, or di- 
 vide them the full length 
 of the wound ; tear apart 
 the underlying fascia, when 
 the pectoralis minor mus- 
 cle will be brought in view ; 
 bring the arm to the side 
 to relax this muscle, which 
 is then drawn to the outer 
 side ; displace the areolar tissue carefully with the finger or a director, 
 when the vein will be seen, which should be carried upward and in- 
 ward with a blunt hook, and the artery will be noticed beneath it, and 
 in close contact with the inner cord of the brachial plexus, which lies 
 to its outer side and above. The needle is then passed from below 
 upward. The cephalic vein, which empties into the axillary vein, 
 should be cautiously avoided, as it passes between the borders of the 
 pectoral and deltoid muscles to its termination (Fig. 142). 
 
 Fallacies. The inner cord of the brachial plexus may be mistaken 
 for the artery. Before tightening the ligature, pressure should be 
 made upon the vessel, and the effect upon the radial pulse noted. 
 
 FIG. 141. Ligature of first portion of axillary.
 
 LIGATURE OF ARTERIES. 
 
 97 
 
 The vessel may be 
 reached by making an 
 incision between the 
 borders of the deltoid 
 and pectoral muscles 
 about three inches in 
 length, which should 
 connect with the one 
 previously made below 
 the lower border of the 
 clavicle. The fat and 
 cellular tissue can then 
 be removed or dis- 
 placed as in the pre- 
 vious instance. 
 
 Results. JSTo def- 
 inite records are given 
 of the results of this 
 operation. 
 
 a 
 
 FIG. 142. Ligature of first portion of axillary artery, a. 
 Pectoralis major, divided in course of fibers, b. tipper 
 border of pectoralis minor, c. Deep fascia (costo-coracoid 
 membrane), d. Axillary vein. e. Axillary artery, f. 
 Inner cord of brachial plexus, g. Acromio-thoracic branch. 
 h. Cephalic vein. 
 
 Ligature in the TJiird Portion. The linear guide to the artery is 
 
 FIG. 143. Linear guide to axillary, third portion. 
 
 a line extending upward into the axilla corresponding to the junction 
 of its anterior and middle thirds (Fig. 143, a). 
 
 Muscular Guide. The inner border of the coraco-brachialis* 
 1
 
 98 
 
 OPERATIVE SURGERY. 
 
 Contiguous Anatomy. 
 
 RELATIONS OF THE THIRD PORTION OF THE AXILLARY ARTERY. (GRAY.) 
 
 In front. 
 
 Integument and fascia. 
 Pectoralis major. 
 
 Outer side. 
 Coraco-brachialis. 
 Median nerve. 
 Musculo-cutaneous nerve. 
 
 Inner side. 
 
 C Axillary } Ulnar nerve. 
 \ artery, Internal cutaneous nerve. 
 
 ' third portion. ) Axillary vein. 
 
 Behind. 
 
 Subscapularis muscle. 
 
 Tendons of latissimus dorsi and teres major. 
 
 Musculo-spiral and circumflex nerves. 
 
 Operation (Fig. 144). The arm should be abducted and rotated 
 outward. Make an incision three inches in length along the inner 
 
 border of the coraco-brachialis in 
 line of the arterial pulsation, ob- 
 serving that its center be above 
 the anterior fold of the axilla ; 
 cautiously divide the tissue upon 
 a director, drawing the median 
 nerve to the outer, and the ax- 
 illary vein to the inner side ; pass 
 the needle from within outward. 
 Fallacies. Large branches 
 may be given off at this situation, 
 which will confuse the operator. 
 Pressure upon the vessel prior to 
 the tightening of the ligature will 
 determine the influence upon the circulation beyond. 
 
 Results. The operation implies in itself no particular danger to 
 the patient. 
 
 Ligature of the Brachial Artery. The brachial artery extends 
 
 FIG. 144. Ligature of third portion of 
 axillary. 
 
 FIG. 145. Linear guide of brachial artery.
 
 LIGATURE OF ARTERIES. 99 
 
 from the lower border of the tendon of the latissimus dorsi to about 
 one inch below the bend of the elbow-joint. 
 
 The linear guide is drawn from the junction of the middle and 
 anterior thirds of the axilla to midway between the apices of the bony 
 condyles of the humerus (Fig. 145). 
 
 Muscular Guide. At its upper third it lies at the inner border of 
 the coraco-brachialis ; in the middle third, at the inner border of the 
 biceps ; in the lower third, at the inner border of the biceps tendon. 
 It may be ligatured in three situations : at its upper, middle, and 
 lower thirds. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE BRACHIAL ARTERY. (GRAY.) 
 
 In front. 
 
 Integument and fasciae. 
 Bicipital fascia, median basilic vein. 
 Median nerve. 
 Outer side. Inner side. 
 
 Median nerve. Internal cutaneous and 
 
 ..... / Bracliial ) 
 
 Coraco-brachiahs. j ulnar nerve. 
 
 Biceps. a er y' ' Median nerve. 
 
 Behind. 
 Triceps. 
 
 Musculo-spiral nerve. 
 Superior profunda artery. 
 Coraco-brachialis. ' 
 Brachialis anticus 
 
 Operation Upper Third (Fig. 145, a). Abduct the arm, and rotate 
 it outward ; make an incision about three inches in length along the in- 
 ner border of the coraco-bra- 
 chialis. The artery, being 
 very superficial, is quickly 
 reached. The median nerve 
 is drawn to the outer, and 
 the ulnar nerve and basilic 
 vein to the inner side ; sep- 
 arate the artery from the 
 vein, and pass the needle 
 
 from within outward. ' l 
 
 si , . . ,7 ,.-. 7 77 FIG. 146. Ligature of brachial in middle third. 
 Operation in the Middle 
 
 Third (Fig. 145, #). Place the arm as before ; make an incision three 
 inches in length along the inner side of the biceps muscle (Fig. 146). 
 The median nerve is found lying upon and a little to its outer side ; 
 push it aside, isolate the artery from the venae comites, and pass the 
 needle in the same direction as before (Fig. 147). 
 
 Operation in the Lower Third (Fig. 145, c). Abduct the arm and
 
 100 
 
 OPERATIVE SURGERY. 
 
 supinate the forearm. Compress the arm above to distend the medi- 
 an basilic vein ; make an incision about three inches in length along 
 
 the inner border of the tendon of 
 the biceps ; draw aside the medi- 
 an basilic vein, when the artery 
 will be felt pulsating beneath the 
 bicipital fascia ; a suitable-sized 
 opening is now cut through this 
 fascia, the forearm partially 
 flexed, the vessel separated from 
 its veins, and the needle passed 
 from within outward (Figs. 148 
 and 149). 
 
 Fallacies. The arteries of 
 the forearm may be given off from 
 the axillary, or the brachial may 
 bifurcate high up, thereby in- 
 creasing the number of the large 
 
 vessels in the arm. This is determined by the comparative size of 
 the brachial, and the influence of pressure on the circulation on the 
 distal side of the proposed liga- 
 ture. The brachial may run to- 
 
 f- 
 
 FIG. 147. Ligature of brachial artery, mid- 
 dle third, a. Sheath of vessels and nerves. 
 c. Brachial artery, d. Venae comites. /. 
 Basilic vein. g. Median nerve, pulled to in- 
 ner side. h. Internal cutaneous nerve, i. 
 Ulnar nerve. 
 
 FIG. 148. Ligature of brachial artery 
 at lower third. 
 
 gether with the ulnar nerve be- 
 
 FIG. 149. Ligature of brachial at lower 
 third, a. Aponeurosis divided and turned 
 back. b. Brachialis anticus muscle, in- 
 ner border. c. Sheath of artery, d. 
 Brachial artery, e. Collateral vein. /. 
 Median nerve. 
 
 hind the inner condyle. If it be 
 not in its normal site, deep press- 
 ure may detect its pulsations elsewhere, which, together with its effect 
 on the circulation beyond, will determine the size and site of the ves- 
 sel. The incisions in the upper two thirds may be made too far in- 
 ward, leading the surgeon to mistake the ulnar nerve for the median. 
 If the forearm be flexed and traction be made upon either, its course 
 will be determined and the mistake corrected. 
 
 The median nerve may pass behind the artery instead of in front,
 
 LIGATURE OF ARTERIES. 
 
 101 
 
 when, if the circulation from above be obstructed, the artery may es- 
 cape notice. The artery not unfrequently 
 lies deeply between the brachialis anticus 
 and biceps muscles. 
 
 Anomalous muscular slips and unusual 
 muscular development may obscure the 
 artery in its normal course. In such in- 
 stances the pulsation will determine its 
 location. 
 
 Occasionally, especially in female sub- 
 jects, when the upper extremity is mark- 
 edly concave on its outer surface, due to 
 an unusual length of the internal condyle, 
 the primary incision may be made to the 
 outer side of the vessel. If, however, it be 
 made midway between the tips of the bony 
 condyles, irrespective of the overhanging 
 soft parts, this error will not arise. 
 
 Results. It has been ligatured seven- 
 ty-six times for hemorrhage, with fifty-five 
 recoveries. 
 
 Ligature of the Radial Artery. This 
 artery arises from the brachial, is an ap- 
 parent continuation of it, and is superficial 
 in its entire course. It may be ligatured 
 in any portion of its course ; it is, how- 
 ever, usually ligatured in three situations 
 at the upper and lower thirds, and at 
 the wrist. 
 
 Tlie linear guide (Fig. 150, a, V) to this 
 vessel is drawn from midway between the 
 tips of the bony condyles of the humer- 
 
 us to the inner side of the extremity of the styloid process of the 
 radius. 
 
 The muscular guide, at its upper portion, is the inner border of the 
 belly of the supinator longus muscle, beneath which it lies. At the 
 lower portion of its course it lies at the inner side of the tendon of 
 the same muscle. The almost universally recognized pulsation of the 
 vessel at the wrist is the best practical guide to it in this location. 
 In fact, it is only when abnormalities of size or situation of it occur 
 at this position that th other guides to it are taken into considera- 
 tion in the living subject, and under these circumstances they are of 
 but little aid to the operator. This same statement will apply with 
 equal force to all arteries that are similarly associated with the super- 
 ficial structures of the body. 
 
 FIG. 150. Linear guides to radial 
 and uluar arteries.
 
 102 
 
 OPERATIVE SURGERY. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE RADIAL ARTERY. 
 
 In front. 
 
 Integument superficial and deep fasciae. 
 Supinator longus. 
 
 Inner side. 
 Pronator radii teres. 
 Flexor carpi radialis. 
 
 Outer side. 
 Supinator longus. 
 Radial nerve (middle third). 
 
 i Radial artery i 
 ( in forearm, j 
 
 Behind. 
 
 Tendon of biceps. 
 Supinator brevis. 
 Pronator radii teres. 
 Flexor sublimis digitorum. 
 Flexor longus pollicis. 
 Pronator quadratus. 
 Radius. 
 
 Operation Upper Third (Fig. 151). Supinate the forearm ; press 
 upon the arm above to distend the superficial veins ; make an incision 
 about three inches in length along the .linear guide to the vessel (Fig. 
 
 150, a). After going through the fasciae, 
 the inner edge of the supinator longus 
 will be found extending beyond the line 
 and overlapping the artery ; separate and 
 pull this outward, when the artery will be 
 seen lying between its veins, with the 
 nerve to the outer side ; separate the ar- 
 tery, and pass the needle from without 
 inward (Fig. 152). 
 
 c 
 
 f 
 
 FIG. 151. Ligature at upper third 
 of radial. 
 
 FIG. 152. Ligature of radial artery, upper 
 third, a. Inner border of supinator longus. 
 b. Deep aponeurosis. c. Pronator radii teres. 
 d. Flexor sublimis digitorum. e. Radial ar- 
 tery. /. Venae comites. 
 
 Operation in the Lower Third (Fig. 153). In this situation the
 
 LIGATURE OF ARTERIES. 
 
 103 
 
 FIG. 153. Ligature at 
 lower third of radial. 
 
 vessel is very superficial, its well-known pulsation being the best guide 
 to it ; with the arm placed as in the preceding position, make an in- 
 cision two inches in length along the course of the vessel (Fig. 150, 
 
 J). After the division 
 of the integument and 
 fasciae, the artery will 
 be seen surrounded by 
 loose areolar tissue, ac- 
 companied by its veins, 
 and lying to the inner 
 side of the tendon of 
 the supinator longus. 
 Separate the tissues 
 FIG. 154. Ligature of radial ar- and ligature the artery, 
 
 tery, lower third, a. Flexor TV , ( ,i no .4-l,p T1 ppdlp from 
 
 carpi radialis muscle, b. Ra- I 
 
 dial artery, c. Venae comites. the nerve (Fig. 154). 
 
 Operation at Apex 
 
 of Styloid Process (Fig. 155). In this situation 
 the vessel is found in a triangular-shaped space, 
 bounded internally by the tendon of the extensor 
 primi internodii pollicis ; externally by that of 
 the secundi internodii pollicis, and the base cor- 
 responding to the apex of the styloid process of 
 the radius. If the thumb be forcibly extended, the outlines of the 
 space will be well marked. 
 
 Operation. Place the hand midway between supination and pro- 
 nation, and, having 
 ascertained the exact 
 situation of the ten- 
 don of the extensor 
 primi internodii polli- 
 cis, make an incision 
 along its outer border 
 about an inch in 
 length ; use care not 
 to divide the superfi- 
 cial veins. The areo- 
 lar tissue and the ex- 
 tensor primi internodii pollicis are pushed aside, and the vessel found 
 somewhat deeply situated. The needle can be carried in either direction. 
 Fallacies. The radial artery may lie upon the fascia and supinator 
 longus instead of beneath them ; it may pass over the extensor tendons 
 of the thumb instead of beneath them. The artery may be mistaken 
 for a radical of the radial vein. The latter is superficial, and has like- 
 wise other characteristics of a vein. 
 
 FIG. 155. Ligature of radial at apex of styloid 
 process.
 
 104 OPERATIVE SURGERY. 
 
 Results. During the late war it was tied twenty times, with four 
 fatal results. 
 
 Ligature of the Ulnar Artery. This vessel is larger than the 
 radial. It is given off from the brachial about one inch below the 
 bend of the elbow, passes, obliquely inward and downward, deeply be- 
 neath the superficial flexors of the forearm, and gains the ulnar side a 
 little above its middle ; becoming superficial, passes along the outer 
 side of the flexor carpi ulnaris to the radial side of the pisiform bone, 
 where it terminates in the superficial palmar arch. It may be ligated 
 in three situations : 1. At the junction of the upper and middle thirds. 
 2. At the lower third. 3. At the wrist. It can be ligatured at its 
 upper third, but such a step has no practical utility except when called 
 for by a direct tying of this portion of the vessel, when, of course, as 
 in all cases, a ligature should be applied at both sides of the bleeding 
 point. 
 
 The linear guide is drawn from the extremity of the internal con- 
 dyle to the pisiform bone (Fig. 150, c, d, e}. 
 
 The muscular guide is the outer border of the flexor carpi ulnaris. 
 
 Contiguous Anatomy. 
 
 PLAN or RELATIONS OF THE ULNAR ARTERY IN THE FOREARM. 
 
 In, front. 
 
 Superficial layer of flexor muscles. ) 
 Median nerve. \ U PP er half " 
 
 Superficial and deep fasciae, lower half. 
 
 Inner side. Outer side. 
 
 Flexor carpi ulnaris. j "Dinar artery ) Flexor sublimis digitorum. 
 
 Ulnar nerve (lower two thirds). \ in forearm. ) 
 
 Behind. 
 
 Brachialis anticus. 
 Flexor profundis digitorum. 
 
 Operation Junction of Middle and Upper Thirds (Fig. 156). 
 Supinate the forearm and make an incision about three inches in 
 
 FIG. 156. Ligature of ulnar artery, FIG. 157. Ligature of ulnar, junction of middle 
 junction of middle and upper and upper thirds, a. Flexor sublimis digitorum. 
 
 thirds. b. Flexor carpi ulnaris. c. Sheath of artery, d. 
 
 Ulnar artery, e. Ulnar nerve. /. Venae comi- 
 tes.
 
 LIGATURE OF ARTERIES. 
 
 105 
 
 length, beginning about four finger-breadths below the internal con- 
 dyle, on the linear guide to the vessel (Fig. 150, c). Divide the fascia 
 on a director; seek for the line of connection 
 between the borders of the flexor carpi ulnaris 
 and the flexor sublimis digitorum. It is of a 
 yellowish-white color. Divide it on a director, 
 and pull the muscles apart, when the ulnar nerve 
 will be seen, to the outer side of which will be 
 found the artery with its accompanying veins ; 
 
 separate the ar- 
 tery and pass 
 the needle from 
 within outward 
 (Fig. 157). 
 
 Operation in 
 the Lower Third 
 (Fig. 158). - 
 Place the arm as 
 
 of ulnar artery, in the prece( ii n g 
 lower third, a. Flexor carpi ulnaris * 
 
 muscle, b. Deep aponeurosis. c. Operation 
 Ulnar artery, d. Venae comites. 
 Ulnar nerve. 
 
 FIG. 1 58. Ligature at low- 
 er third of ulnar artery. 
 
 ex- 
 
 e - tend the hand to 
 make the tendon 
 
 of the flexor carpi ulnaris tense ; make an incision about three 
 inches in length along the radial border of this muscle down to the 
 fascia (Fig. 150, d), which should be divided on a director, expos- 
 ing the tendon of the flexor 
 carpi ulnaris, which should be 
 drawn inward, and the artery 
 is seen beneath it. Isolate the 
 vessel from its veins and pass 
 the needle from within out- 
 ward (Fig. 159). 
 
 Operation at the Wrist 
 (Fig. 160). Place the hand 
 
 On its dorsal surface and make FlG igO.-Ligature of ulnar artery at wrist. 
 
 an incision about two inches 
 
 in length along the radial side of the pisiform bone, with its con- 
 vexity outward (Fig. 150, e) ; carry it downward along the side of that 
 bone through the fascia and fatty tissue to the vessel. Flex the hand 
 and pass the ligature from within outward. 
 
 Fallacies. Between the upper and middle thirds (150, e), the in- 
 terspace between the flexor carpi ulnaris and flexor sublimis may be 
 mistaken for the space between the flexor carpi ulnaris and the pal- 
 maris longus, or flexor carpi radialis. If the hand and fingers be 
 moved alternately, the proper muscles can be ascertained.
 
 106 
 
 OPERATIVE SURGERY. 
 
 In the upper third the vessel runs inward to meet its linear guide ; 
 therefore an attempt to find the artery by the linear guide, in this situ- 
 ation, will be futile. The artery may run beneath the fascia, or oth- 
 erwise vary in its course ; if not in its 
 normal situation, deep pressure may 
 define it. 
 
 Results. The ulnar artery was lig- 
 atured during the war ten times, with 
 three deaths. 
 
 The Superficial Palmar Arch can be 
 tied at the seat of injury. It must be 
 remembered that beneath it lie the 
 tendons of the flexors of the fingers 
 and the divisions of the median and 
 ulnar nerves. 
 
 Linear Guide (Fig. 161). Extend 
 the thumb at nearly a right angle to 
 the carpus, and draw a line transverse- 
 ly across it corresponding to its palmar 
 border ; this will denote the lower lim- 
 it of the arch. 
 
 Operation. Make an incision half 
 or three quarters of an inch in length 
 at the seat of the injury, through the 
 
 integument, palmaris brevis muscle, and palmar fascia, down to the ves- 
 sel. Ligature all bleeding 
 points, and also all un- 
 injured branches arising 
 close to the seat of the 
 injury of the main vessel, 
 to avoid the possibility 
 of secondary hemorrhage. 
 Ligature of the Com- 
 mon Carotid Artery. 
 The right common carot- 
 id arises from the innom- 
 inate artery, and the left 
 from the arch of the aorta. 
 The left is consequently 
 longer and more deeply 
 situated in the chest. 
 The left, after leaving 
 the aorta, passes oblique- 
 ly upward to a point op- 
 posite the left Stemo-Cla- F..G. 162. Surgical anatomy of the common carotid. 
 
 Fio. 161. Linear guide to superficial 
 arch and flexor tendons.
 
 LIGATURE OF ARTERIES. 
 
 107 
 
 victilar articulation ; and, from this point upward, the right and left 
 common carotids maintain substantially the same course to the upper 
 border of the thyroid cartilage, where each divides into the internal 
 and external carotids. 
 
 Each vessel may be ligatured in three situations : 1. At the root of 
 the neck. 2. Below the omo-hyoid muscle. 3. Above the muscle. 
 The last two are the situations commonly selected, the first not being 
 employed except under forced circumstances. 
 
 The linear guide to the vessel is a line drawn from the sterno- 
 clavicular articulation to midway between the angle of the jaw and 
 mastoid process (Fig. 136). 
 
 The muscular guide to the operation is the anterior border of the 
 stern o-clei do-mastoid. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE COMMON CAROTID ARTERY. (GRAY.) 
 
 Integument and fascia. 
 
 Platjsma. 
 
 Sterno-mastoid. 
 
 Sterno-hyoid. 
 
 Sterno-thyroid. 
 
 Externally. 
 Internal jugular vein. 
 Pneumogastric nerve. 
 
 In front. 
 
 ( Common 1 
 < carotid > 
 ( artery. ) 
 
 Behind. 
 Longus colli. 
 Rectus capitis anticus major. 
 
 Recurrent laryngeal 
 
 Omo hyoid. 
 
 Descendens noni nerve. 
 
 Sterno-mastoid artery. 
 
 Superior thyroid, lingual, and facial 
 
 veins. 
 Anterior jugular vein. 
 
 Internally. 
 Trachea. 
 Thyroid gland. 
 Recurrent laryngeal nerve. 
 Inferior thyroid artery. 
 Larynx. 
 Pharynx. 
 
 Sympathetic nerve. 
 Inferior thyroid artery, 
 nerve. 
 
 Operation below the Omo-hyoid (Fig. 163). Place the patient on 
 the back, with the shoulders slightly elevated, and the head turned to 
 the opposite side ; make an incision three inches in length, beginning 
 a little above the cricoid cartilage, on the line stated, and carry it 
 downward along the anterior border of the sterno-mastoid (Fig. 136, 
 c) ; divide the superficial fascia, platysma, and deep fascia on a direct- 
 or, thus exposing the anterior border of the sterno-mastoid muscle. If 
 the sterno-mastoid artery be divided, ligature it. If not injured, push 
 it aside, together with the thyroid vein ; draw the sterno-mastoid 
 muscle outward, and the sterno-thyroid and hyoid muscles inward, 
 when the lower border of the omo-hyoid will be seen above ; divide 
 the fascia beneath these muscles and draw it apart, when the descend- 
 ens noni nerve will be seen resting upon the inner portion of the
 
 108 
 
 OPERATIVE SURGERY. 
 
 FIG. 163. Ligature below omo-hyoid. 
 
 common sheath of the carotid, internal jugular vein, and the pneumo- 
 gastric nerve, the artery being to the inner side, the nerve behind 
 
 and between the two and 
 out of sight. Place the 
 finger upon the sheath, 
 to ascertain the exact 
 location of the artery ; 
 raise the portion of the 
 sheath, at its inner side 
 corresponding to the site 
 of the artery, with a te- 
 naculum or the thumb- 
 forceps, cut a small 
 opening into it, and pass 
 the needle from without 
 inward, cautiously in- 
 sinuating it between the 
 vessel and its sheath 
 (Fig. 164). This ma- 
 nipulation should be carefully done, else either the vein, pneumogas- 
 tric, or recurrent laryngeal nerves may be injured. 
 
 Operation above the Omo-hyoid. The vessel is more superficial in 
 this situation, which is some- 
 times denominated " The site 
 of election" (Fig. 136, V). 
 
 Place the patient as before, 
 and make an incision along 
 the anterior border of the 
 sterno-mastoid, beginning at 
 about the angle of the lower 
 jaw, and extending it a little 
 below the cricoid cartilage ; 
 divide the superficial fascia, 
 platysma, and deep fascia on a 
 director, carefully avoidingthe 
 small veins ; expose the ante- 
 rior border of the sterno-mas- 
 toid, and slightly flex the head 
 to relax the tissues of the 
 
 neck ; draw the edges of the 
 wound apart, and the artery 
 will be felt pulsating in its 
 sheath. If the jugular vein 
 overlap it, it should be emp- 
 tied by pressure above and below, and be drawn outward 
 
 FIG. 164. Ligature of the common carotid, a. 
 Platysma myoides muscle and fascia, b. Ster- 
 no-mastoid, drawn outward, c. Omo-hyoid, 
 crossing the artery, d. Sterno-hyoid muscle. 
 e. Sterno-thyroid muscle. /. Sheath of the 
 vessels, g. Common carotid raised from its 
 sheath. h. Jugular vein, pushed back. i. 
 Pneumogastric nerve, abnormally prominent. 
 j. Descendens noni nerve sometimes in the 
 sheath. 
 
 then care"
 
 LIGATURE OF ARTERIES. 
 
 109 
 
 fully open the sheath as before, avoiding the descendens noni nerve ; 
 pass the needle carefully from without inward. It is well to observe 
 the upper border of the omo-hyoid muscle before opening the sheath, 
 that the exact location to apply the ligature be assured. 
 
 Fallacies. The artery may bifurcate at the cricoid cartilage, and 
 even lower ; however, this is extremely rare ; under such circum- 
 stances both branches should be secured. If the vessel be pressed 
 upon before the ligature is tied, it will determine the influence of the 
 ligaturing upon the branches above. 
 
 The jugular vein may be much dilated, overlie and receive the im- 
 pulse of the artery, and therefore be mistaken for it. This fallacy may 
 be avoided if that vessel be emptied of its blood in the manner before 
 described. The thyroid gland may be enlarged and obscure the ar- 
 tery by displacing or overlapping it. Under these conditions it should 
 be pushed aside. It is reported that the omo-hyoid muscle has been 
 mistaken for the artery ; the fact of its being muscular, taken in con- 
 nection with the direction of its fibers, together with its anatomical 
 relations, should eliminate any danger of this mistake. If branches 
 arise from the main trunk, they may be mistaken for the external caro- 
 tid. The comparative size of the vessel and the influence of pressure 
 on the circulation of the internal carotid will effectually solve the 
 question. If branches be given off from the common carotid near the 
 site of the proposed ligaturing, they should be tied also. 
 
 FIG. 165. Surgical anatomy of external carotid. 
 
 Results. This vessel has been tied seven hundred and eighty-nine
 
 HO OPERATIVE SURGERY. 
 
 times, for various reasons, of which three hundred and twenty-three, 
 or about forty-one per cent, have died. 
 
 Ligaturing of both common carotids, either simultaneously or at 
 variable intervals, has been done thirty-six times. The shortest in- 
 terval between the operations in which recovery has taken place is four 
 and one half days. Instances where the interval varied from thirteen 
 to thirty days are reported, with recovery of the patients. 
 
 Ligature of the External Carotid Artery. This artery arises from 
 the common carotid at or just above the upper border of the thyroid 
 cartilage. It ascends in a slightly curved course, with the convexity 
 forward, to a point midway between the neck of the condyle of the 
 lower jaw and the external auditory meatus. The upper part of its 
 course lies in the substance of the parotid gland (Fig. 165). 
 
 This artery may be tied in two situations : 1, between the posterior 
 belly of the digastric and its origin ; 2, above the belly of the digas- 
 tric. The former situation is the one to be selected, if possible. 
 
 The linear and the muscular guides are substantially the same as 
 for the common carotid. 
 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE EXTERNAL CAROTID. (GRAY.) 
 
 In front. Behind. 
 
 Integument, superficial fascia. Superior laryngeal nerve. 
 
 Platysma and deep fascia. ( External ) Stylo-glossus. 
 
 Hypoglossal nerve. J carotid \ Stylo-pharyngeus. 
 
 Lingual and facial veins. ( artery. ) Glosso-pharyngeal nerve. 
 
 Digastric and stylo-hyoid muscles. Parotid gland. 
 
 Parotid gland, with facial nerve and 
 temporo-maxillary vein in its sub- 
 stance. 
 
 Internally. 
 
 Ilyoid bone. 
 Pharynx. 
 Parotid gland. 
 Ramus of jaw. 
 
 Operation below the Digastric Muscle. With the patient on the 
 back, head slightly extended and turned to the opposite side, make 
 an incision along the anterior border of the sterno-mastoid, beginning 
 opposite the angle of the lower jaw, and carry it downward to a point 
 nearly opposite the cricoid cartilage (Fig. 137, b). Divide the su- 
 perficial fascia, platysma, and deep fascia on a director ; expose the 
 anterior border of the sterno-mastoid. The edges of the wound should 
 be well drawn apart, when the hypoglossal nerve and the digastric 
 and stylo-hyoid muscles will come into view. 
 
 The end of a grooved director should now be employed to separate 
 and push aside the lingual and facial veins, together with the areolar 
 tissue and lymphatic glands that rest upon the vessel. Expose the
 
 LIGATURE OF ARTERIES. HI 
 
 artery and pass the ligature from without inward. The internal jugu- 
 lar vein ofttimes overlaps the vessel, and should be carefully drawn 
 aside, or treated as recommended in ligaturing the common carotid. 
 
 Before the ligature is tied the following facts should be carefully 
 observed : 1. If it be the external carotid around which the ligature 
 is passed, this can be ascertained by pressing upon the vessel and ob- 
 serving its effect upon the circulation of the facial. 2. The distance 
 of the seat of the ligature from collateral branches ; this can only be 
 determined by carefully exposing the vessel for half an inch above and 
 below the seat of the ligature. If vessels be found within this extent, 
 they too should be ligatured to destroy the possibility of any inter- 
 ference with the formation of the internal clot. 3. That the ligature 
 be not carried around the external and internal carotids at, or just 
 above, their point of bifurcation ; if it be around both, pressure will 
 check the pulsation of both ; if but one, it will liave a like effect on 
 the circulation of the vessel pressed upon. 
 
 Other Fallacies. Enlarged lymphatic glands resting on the vessel 
 may be mistaken for it. They need cause but momentary thought, since 
 their circumscribed outline and mobility will determine their nature. 
 If enlarged, they should be removed, otherwise they can be pushed 
 aside. The superior thyroid branch may be confounded with the 
 lingual. If the course of the respective vessels be observed, they can 
 be readily distinguished ; the superior thyroid arises nearest the bifur- 
 cation, arches upward and forward, then passes quite directly down- 
 ward. The lingual does not arch downward, but passes upward and 
 inward to gain the upper border of the great cornu of. the hyoid bone, 
 which can be easily outlined by the finger. 
 
 Operation above the Digastric. Make an incision from the lobule 
 of the ear to the greater cornu of the hyoid bone, along the anterior 
 border of the sterno-mastoid, carefully avoiding the parotid gland. 
 Divide the superimposed tissues as before, down to the digastric mus- 
 cle ; pull it, together with the stylo-hyoid, downward, and if the 
 jugular vein be in the way, push it outward, and pass the ligature from 
 without inward. 
 
 Results. The external carotid has been ligatured seventy-eight 
 times, with four deaths from the operation. 
 
 Ligature of the Internal Carotid Artery. The internal carotid be- 
 gins at the bifurcation of the common carotid, at or a little above the 
 upper border of the thyroid cartilage, and passes perpendicularly up- 
 ward in front of the transverse processes ctf the three upper cervical 
 vertebrae, to the carotid foramen in the petrous portion of the tempo- 
 ral bone, through which it enters into the cranial cavity. At its 
 origin and in the lower portion of its course it lies externally and 
 posteriorly to the external carotid artery. It may be ligatured in any 
 part of the course between its origin and the angle of the lower jaw.
 
 112 OPERATIVE SURGERY. 
 
 The linear and muscular guides of the external carotid artery are 
 suitably adapted to properly locate the internal carotid. 
 Contiguous Anatomy. 
 
 PLAN OF THE RELATIONS OF THE INTERNAL. CAROTID ARTERY IN THE NECK. (GRAY.) 
 
 In front. 
 
 Skin, superficial and deep fasciae. 
 Parotid gland (above the angle of the jaw). 
 Stylo-glossus and stylo-pharyngeus muscles. 
 Glosso-pharyngeal nerve. 
 
 Externally. Internally. 
 
 Internal jugular vein. Pharynx. 
 
 Pneumogastric nerve. \ Internal carotid ) Ascending pharyngeal 
 
 1 artery. f artery. 
 
 Tonsil. 
 Behind. 
 
 Rectus capitis anticus major. 
 
 Sympathetic. 
 
 Superior laryngeal nerve. 
 
 It may become necessary to ligature this artery on account of a 
 penetrating wound received from without or from within the mouth. 
 Ulcerations of and operations on the tonsils have been complicated 
 with injuries to this vessel that have caused death from hemorrhage. 
 It is therefore very important to recall the relations of the tonsil and 
 pillars of the pharynx to this artery, in connection with all injuries 
 and morbid processes of their structures. The angle of the jaw is lo- 
 cated directly externally to the tonsil, and it therefore may become a 
 practical guide to the incision for ligaturing the artery in this situation. 
 
 Operation. The position of the neck of the patient and the loca- 
 tion of the primary incision are similar to those for the ligaturing 
 of the external carotid. The respective tissues are carefully divided 
 on a director down to the muscles, which are then pulled aside, and 
 the ligature is passed from without inward, carefully avoiding the 
 jugular vein and the pneumogastric nerve at the center, and the 
 pharynx at the inner side. 
 
 Fallacies. The internal carotid may arise from the arch of the 
 aorta, and when this occurs hemorrhage from it can be checked only 
 by ligaturing the internal carotid itself. If but one ligature be ap- 
 plied to the internal carotid for hemorrhage, or if the common caro- 
 tid be ligatured alone for the same reason, the collateral circula- 
 tion may cause a continuation of the bleeding, A ligaturing of the 
 internal carotid at both sides of the bleeding point is the only cer- 
 tain means of arresting the hemorrhage permanently. The inter- 
 nal carotid may lie internal to the external carotid. It may be tor- 
 tuous, or even be absent. 
 
 Results. This vessel has been tied alone three or four times ; with
 
 LIGATURE OF ARTERIES. 113 
 
 either the common or external carotid, or both, fifteen times. Only 
 six of these patients died, and from the causes calling for the pro- 
 cedure. 
 
 Ligature of the Superior Thyroid Artery. This vessel comes from 
 the external, or from the common carotid near the point of its bifur- 
 cation. It passes upward and forward, at first quite superficially, 
 then runs downward and less superficially to enter the thyroid gland. 
 
 Operation. Make an incision about three inches in length along 
 the anterior border of the sterno-mastoid, its center corresponding to 
 a point opposite the thyro-hyoid space. The carotid sheath should be 
 exposed as in the ligaturing of that vessel, and the artery sought for 
 along its inner border. 
 
 Ligature of the Lingual Artery. This vessel arises from the ex- 
 ternal carotid opposite th.3 hyoid bone, and runs upward and inward 
 to about one quarter of an inch above the upper border of its greater 
 cornu, and passes horizontally parallel with it, resting upon the mid- 
 dle constrictor of the pharynx, and is covered first by the digastric 
 and stylo-hyoid muscles, and more internally by the hyo-glossus. It 
 then ascends between the hyo-glossus and genio-hyo-glossus muscles 
 and terminates in the ranine artery. 
 
 It has no superficial muscular guide ; a linear guide may be drawn 
 parallel with, and a fourth of an inch above, the greater cornu of the 
 hyoid bone (Fig. 136, a) ; practically, however, the upper border of 
 the greater cornu of the hyoid bone marks its situation. It may be 
 ligatured in three situations : 1. At the apex of the greater cornu. 
 2. Between the cornu and the posterior belly of the digastric. 3. In 
 the triangle made by the digastric and mylo-hyoid muscles, and hypo- 
 glossal nerve. 
 
 Operation between the Digastric and the Greater Cornu. Place the 
 patient on the back, and turn the head to the opposite side ; carefully 
 define the greater cornu of the hyoid bone. If the neck be fleshy, this 
 will be somewhat difficult. It can be made more prominent on the 
 side of the operation by pushing against its body on the opposite side, 
 being careful to press it directly toward that point, otherwise it may 
 mislead the operator. After the patient is thoroughly anaesthetized to 
 prevent spasmodic movements of the muscles attached to the hyoid 
 bone, make an incision about two or three inches in length parallel 
 with the upper border of the cornu, which should pass downward 
 and outward to nearly the anterior border of the sterno-mastoid (Fig. 
 136, ). Divide the superficial fascia, platysma, and deep fascia on a 
 director ; draw upward the submaxillary gland and divide the deep 
 aponeurosis, when the digastric and stylo-hyoid muscles and the hypo- 
 glossal nerve will be exposed. Accurately locate the greater cornu 
 with the finger and fix it with a tenaculum, draw up the digastric and 
 the stylo-hyoid muscles and hypoglossal nerve with a blunt hook, push
 
 114 
 
 OPERATIVE SURGERY. 
 
 aside the lingual vein if seen, and pick up the fibers of the hyo-glossus 
 with a pair of forceps, and incise them in the direction of the external 
 incision about one quarter of an inch above the greater co*nu ; beneath 
 
 them will be found the 
 vessel, sometimes accom- 
 panied by the lingual 
 vein (Fig. 166). Pass 
 the needle from the vein. 
 Before tying the liga- 
 ture, ascertain if pres- 
 sure will stop the pulsa- 
 tion of the artery. 
 
 Ligature in the 
 Third Situation. This 
 is often called " the 
 place of election." Make 
 an incision transversely 
 two inches long, con- 
 
 FIG. 166.-Ligature of lingual artery. Cavit ? U P Ward > and its 
 
 center just within the 
 
 middle of the cornu of the hyoid bone. Divide the integument, su- 
 perficial fascia, and platysma, carefully avoiding the superficial veins ; 
 
 FIG. 167. Surgical anatomy of the lingual artery. 1. Submaxillary gland. 2. Lingual 
 artery. 3. Lingual vein. 4. Hypoglossal nerve. 5. Stylo-hyoid muscle. 6. Digastric 
 muscle. 7. Mylo-hyoid muscle. 8. Hyoid bone. 9. Hyo-glossus muscle. 
 
 divide the deep fascia and pull upward the submaxillary gland, when 
 the posterior belly of the digastric will come into view, as also the 
 posterior border of the stylo-hyoid muscle* and the hypoglossal nerve, 
 accompanied usually by the lingual vein. Carefully outline the trian- 
 gle before mentioned, pinch up the fibers of the hyo-glossus, and divide 
 them midway between the hyoid bone and the nerve, when the artery
 
 LIGATURE OF ARTERIES. 115 
 
 will be seen beneath (Fig. 167). Separate it from the vein, if the vein 
 lie beneath, the muscle and has not been seen before, and pass the liga- 
 ture. 
 
 Ligature in the First Portion. In this situation the vessel is tied 
 between the point of its giving off and the tip of the greater cornu of 
 the hyoid bone. 
 
 Operation. Make an incision three inches in length running ob- 
 liquely downward and backward, its center corresponding to the greater 
 cornu. The various tissues are carefully divided as before, and the 
 hypoglossal nerve is exposed. The numerous veins located in the 
 course are now pushed aside, and the artery carefully sought for at the 
 point of the cornu, and ligatured. This operation, on account of the 
 absence of a definite deep guide to the location of the vessel, and the 
 uncertainty of its point of origin, together with the great number of 
 large veins in the course of the search, is much less feasible than either 
 of the other two. 
 
 Fallacies. The hypoglossal nerve may be mistaken for the artery. 
 The nerve rests on the hyo-glossus ; the artery runs beneath it. This, 
 together with the pulsation of the artery and other distinctive ana- 
 tomical features, should render the discrimination easy. It is well to 
 know, however, that the movements of the tissues dependent on the 
 acts of respiration make it somewhat difficult, and often impossible, to 
 detect the arterial impulse. If, however, the supposed artery be care- 
 fully isolated, the ligature passed around it, and a good light thrown 
 into the wound, its tortuous outline will be noticed with each pulsa- 
 tion. The pulsation can be seen best in the interval of the respiratory 
 acts, when the tissues are quiet. 
 
 The lingual vein may be mistaken for the artery. This vessel 
 sometimes runs with the artery behind the hyo-glossus ; more fre- 
 quently, however, it rests on this muscle. It has the characteristic 
 color of a vein, and is larger than the artery. The lingual artery 
 may be absent on one side. After the division of the fibers of the 
 hyo-glossus, the search for the vessel must be conducted cautiously 
 to avoid opening into the pharynx. 
 
 Results. It has been tied repeatedly with great advantage, for the 
 purpose of controlling hemorrhage from the tongue, and delaying a 
 morbid growth of the same. 
 
 Ligature of the Facial Artery. The facial is one of the large 
 branches of the external carotid. It arises from it just above the tip 
 of the greater cornu, or about one inch from the bifurcation of the 
 common carotid, passes forward and upward beneath the ramus of the 
 lower jaw, going through the substance of the submaxillary gland, 
 and gains the external surface of the ramus at the anterior inferior 
 angle of the masseter muscle, lying in a groove in the outer border of 
 the bone. The masseter muscle, therefore, becomes its muscular
 
 116 
 
 OPERATIVE SURGERY. 
 
 guide in a portion of its course. It may be ligatured in two situa- 
 tions : in the neck, and as it crosses the ramus of the jaw, the latter 
 being the better. In the former, the head is turned to the opposite 
 side, and an incision of about three inches in length is made obliquely 
 downward and forward a little in front of the anterior border of the 
 sterno-mastoid, its center being at a point about one third of an inch 
 above the tip of the greater cornu. The dissection is carefully made 
 as in ligaturing the lingual at this first portion, pushing aside the 
 facial and other contiguous veins, drawing up the digastric and pass- 
 ing the ligature. 
 
 Operation at the Ramus of the Jaw. Place the patient as before, 
 draw the skin upward over the ramus, so that when retraction of the 
 tissues occurs the cicatrix will be beneath the jaw ; make an incision 
 about two inches in length along the border of the jaw, divide the 
 tissues on a director (Fig. 137, c), down to the vessel ; isolate it, and 
 pass the ligature. If a resulting cicatrix be of no moment, the pri- 
 mary incision can be 
 made in the long axis of 
 the vessel along the an- 
 terior border of the mas- 
 seter muscle (Fig. 168). 
 Fallacies. At its or- 
 igin this vessel may be 
 mistaken for the lingual. 
 Interruption of the cir- 
 culation will easily deter- 
 mine the difference. 
 
 Ligature of the Tem- 
 poral Artery. The tem- 
 poral is one of the term- 
 inal branches of the ex- 
 ternal carotid. It begins 
 in the substance of the 
 parotid gland between 
 the neck of the lower jaw and the external meatus and passes upward 
 across the root of the zygoma, subcutaneously, where its pulsation can 
 be distinctly felt. About two inches above the zygomatic process it 
 divides into its terminal branches. 
 
 The zygomatic process is the bony guide to it. 
 Operation (Fig. 137, d). Make an incision in the line of the ves- 
 sel, as indicated by its pulsation, about one fourth of an inch in front 
 of the tragus and one inch in length ; divide the skin and fascia ; 
 expose the vessel and pass the needle so as to avoid the vein and 
 nerve (Fig. 168). 
 
 The Ligature of the Occipital Artery. This artery arises from the 
 
 FIG. 168. Ligature of facial and temporal arteries.
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 m 
 
 external carotid a trifle above the facial, and passes upward and out- 
 ward to the interval between the transverse process of the atlas and 
 the mastoid process of the occipital bone. It then passes over the 
 posterior portion of the skull midway 
 between the external occipital pro- 
 tuberance and the mastoid process 
 (Fig. 137, e). It has no muscular 
 guide. It may be tied at its origin 
 or behind the mastoid process. 
 
 Operation at its Origin. Make 
 an incision along the inner border of 
 the sterno-mastoid, about three inch- 
 es in length, its center correspond- 
 ing to a point a little above the apex 
 of the greater cornu of the hyoid 
 bone. Divide the superficial tissues 
 carefully on a director ; separate the 
 areolar tissue with its blunt extrem- 
 ity ; push aside the veins and find 
 the posterior belly of the digastric. 
 
 the ninth pair of nerves, winding around the object of search, 
 the needle from the nerve. 
 
 Operation behind the Mastoid Process (Fig. 169). Make an incision 
 about two inches in length one-half inch behind and a little below the 
 mastoid process. Divide the integument and attachments of the 
 sterno-mastoid and the splenius muscles ; feel for the pulsation at the 
 bottom of the wound. Isolate the artery and pass the ligature. 
 
 FIG. 169. Ligature of occipital artery. 
 
 A little below this will be seen 
 
 Pass 
 
 CHAPTER V. 
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 Ligature of Veins. Veins, like arteries, may be ligatured in their 
 continuity or at their divided extremities. Large venous branches, 
 when divided in the course of an operation, should always be tied, 
 otherwise they may give rise to an objectionable amount of oozing, 
 which will interfere with the rapidity of the union of the divided sur- 
 faces, and possibly require the re-opening of the wound to secure the 
 bleeding points. If a large vein be nicked during an operation as the 
 internal jugular, during the removal of growths from the neck liga- 
 tures may be thrown around it, above and below the opening, rather
 
 118 OPERATIVE SURGERY. 
 
 than to tie the nicked portion. The latter procedure is liable to be 
 followed by secondary hemorrhage. The practice of ligaturing the 
 opening, or of sewing its divided borders by fine catgut, is highly 
 extolled by many writers. If it be determined to tie the vessel, it 
 should be done above and below the wound of the vessel, else the re- 
 turn circulation will cause secondary hemorrhage. If it be possible 
 at the onset to surround the patient with the degree of surveillance 
 necessary to detect and treat secondary hemorrhage, I am of the opin- 
 ion that the practice of sewing the nick with the continuous or other 
 suitable form of suture such as is used for intestinal wounds offers 
 the better opportunity for rapid recovery. Aside from the ligaturing of 
 veins on account of traumatism, they are ligatured in their continuity 
 for the purpose of causing their occlusion in those cases in which they 
 are in a dilated or varicose condition. 
 
 Operations for Varicose Veins. When the veins of the lower ex- 
 tremities become too much distended to be amenable to palliative 
 measures, it is often necessary to resort to operative interference, 
 which has for its object the occlusion of the distended canals. Injec- 
 tion, acupressure, and ligaturing are the common means employed. 
 
 Injection. The vein is compressed by the fingers above and below 
 the proposed point of injection leaving an intervening space of an 
 inch or less or by small pads confined in position with adhesive plas- 
 ter, the latter being the better plan. Into the isolated portion twenty 
 or thirty drops of a twenty-per-cent solution of liquor ferri subsul- 
 phatis and water are then slowly injected. Almost immediately the 
 contents of the vessel become coagulated, when the pressure can be 
 removed. The limb should be kept quiet for a few days, and any 
 tendency to undue inflammation combated. 
 
 The results of this operation, while not so favorable as other expe- 
 dients, are, nevertheless, very satisfactory. Of the one hundred and 
 three cases some time since reported, seventy-nine were cured, one 
 died, and of the remainder, sixteen were failures. 
 
 Acupressure. This is substantially the same as the application of 
 acupressure for arresting the circulation of arterial trunks. It con- 
 sists simply of carrying thoroughly purified needles or pins, which 
 may or may not have been constructed for the purpose, beneath the 
 vein at intervals of an inch or so, and compressing the superimposed 
 tissues by means of carbolized silk or cotton yarn wound over the 
 protruding ends of the pins. The pins are removed on the sixth or 
 seventh day, depending on the degree of ulceration produced. Cau- 
 tion should be observed that the pins be not passed through instead 
 of beneath the vein, otherwise a serious phlebitis may follow. 
 
 Subcutaneous Ligaturing. This is accomplished by passing a car- 
 bolized needle, armed with a fine wire or a catgut ligature, in front of 
 and across the vein, after which the direction is changed so as to
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. H9 
 
 carry it beneath the vessel and out at the point of entrance. If wire 
 be used it is then twisted and cut short, and the opening closed anti- 
 septically. Should catgut be employed, it is tied, and cut, and the 
 opening treated in the same manner. Three or four of these constric- 
 tions may be applied at intervals of an inch. If the blood in the in- 
 tervening spaces becomes necrosed, giving rise to fluctuation, it should 
 be evacuated, as absorption is then impossible. In the subcutaneous 
 ligaturing of varicose veins such as the long and short saphenous 
 veins that are accompanied by nerves, the nerves may be accident- 
 ally included by the ligature. It is safer, in such instances, to ex- 
 pose the vein and pass the ligatures, as in arterial ligaturing, after 
 which the included portion of the vein can be excised, or simply 
 divided. Thorough antisepsis should be practiced in such cases. 
 
 Hemorrhoids. A varicose condition of the hemorrhoidal veins 
 causes a disease denominated hemorrhoids or piles, for the cure of 
 which various radical measures are recommended. The patient is 
 prepared by a saline cathartic, which should be followed by an enema, 
 a few hours prior to the operation. He should then be etherized, 
 placed upon a table of suitable height, with the buttocks drawn down 
 to the edge ; the thighs are then elevated, drawn apart, and the nates 
 separated. If the growths be of the external variety, and not inflamed, 
 they can be nipped off with a pair of scissors, being careful not to cut 
 them too closely, else the resulting cicatrization may cause a narrow- 
 ing of the anal orifice. Local anaesthesia is sufficient to overcome the 
 pain attending this operation. If the hemorrhoid be distended, ten- 
 der, and painful, it is generally necessary to employ general anassthe- 
 sia. The tumor should be taken between the thumb and finger, raised 
 up, drawn out, transfixed near the base, and cut outward ; gentle 
 pressure will then evacuate its contents, after which a pellet of fine 
 oakum saturated with balsam of Peru, marine lint, or iodoform gauze, 
 should be placed in the bottom of the sack, and the operation is com- 
 pleted. To facilitate union, the transfixing incision is made in the 
 direction of the radiating folds of the anus. 
 
 Operations for Internal Hemorrhoids. These are quite numerous, 
 but the following are believed to secure the best results : 
 
 Excision. This method is reckoned among those which secure the 
 best results in selected cases. It causes little after-pain, and recovery 
 takes place within a week or ten days. It is applicable to those cases 
 where but three or four tumors exist, which are not very large, and 
 have well-defined bases. The sphincter should be well dilated and the 
 anus opened with a speculum or retractor. The pile is then seized at 
 the base with a volsella, and cut off with a pair of scissors above the 
 point grasped, which should be held till all arterial hemorrhage is 
 stopped by twisting the bleeding points. After it has ceased, pledgets 
 of lint saturated with tannin and water, or with liquor ferri subsul-
 
 120 
 
 OPERATIVE SURGERY. 
 
 phatis, are applied to the cut surfaces, and the patient kept quiet for 
 twenty-four to forty-eight hours. 
 
 Results. This method of operating has been frequently per- 
 formed, and with eminent success. 
 
 Crushing. This method consists in crushing the pedicle of the 
 
 growth by an 
 improvised in- 
 strument or one 
 especially con- 
 structed for 
 that purpose 
 (Fig. 170). It 
 is not suitable 
 for universal 
 application,but 
 rather to those 
 
 1 10. 170. Alhngnam's screw crushing instrument for hemorrhoids. , , . , 
 
 tumors which 
 
 possess well-defined bases. The integument, if it be connected with 
 the tumor, should be incised, otherwise too great pain will be caused. 
 
 Operation. The patient being prepared as in the preceding in- 
 stance, the pile is pulled between the bars of the instrument by the 
 aid of a hook or a volsella. after which the screw is turned tightly 
 against it. The projecting portion is then cut off. The instrument 
 is retained in position for half a minute or so, to insure against the 
 danger of hemorrhage. While this method may be classed among the 
 satisfactory ones, it possesses no superiority over the treatment by 
 ligature, and as a rule causes more pain, less speedy recovery, and 
 exposes the patient to the possible danger of subsequent hemorrhage. 
 
 Ligaturing. This method may be employed with or without in- 
 cision, the latter being preferable. The treatment without incision is 
 to pass a needle, armed with a double ligature bf stout carbolized silk 
 or catgut, through the base of the growth, tying each half separately, 
 after which the pile is cut off below the ligature. If strong catgut be 
 used, the ends should be divided close to the pedicle, while with silk, 
 one end may be allowed to hang from the anus. 
 
 Ligature with incision consists in drawing down the- tumors by 
 aid of forceps or volsella to the anus, or beyond it, and with a pair of 
 curved scissors dividing them from their connection with the sub- 
 mucous membrane from below upward, parallel with the bowel, far 
 enough to leave the pile connected only by a slim pedicle, around 
 which a strong ligature should be cast and securely tied. The liga- 
 tured portion is then cut off and the parts returned. The vessels 
 connected with the growth enter it from above downward, parallel 
 with the gut, and are therefore secure from injury, if ordinary caution 
 be observed.
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 121 
 
 Injection. The injection of carbolic acid and astringent agents, 
 together with the application of caustics, is hardly entitled to the dig- 
 nity of being considered an operation. Nor are the results, notwith- 
 standing the claims of some to the contrary, on the whole better than 
 by ligature, either with or without incision. The occasional severe 
 inflammatory reaction, often followed by abscesses and gangrene, de- 
 tract from that which might otherwise become an extremely satisfac- 
 tory remedy. The full explanation of these methods can be found in 
 systematic treatises upon the subject. 
 
 Varicocele. This is caused by a varicose condition of the spermatic 
 veins (Fig. 171). The treatment of the varicose veins of the cord, 
 
 like that for varicose veins in other sit- 
 uations, is divided into the palliative 
 and radical methods, the object of the 
 latter being to obliterate the lumen of 
 the vessels. The same dangers apper- 
 tain to operations upon these veins as 
 upon those of other portions of the ve- 
 nous system. Erysipelas, phlebitis, pyae- 
 mia, to which may be added a conse- 
 quent atrophy of the testicle depending 
 upon the occlusion of the vein or arte- 
 ry, may follow ; therefore, radical mea- 
 
 FIG. 171. Varicose spermatic veins. 
 
 FIG. 172. Morgan's suspensory. 
 
 sures directed to the vessels should not be entertained, except in old 
 age, until the disease becomes a source of discomfort and even dis- 
 tress. The palliative treatment consists in shortening the cord by 
 raising the scrotum and its contents, which lessens the weight of the 
 column of blood contained in the vessels. This is achieved by the 
 various forms of suspensories, as Morgan's (Fig. 172), or the one in 
 ordinary use. Should these serve to relieve the urgent symptoms, the 
 patient may not deem it desirable to submit to an operation of any 
 kind. If, however, the characteristic symptoms recur or continue,
 
 122 
 
 OPERATIVE SURGERY. 
 
 then the palliative operation for shortening the scrotum should be 
 made. 
 
 Excision of the Scrotum. The instruments required for this sim- 
 ple operation are the scrotal clamp the one devised by Dr. Henry 
 being in every way suitable (Fig. 173) a sharp bistoury, needles 
 
 armed with silver wire or carbolized silk, 
 artery forceps, and catgut ligatures. The 
 scrotum should be thoroughly cleansed 
 and the patient anaesthetized ; the clamp 
 is then applied to the side afflicted by 
 drawing the bottom of the scrotum be- 
 tween the blades, which should be applied 
 as nearly as possible parallel with the 
 raphe ; all danger of including the testi- 
 cle is obviated by pressing it upward to 
 the external abdominal ring. When a 
 sufficient amount of tissue is grasped to 
 meet the indication, the blades are tight- 
 ened to cut off all circulation, at the same 
 time. to securely hold the scrotal tissue ; 
 the protruding portion is then transfixed, 
 on a level with the adjustable bar (Fig. 173, 
 a), by a sharp, narrow-bladed bistoury, 
 and cut off. Before the blades are loos- 
 ened it is better to pass the sutures, which 
 should be at least ten inches in length, 
 through the divided borders. Having ad- 
 justed them, remove the clamp, tie the 
 bleeding points, and close the wound. 
 Care must always be taken to stop all 
 bleeding points before the edges of the 
 wound are united ; else, owing to the 
 looseness of the scrotal tissues, an ordinary 
 oozing may cause the formation of large 
 bloody clots, which must be removed. If 
 a drainage-tube be introduced 'throughout its course and allowed to 
 protrude at its most dependent extremity, this danger will be further 
 avoided. Place the patient in bed, elevate the scrotum, and dress the 
 wound antiseptically. It usually heals quickly, and affords sufficient 
 relief to amply recompense the patient for the annoyance incurred 
 from the operation. If the instrument just described be not at hand, 
 the operation should not be rejected for this reason. A clamp of 
 practical utility maybe extemporized from long^handled forceps, or by 
 adjusting to the scrotum two narrow bars of metal or stiff wood, the 
 extremities of which can be firmly held by the hands of an assistant. 
 
 FIG. 173. Henry's scrotal clamp.
 
 OPERATIONS OX VEINS, CAPILLARIES, ETC. 
 
 123 
 
 Radical Treatment for Varicocele. The means employed to ob- 
 literate the dilated vessels are quite numerous. They all, however, 
 accomplish the result by compression. Only such as are considered 
 practically consistent with the safety of the patient are here described. 
 In all the operations great care must be exercised to avoid the vas 
 deferens and artery. They lie posteriorly to the enlarged and worm- 
 like congeries of vessels, around which the compression is to be ap- 
 plied. If the patient be caused to lie down with the hips elevated, the 
 blood will return from the varicose veins into the general circulation, 
 after which the vas deferens and the artery can be easily isolated and 
 separated from the veins. If the patient then assume an erect posi- 
 tion the veins will again become distended, when, if pressure be main- 
 tained upon the cord at the external ring, the vessels can be distinctly 
 outlined if the patient be again placed in the recumbent position. The 
 operator having thus carefully located the vas deferens and the artery, 
 the patient can be etherized and the operations proceeded with. 
 
 Compression ~by Pins (Fig. 174). This consists simply of passing 
 
 FIG. 174. Occlusion 
 by pins. 
 
 FIG. 175. Wires in 
 position. (Videl's 
 operation.) 
 
 FIG. 176. Wires 
 twisted. (Videl's 
 operation.) 
 
 FIG. 177. Vessels 
 occluded. (Videl's 
 operation.) 
 
 a strong pin through the scrotal tissues in front of the vas deferens 
 and the artery, and throwing around its protruding extremities an 
 elastic ligature, or cotton yarn, drawn sufficiently tight to cut off the 
 circulation. This procedure should be repeated at about one inch 
 from the first application. The pins can be withdrawn at the end of 
 three or four days. 
 
 Compression ly Wires (Videl's). This is done by passing a stout 
 wire either in front of or behind the veins, preferably the latter, then 
 passing a second but smaller one at the opposite side, but through the 
 same opening in the integument (Fig. 175). They are then twisted 
 together till the veins are thoroughly compressed and rolled around 
 them (Figs. 176 and 177). 
 
 Subcutaneous Ligaturing. This is accomplished by carrying a
 
 124 
 
 OPERATIVE SURGERY. 
 
 needle armed with a silver wire between the veins and the remaining 
 vessels of the cord, returning it at the point of entrance, going in 
 front of the veins. The wire is then twisted firmly. A strong silk 
 
 ligature can be applied in 
 a similar manner. The 
 amount of tissue in their 
 grasp renders the separa- 
 tion somewhat tedious. 
 The process of separa- 
 tion can be hastened by 
 tying the ligature over 
 a small cylinder of elas- 
 tic tubing (Levis), the 
 resistancy of which will 
 exercise a constant trac- 
 tion (Fig. 178). If this 
 be done, a button should 
 be introduced between 
 the tissues and tubing to protect the skin (Pancoast). 
 
 Strong catgut ligatures, or antiseptic silk, can be carried around 
 the dilated veins, an inch or so apart, by means of an ordinary needle 
 or by an instrument especially devised for the purpose and caused 
 to emerge at the point of entrance, tied, ends cut short, and permitted 
 to remain until they are absorbed. The veins may be divided subcu- 
 taneously between the ligatures after they have been tied. 
 
 The expedient advised by Prof. E. L. Keyes for passing the liga- 
 tures is not only ingenious but also simple. A needle with a fixed 
 handle, having two eyes at its point (Fig. 179), is armed with two 
 antiseptic ligatures one carried through each eye. The ends of the 
 
 FIG. 178. Elastic traction. 
 
 FIG. 179. Keyes' needle. 
 
 posterior ligature are tied to form a loop ; the anterior ligature is 
 permitted to hang loosely, with an equal portion at each side of 
 the needle. The enlarged veins are isolated, and the point of the 
 needle is pushed through the scrotal tissues in close contact with 
 their posterior surfaces. One end of the untied ligature is then 
 drawn through the tissues with forceps, and caused to remain in this 
 position, while the needle is withdrawn sufficiently to permit its 
 point to be carried in front of the distended veins, out through the 
 original point of exit, when the distal end of the untied ligature is 
 passed through the advanced portion of the looped one and drawn 
 by it through the point of entrance to the scrotal tissues by the
 
 OPERATIONS OX VEINS, CAPILLARIES, ETC. 
 
 125 
 
 FIG. 180. Ricord's loops. 
 
 complete withdrawal of the needle. The deposited ligature is then 
 freed from the scrotal tissues by making one or two sharp pulls upon 
 it, tied firmly around the veins, its extremities cut short and allowed 
 to disappear within the scrotum. If thorough antiseptic precautions 
 be observed, the ligatures will rarely cause subsequent local trouble. 
 
 The Double-Loop Compression of Ricord (Fig. 180). This is an 
 excellent plan, and can be readily exe- 
 cuted by passing a needle armed with a 
 silk ligature between the veins and the 
 vas deferens ; to this is fastened a double 
 ligature, which is drawn through and left 
 in position. The needle with its silk 
 ligature is then passed in front of the veins 
 in the opposite direction, entering and emerging at the points pre- 
 viously made. A second double ligature is then drawn through and 
 left in position. The extremities on the respective sides are now 
 tucked through the loops on the same side and drawn tight, and tied 
 over a narrow roller or piece of elastic tubing. The ligatures will cut 
 their way through in five or six days. The methods of cure by ex- 
 posure, division, and ex- 
 cision of the vessels are 
 more dangerous, and 
 have infrequently re- 
 sulted in death from 
 
 pyaemia. 
 
 Venesection. While 
 the withdrawing of blood 
 from a vein can hardly 
 be classed as an operation 
 of much moment in a 
 surgical sense, yet the 
 infrequency of its em- 
 ployment at the present 
 time is quite apt to ren- 
 der the details connected 
 therewith somewhat un- 
 certain in the minds of a 
 majority of the practi- 
 tioners of the present 
 generation. The veins 
 selected for the proce- 
 dure are the internal 
 saphenous at the ankle, 
 
 FIG. 181. Opening the vein with scalpel. 
 
 the median basilic, or median cephalic at the bend of the elbow, and 
 external jugular in the neck. The instruments required are the or-
 
 126 OPERATIVE SURGERY. 
 
 dinary thumb-lancet, or a curved or straight sharp-pointed bistoury ; 
 the first, however, possesses the greater number of traditional virtues. 
 Should the lancet be not at hand, either of the others can be used 
 as satisfactory substitutes. If the region of the elbow be selected, the* 
 median cephalic vein is preferred on account of its greater distance 
 from the brachial artery. The arm should be constricted by a band- 
 age drawn sufficiently tight to obstruct venous return, without inter- 
 fering with arterial circulation : this will cause the veins to become 
 prominently distended, unless the patient be very fleshy. The veins, 
 should be well defined by the finger, and held in position by the 
 thumb or finger placed just below the point for incision, which is 
 made obliquely to the transverse diameter, and of sufficient depth to 
 freely open the vessel without severing it (Fig. 181). The flow may 
 be increased by causing the patient to firmly grasp a stick or broom- 
 handle ; it may be impeded by the interposition of the subcutaneous 
 fat, which should be pushed aside. The amount drawn will be gov- 
 erned by the strength of the patient, as well as his position. If stand- 
 ing or sitting, its effects will be felt sooner than if in a recumbent 
 posture. Usually, however, from half a pint to a pint will suffice. 
 The flow is arrested by removing the bandage above and applying the 
 finger to the bleeding point, after which a small compress is placed 
 over the incision, and confined in position by adhesive plaster, so ar- 
 ranged as not to impede the venous return. 
 
 These directions will apply with equal force to venesection in all 
 situations other than the external jugular. If this vein be selected, 
 the compress is placed just above the clavicle, and confined in position 
 by a bandage carried under the opposite axilla. The finger is then 
 placed above the point of proposed incision, and the vessel opened at 
 a right angle with the fibers of the platysma myoides muscle. The 
 finger must always be placed on the opening before the compress is 
 removed, in order to prevent the entrance of air into the circulation. 
 
 Transfusion. This is a means sometimes employed to overcome 
 the exhaustion produced by disease or the loss of blood, the latter 
 being the only condition to which it can, thus far, be said to be prac- 
 tically adapted. It consists in conveying the blood from one person 
 to another, either directly, or by collecting it in a suitable receptacle, 
 removing the fibrin, and introducing the remaining plasma and cor- 
 puscles. The dangers to be avoided are, the introduction of air, blood- 
 clots, and too great a quantity of blood into the patient's veins, which 
 might overpower an already weakened heart. From six to eight 
 ounces are usually sufficient, and should be thrown in slowly and 
 carefully, watching the effects upon the circulation, respiration, and 
 sensorium of the patient. If its introduction cause a depression of 
 the pulse, or give rise to nervous tremors, or difficulty in breathing, 
 it should cease at once. The blood to be transfused should be taken
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 127 
 
 from a person of strong physique, and free from any constitutional 
 taint. 
 
 Direct Transfusion from Arm to Arm. The requirements for 
 this are an apparatus for the transmission of the blood, together with a 
 pair of forceps and a scalpel to open 
 the vessels, and a basin of water or sa- 
 line solution, at a temperature of 
 about 100 F., into which the appa- 
 ratus should be laid to impart to it 
 the requisite degree of warmth, and 
 to exclude the air. The arm of the 
 donor and receiver are constricted 
 above the point for incision, as in 
 
 FIG. 182. Introducing the tube in transfusion. 
 
 phlebotomy ; the skin covering the distended vessels is pinched up, 
 transfixed, and cut through, leaving the veins exposed at the bottom of 
 the wounds ; they are then seized with a pair of forceps, and a V-shaped 
 opening made with the scissors for the purpose of introducing the tube 
 (Fig. 182). The tube A (Fig. 183) is then taken from the bottom of 
 the basin, and, with the thumb applied to its larger extremity to keep 
 it filled, it is inserted into the opening in the vein of the receiver ; the 
 tube B is inserted in like manner into the vein of the donor, after which 
 the propelling power the apparatus likewise filled with fluid and 
 kept so by turning the stop-cocks, is attached to the two tubes ; the 
 cocks are now opened, and the fluid contained in the instrument is 
 thrown into the circulation by squeezing the bulb C, while the tube 
 D" is compressed. After the bulb C is emptied, and before it is per- 
 mitted to expand, the compression should be changed from D" to D. 
 If the bulb be now allowed to expand, it will become filled with the
 
 128 
 
 OPERATIVE SURGERY. 
 
 blood of the donor, which can be injected into the circulation as in 
 the preceding instance. The bulb should be allowed to fill slowly, 
 
 FIG. 183. Direct transfusion. 
 
 and the amount introduced is estimated by counting the number of 
 times it is emptied. After the operation is completed, the incisions 
 are treated the same as in phlebotomy. The instrument devised by 
 Fryer (Fig. 184) differs from the former in being cast whole, with an 
 
 FIG. 184. Fryer's transfusion apparatus. 
 
 additional bulb, which does away with the metallic couplings, and 
 presents a continuously smooth surface to the blood current ; and, 
 moreover, the additional bulb saves time by producing an almost con- 
 tinuous current. It will be seen that a funnel is added to this instru- 
 ment which allows it to be employed in mediate transfusion. 
 
 Mediate transfusion is collecting the blood from the arm of the 
 donor and injecting it into the circulation, either with or without the 
 removal of the fibrin. For this purpose the instrument devised by 
 Collins (Fig. 185) can be especially recommended. It consists of a 
 pump attached to a funnel in such a manner as to carry the blood 
 easily and without danger of coagulation or the introduction of air.
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 129 
 
 It can be used equally well with the detibrinated or with the un- 
 whipped blood ; with the 
 latter it is particularly con- 
 venient, since the blood can 
 be caught in the funnel and 
 injected while flowing from 
 the donor, which saves time, 
 and avoids the blood-changes 
 induced by exposure. In 
 
 FIG. 185. Collins' instrument. 
 
 the use of this, and all other implements brought in contact with the 
 blood, the temperature of the instrument, and of the blood injected, 
 should be kept at about 100 
 F. by means of warm water, 
 or a warm saline solution.* 
 
 If defibrinated Hood be 
 employed, it should be pre- 
 pared by agitation (Fig. 186), 
 after being collected in a 
 vessel of the temperature 
 stated, then strained into 
 the funnel of the instru- 
 ment and pumped into the 
 system. 
 
 The introduction into the 
 funnel, or into the bulbs, of 
 two or three ounces of a sa- 
 line solution, or of a carbon- 
 ate of ammonia solution, 
 four to six grains to the FIG. 186. Removing fibrin. 
 
 * 9 Chloride of sodium 3 j. 
 
 Chloride of potassium gr. vj. 
 
 Phosphate of soda gr. iij. 
 
 Carbonate of soda 3 j- 
 
 Aquae xx. 
 
 M. Heat to 100 F. 
 
 9
 
 130 
 
 OPERATIVE SURGERY. 
 
 ounce, prevents the entrance of air into the instrument, and also has 
 a stimulating effect upon the patient. 
 
 FIG. 1 87. Bull's apparatus for injection of saline solutions. 
 
 Injection of Saline Solutions. The introduction into the veins, 
 and the arteries, of various solutions, the chief ingredients of which 
 are common salt and carbonate of soda, is highly recommended. The 
 following is the formula of Schwartz : Distilled water, 32 ounces ; 
 common salt, 1^ drachm ; officinal solution of soda, 2 drops, raised to 
 100 or 104 F. 
 
 Szumann recommended the following : Water, 32 ounces ; com- 
 mon salt, 1^ drachm ; carbonate of soda, 15 grains. The saline solu- 
 tion on page 129 is suitable for this purpose. The amount of fluid 
 to be injected will depend on the condition of the patient, also upon 
 its effect. It is seldom that less than eight ounces are used, frequently 
 eighteen or twenty, and even more may be advisable. The introduc- 
 tion of the fluid should be made slowly, occupying fifteen or twenty 
 minutes, by means of the apparatus already figured, or by an extem- 
 porized siphon. If an aspirating needle a sixteenth of an inch in diam- 
 eter be attached to a small rubber tube, connected with a receptacle 
 containing the solution, and raised three or four feet above the pa- 
 tient, no trouble will be experienced in carrying the fluid into the 
 general circulation. The vein is exposed, distended, and punctured 
 under complete antiseptic precautions, if possible. The apparatus 
 devised by Dr. W. T. Bull, of this city, for this purpose, is admirable, 
 owing to its simplicity, and being accompanied by the saline ingredi- 
 ents necessary to charge the instrument (Fig. 187). These fluids seem 
 to meet the indications quite as well as blood, are easily obtained, and
 
 OPERATIONS ON VEINS, CAPILLARIES, ETC. 
 
 131 
 
 do not expose the patient to the dangers attendant on the use of the 
 latter. 
 
 Infra-venous injection of milk has been done to counteract the 
 conditions similar to those calling for the use of blood. The milk 
 should be freshly drawn from 
 the cow and covered with a 
 fine gauze, through which it is 
 strained into a transfusion in- 
 strument, which can be ex- 
 temporized by joining a glass 
 funnel to one end of a rub- 
 ber tube, and to the other a 
 small conducting canula. 
 
 If the canula be introduced 
 into the vein, and the funnel 
 be raised after having been 
 filled with six or eight ounces 
 of milk, the force of gravity 
 will become the propelling 
 agent. 
 
 Arterial transfusion has 
 been advocated on the basis 
 that it conveys the blood more 
 equably to the heart, with less 
 danger of exciting undue dis- 
 turbance of the circulation. 
 
 The admission of a small amount of air does no harm, and the dan- 
 ger of phlebitis is avoided. The vessel selected should be the radial 
 at the wrist, or the posterior tibial at the ankle, either one of which 
 is exposed, and three ligatures are placed around it ; the distal one is 
 ligatured and the proximal one tightened sufficiently to interrupt the 
 circulation in the vessel. The vessel is now opened and the tube in- 
 serted and tied in position by the third or middle ligature, then the 
 proximal one is loosened and the fluid injected into the circulation. 
 It is better to inject the fluid against than with the natural flow of the 
 blood current, to avoid over-distention of the capillaries. As soon as 
 the injection of the fluid is completed the proximal one is tied, and 
 the intervening portion of the vessel removed with the tube. The 
 vein may be tied in venous transfusion with two ligatures in the fol- 
 lowing manner : Tie the distal one, open the vein, introduce the tube, 
 then tie the proximal one, including the tube ; this will prevent all 
 loss of blood. 
 
 Operations on the Capillaries. This system of vessels, like the 
 venous, may undergo dilatation of sufficient size to create distinct but 
 slowly developing and painless deformities, or tumors. The morbid 
 
 FIG. 188. Straining the blood.
 
 132 OPERATIVE SURGERY. 
 
 process may be, and usually is, limited entirely to the capillaries of 
 the integument ; however, the larger vessels are not infrequently in- 
 volved, in the beginning, or during their development ; they likewise 
 vary in size, shape, and color. The simplest form is known as the 
 " Mother's mark," " Birth-mark," etc. 
 
 A birth-mark can be treated by pressure, caustic, hot needles, vac- 
 cination, etc., depending upon its size and situation. It is not well 
 to interfere with it at all except by simple means, unless it increases 
 rapidly in size. The majority of these growths will disappear of them- 
 selves before their presence becomes a source of annoyance or regret to 
 the possessor. There are, however, several simple means which will 
 often hasten their departure the use of simple compresses, repeated 
 application of collodion, or vaccination, if the birth-mark be located 
 suitably therefor. The following method, introduced by Dr. Squire 
 some time since, which bade fair at one time to meet the desired end, 
 can be employed : 
 
 The " mark " is frozen with an ether spray, and numerous parallel 
 incisions are made about one sixteenth of an inch apart and extending 
 the same depth, and the whole covered with blotting-paper, held upon 
 it with sufficient force to prevent any gaping of the cuts and escape 
 of blood ; after fifteen or twenty minutes the paper is thoroughly wet 
 with water and removed. Sometimes a thin underlying clot of blood 
 will be found ; this must be carefully washed away with water and a 
 soft brush. It is sometimes necessary to repeat the operation, when 
 the incisions should be made at right angles to the previous incisions. 
 If proper care be taken, in suitable cases a perfect cure is secured 
 without any scarring. The injection of ergot, liquor ferri subsulphat- 
 is, or various other astringents, has been recommended. They are, 
 however, uncertain in their action, and are liable to be followed by 
 inflammation, ulceration, and sometimes by embolism. The solutions 
 can be injected by aid of the ordinary hypodermic syringe, three or 
 four drops at a time, in various portions of the growth, or, red-hot 
 needles can be introduced at different points. The application of 
 red heat around the base and over the surface of the growth by means 
 of the Paquelin cautery is an admirable method, provided it involves 
 the skin alone or only the capillaries in the tissue immediately be- 
 neath it. It is usually followed by more or less disfigurement, depend- 
 ing upon the extent of the cauterization. 
 
 Subcutaneous Ligaturing. If the naevus be of large size, persist- 
 ent, of a dark color, and markedly elevated, it is suitable for this meas- 
 ure, which is done in several ways, depending upon the size and shape 
 of the tumor, and fancy of the operator. 
 
 Fig. 189 represents a simple method. In it the needle, armed 
 with a strong, well-carbolized hemp or silk ligature, is thrust through 
 the integument at its base, carried as far as possible around the base,
 
 OPERATIONS OX VEINS, CAPILLARIES, ETC. 
 
 133 
 
 and passed out, to be again introduced at the point of exit, and car- 
 ried still farther around, and pushed through as before, and so on 
 until it is caused to emerge at the first point of insertion ; the ends 
 are then tied in a firm, hard knot. 
 
 In Fig. 190 a double ligature is carried through the base and 
 
 FIG. 189. By a sin- 
 gle ligature. 
 
 FIG. 190 By a double 
 ligature. 
 
 FIG. 191. Ligation in quar- 
 ter sections. 
 
 divided ; each portion is then carried around its half of the base as be- 
 fore, and tied. This is applicable to those having a larger base. Fig. 
 191 represents the application of the ligature to quarter-sections of 
 the base. It is employed when the growth is large. Pass a double 
 ligature through the center of the base, cut the loop near to its center, 
 leaving one end of the divided thread in the eye of the needle ; then, 
 after threading the needle with the other end of the portion of the 
 ligature which was liberated by the division of the loop (Fig. 192), 
 pass the needle through the base at right angles to its primary course. 
 The ends are then to be firmly tied after the integument has been in- 
 cised, to allow the ligature to sink deeply into the base, as well as to 
 avoid the pain and ulceration incident to the constriction of the in- 
 
 FIG. 192. Quarter sec- 
 tions, second step. 
 
 FIG. 193. Tying lig- 
 ature. 
 
 FIG. 194. Ligature of elon- 
 gated base. 
 
 tegument (Fig. 193). It will simplify the selection and uniting of the 
 proper extremities if one half the ligature be colored before its primary 
 introduction. Fig. 194 represents the ligation of a growth with an 
 elongated base. In this the double ligature is required, and should be 
 colored as suggested above ; pass it through the base from side to side, 
 commencing and terminating just outside of the extreme limits of the 
 growth ; if the white loops be now divided on one side and the black 
 on the other, independent sets of ligatures will be had, which should 
 be tied ; the skin coming within the grasp of each ligature is incised
 
 134: OPERATIVE SURGERY. 
 
 as in the preceding instance. The separation of the growth is has- 
 tened by the use of an elastic or rubber ligature, applied in a similar 
 manner. 
 
 Division and Ligation. Cirsoid growths of the scalp can be suc- 
 cessfully treated by making a free incision nearly around and outside 
 of them, down to the periosteum, leaving that portion of the growth 
 that contains the largest vessel undisturbed to form a pedicle to nour- 
 ish the flap. The flap is raised and all bleeding points are tied, after 
 which it is kept separated from its former bed by antiseptic gauze 
 until the new surfaces granulate. The granulating surfaces are then 
 placed in contact, and soon unite, thereby destroying the growth 
 without loss of substance." If the pulsations in the flap continue for 
 four or five days, the dilated vessel entering it should be tied at a 
 distance from the pedicle. The hemorrhage is, to a degree, con- 
 trolled during the primary operation by passing a strong rubber 
 band around the head, beneath which compresses are placed corre- 
 sponding in situation to the course of the vessels that supply the 
 scalp. The bleeding points can also be closed by direct pressure 
 against the underlying bone ; yet, notwithstanding these means, the 
 loss of blood may be quite severe, and the operation should not be 
 attempted if the patient be already exsanguinated or otherwise debili- 
 tated. Care should be taken to form a pedicle of sufficient width to 
 nourish the flap ; from half an inch to an inch, depending on the size 
 of the flap, has, in my experience, been ample for the purpose. If 
 the dressing be applied too firmly, the integrity of the flap will be en- 
 dan ee red. 
 
 CHAPTER VI. 
 
 OPERATIONS ON THE NERVOUS SYSTEM. 
 
 THE brain, spinal cord, and the nerves arising from the cerebro- 
 spinal axis, owing to the various morbid processes and injuries to 
 which they, together with their coverings, are subjected, are often the 
 seat of common and yet important surgical procedures. 
 
 Hydroccplialus. Tapping for the removal of the superfluous fluid 
 is the only practical surgical procedure to which this condition is 
 amenable. This may be done with a small aspirating trocar, or, what 
 is better, with an aspirator. In either instance the puncturing agent 
 is introduced through the anterior fontanelle, close to its outer border, 
 and passed perpendicularly into the fluid accumulation, cautiously 
 avoiding the brain substance when possible. The fluid must be slowly
 
 OPERATIONS ON THE NERVOUS SYSTEM. 135 
 
 withdrawn, accompanied by moderate and equable pressure upon the 
 external surface by means of a skull-cap bandage. Whenever any 
 manifestations referable to the circulatory or nervous centers appear, 
 the needle should be withdrawn and the puncture carefully closed 
 with a catgut suture and dressed antiseptically. Often the removal of 
 less than three or four ounces will cause feebleness of the pulse, con- 
 traction of the pupil, and evidences of approaching convulsion. After 
 the withdrawal of the fluid, gentle and uniform pressure should be 
 maintained by aid of bandages, adhesive plaster, or a tightly-fitting 
 perforated rubber cap. Care is necessary, else the combined pressure 
 of the reaccumulating fluid and external dressing will cause alarming 
 symptoms. 
 
 Meningocele is a protrusion of the meninges of the brain, caused 
 often by an accumulation of the hydrocephalic fluid within the cra- 
 nium, and must of necessity occur before the closure of the fontanelles. 
 It may be present at any point of separation between the cranial 
 bones, although it occurs more frequently at the posterior fontanelle 
 than elsewhere. As a rule, little can be done, other than to pro- 
 tect the tumor from external irritation. If it have a well-defined 
 pedicle, this can be clamped and the fluid withdrawn, either by in- 
 cision or with a small trocar. The clamp must be applied with cau- 
 tion, else the pressure caused by it may produce convulsions or other 
 nervous phenomena. If it be determined to puncture it, a small 
 amount of fluid may be withdrawn, when the clamp can be the more 
 readily adjusted. As long as the pedicle is open, any operative in- 
 terference is liable to be followed by death from a resulting menin- 
 gitis. If the pedicle be occluded, the sac may be incised and the 
 tumor removed. In air instances where it is removed, sufficient in- 
 tegument should be left to insure a complete and proper closure of the 
 divided surfaces. 
 
 Hydro-racliis. This is a congenital defect, comprising a cleft in 
 the laminae of the vertebrae, and a protrusion of the membranes of the 
 spinal cord. It occurs most frequently in the lumbar region, al- 
 though it is found in the other portions of the spinal column. Vari- 
 ous operative expedients have been employed to cure the defect, 
 nearly all of which have, at one time or another, resulted in occasional 
 cures. 
 
 The two methods which have secured the best results are : 1. Re- 
 peated punctures with a small needle at various points through the 
 sides of the sack, followed by gentle and uniform pressure over the 
 surface. 2. Consists of injecting into the sack, after having been par- 
 tially emptied of its fluid, one or two drachms of the iodo-glycerin 
 solution, which is made by dissolving, ten grains of iodine and thirty 
 grains of iodide of potassium in one ounce of glycerin. Exercise cau- 
 tion that none of the fluid escapes after the operation. This must be
 
 136 
 
 OPERATIVE SURGERY. 
 
 repeated from time to time, always allowing the irritation due to the 
 previous operation to subside before it is again repeated. 
 
 Results. The latter method has been very successful. Of forty- 
 four cases treated, thirty-five were cured. 
 
 Trephining the Cranium is an operation which is, without doubt, 
 performed more frequently than the requirements of many of the cases 
 
 FIG. 195. FIG. 196. FIG. 197. Gait's FIG. 198. 
 Crown tre- Handle of trephine. Elevator, 
 
 phine. trephine. 
 
 FIG. 199. FIG. 200. 
 Elevator. Eleva- 
 tor. 
 
 warrant. In every instance, before attempting it, the indications 
 should be most carefully studied. 
 
 The special instruments required for the operation are the trephine 
 (Figs. 195, 196, 197), the conical, or Gait's, being by far the safer ; an 
 elevator (Figs. 198, 199, 200) and rongeur (Fig. 201), sequestrum for- 
 ceps (Figs. 202 and 
 203), gouges and mal- 
 lets (Figs. 204, 205, 
 206, 207, 208). The 
 traditional tooth- 
 pick, and the brush, 
 to remove the dust 
 FIG. 201. Rongeur. from the track of the 
 
 trephine, while not 
 
 absolutely necessary, have, nevertheless (especially the former), be- 
 come so closely associated with the operation as to be entitled to a most 
 respectful consideration. The patient is prepared by shaving the head
 
 OPERATIONS ON THE NERVOUS SYSTEM. 137 
 
 for a considerable distance around the seat of the proposed operation. 
 
 FIG. 202. Van Buren's sequestrum forceps. 
 
 If unconscious, an anaesthetic is unnecessary. Strict antiseptic pre- 
 cautions should be enjoined. . 
 
 Operation. Make an incision of an oval shape through the scalp 
 
 FIG. 203. Ferguson's sequestrum forceps. 
 
 down to the bone, expose the portion of the cranium be pot oerated 
 upon, and at the same time avoid large vessels and secure good drainage 
 when possible. Lay back the integumentary flap, together with the 
 
 FIG. 204. FIG. 205. FIG. 206. Szy- FIG. 207. Hoffman's FIG. 208. Lead 
 Straight Curved manowsky's gouge forceps. mallet, 
 
 gouge. gouge. gouge.
 
 138 
 
 OPERATIVE SURGERY. 
 
 FIG. 209. Course of arteries and sinuses. 
 
 periosteum covering the portion of bone to be removed. Lower the cen- 
 b ter-pin a little below the teeth 
 
 of the trephine, and fasten it 
 firmly in position by means of 
 its adjusting screw ; place the 
 point of the center-pin as 
 nearly as practicable upon 
 that portion of the solid and 
 undepressed bone which, 
 when removed, will allow the 
 best opportunity of elevating 
 that which is depressed, pro- 
 vided, however, that it be not 
 placed, when avoidable, over 
 the course of the middle me- 
 ningeal artery, or a large sinus 
 (Fig. 209). The trunk of the 
 middle meningcal artery (Fig. 209, a) is located an inch and a half be- 
 hind the external angu- 
 lar process of the fron- 
 tal bone, and the same 
 distance above the zy- 
 goma. The median line 
 of the skull, from the 
 root of the nose to the 
 occipital protuberance, 
 corresponds to the su- 
 perior longitudinal si- 
 nus (Fig. 209, b). The 
 course of the lateral si- 
 nus (Fig. 209, c) is indi- 
 cated by a line drawn 
 from the occipital pro- 
 tuberance to the ante- 
 rior border of the mas- 
 toid process. Bearfirm- 
 ly upon the instru- 
 ment, at the same time 
 turn it quickly from 
 right to left, till asui ta- 
 ble track is established 
 to retain it in position 
 (Fig. 210). The center- FIG. 210. Applying the cylindrical trephine, 
 
 pin is then withdrawn 
 and fastened back in place, otherwise it may perforate the membranes. 

 
 OPERATIONS ON THE NERVOUS SYSTEM. 139 
 
 The instrument must be held perpendicularly to the point of sec- 
 tion, and the pressure evenly distributed ; if not, one side of the circle 
 will be penetrated more quickly than the other, thereby jeopardizing 
 the integrity of the membranes. During the process the trephine 
 must be frequently raised from the track, that it may be cleared of 
 bone-dust, the color of which should be carefully noticed ; at first it 
 is of a pale white, but as soon as the diploe is reached it becomes red- 
 dened ; from this time on the tooth-pick must be frequently used to 
 clear out the track as well as to detect the first point of complete sec- 
 tion. But little pressure is now allowable, since to use it might force 
 the crown of the instrument through the membranes and into the 
 brain structure itself, especially if the trephine be of a horizontal pat- 
 tern. Gait's, or the conical trephine (Fig. 197), is far safer than the 
 crown pattern, since, as soon as the inner table is divided, it is con- 
 verted into a screw and becomes immovably fixed in the opening. If 
 the button of bone be percussed with the handle of a scalpel or forceps, 
 it will emit a low-pitched sound, and vibrate when a considerable por- 
 tion of the circle is cut through ; moreover, it can, probably, be raised 
 from its bed at this time by the aid of the elevator. As soon as the 
 button is removed, the elevator is inserted beneath the depressed por- 
 tion, and it is raised to its proper level. 
 
 This is sometimes difficult to accomplish, owing to the dovetailing 
 of the fragments. The solid bone is used as a fulcrum when much force 
 is necessary. If great force be employed, and a fragment be suddenly 
 loosened, its distal, sharp, or jagged border may cut through the mem- 
 branes ; it is therefore necessary that force be used in a guarded manner. 
 
 All detached fragments are removed ; those that will retain their 
 position when elevated, owing to continuity of structure, may be al- 
 lowed to remain. All projecting points of bone must be cut away 
 with the rongeur, else the pulsation of the brain may cause them to 
 perforate the dura mater. Clots of blood and pus are likewise to 
 be cleared out by a stream of antiseptic fluid. If the compressing 
 agents be below the dura mater, it may be opened sufficiently to ad- 
 mit of their escape ; before this is done, however, their presence 
 should be clearly established. If the dura mater be lacerated, it 
 may be closed by fine catgut sutures, especially when the opening is 
 large enough to predispose the formation of hernia cerebri. If the 
 middle meningeal branches be divided or a sinus opened, the hemor- 
 rhage is controlled by antiseptic compresses, so applied as not to exert 
 undue pressure on the brain. If the membranes be lacerated, the 
 fragments of bone removed must be fitted to each other, in order 
 that the absence of any osseous portion may be ascertained and it be 
 sought after. The opening in the skull made by the trephine can be 
 enlarged more rapidly and safely by the rongeur (Fig. 201) than by 
 repeated applications of the trephine.
 
 140 
 
 OPERATIVE SURGERY. 
 
 The wound should now be thoroughly cleansed with carbolic acid, 
 the flaps .adjusted, suitable drainage established, and the antiseptic 
 dressing applied. It is often possible to elevate the fragments with- 
 out the use of the trephine, an expedient that should always be tried, 
 if a reasonable prospect of success be apparent. 
 
 Results. The nature of the cause calling for the operation, the 
 length of time intervening prior to its performance, and the ability to 
 secure complete drainage and asepsis, are the chief factors that modify 
 the prognosis. A death-rate of from four to fifteen per cent, is a fail- 
 estimate in civil practice. 
 
 The advance which is being made in cerebral localization is worthy 
 of the closest scrutiny of the operating surgeon. Not only should he 
 operate on the skull in the accepted sense of the term, but he should 
 also note the exact seat of the lesion calling for his action. The va- 
 riations in the symptoms, before and after the procedure, should like- 
 wise be carefully scrutinized. The precise seat of an operation can be 
 determined by measurements made from established points, as from 
 the external auditory meatus, the external angular process of the 
 
 FIG. 211. Relation of chief fissures and convolutions to external surface of skull, a. 
 Inferior frontal fissure, b. Superior frontal fissure, c. Fissure of Rolando, d. Calloso- 
 marginal fissure, e. Inter-parietal fissure, f. Pai'icto-occipital fissure, g. Parallel fis- 
 sure, h. Fissure of Sylvius. 
 
 frontal bone, various sutures, etc. Fig. 211 shows the relations borne 
 by important convolutions and fissures of the cerebrum to the su- 
 tures, and to other external points on the skull. Fig. 212, showing 
 the exterior of the skull, is of especial importance when studied
 
 OPERATIONS ON THE NERVOUS SYSTEM. 
 
 141 
 
 FIG. 212. Location of fissure of Rolando (R) and the special areas. 
 
 in connection with the preceding figure ; upon it are indicated the 
 measurements necessary to properly locate the underlying convo- 
 lutions with which definite functions have been found to be asso- 
 ciated. 
 
 Operations on the Nerves of the Cranium. It may become neces- 
 sary, owing to neuralgia, spasm, tremor, etc., after all ordinary means 
 have failed, to operate upon the trunk of the nerve involved, either 
 by division, excision, or stretching. The first method can afford but 
 temporary relief, since the divided extremities will speedily unite. 
 
 If excision be done, not less than two inches, if possible, should be 
 removed from the continuity of the trunk ; otherwise, at a greater or 
 lesser period, the extremities will become united. If the nerve be a 
 small one, the tendency to union is less, but the rule to remove a long 
 piece must not be deviated from. Stretching consists in cutting down 
 on the affected nerve, seizing it with the fingers, and making firm and 
 steady traction for from half a minute to a minute. It is applied 
 more properly to the large nerves, and those which can not be divided 
 without the sacrifice of important functions. 
 
 Supra- Orbital Nerve. This may be divided or excised at its exit 
 from the supra-orbital foramen or notch at the junction of the inner 
 and middle thirds of the supra-orbital arch. It is covered by integu- 
 ment, fascia, and the combined fibers of the orbicularis oculi, occipito- 
 frontalis, and corrugator supercilii muscles. 
 
 To divide it, locate the notch by the fingers of the left hand, then
 
 142 OPERATIVE SURGERY. 
 
 pass the point of a narrow bistoury beneath the integument, from its 
 inner to its outer side ; turn the edge backward, and cut firmly down 
 and across the opening upon its inferior wall. 
 
 Excision and Stretching. The nerve can be found by elevating the 
 brow and making an incision between it and the lid, one inch in length, 
 through the tissues down upon the site of the nerve ; the connective 
 tissue is then displaced by a director and its branches are sought for, 
 and excised or stretched, as seems better. The nerve may be pulled 
 out with a small blunt hook from the roof of the orbit, and excised 
 before it enters the foramen ; or it may be stretched and allowed to 
 remain. 
 
 The Infra- Orbital Nerves are the terminal branches of the supra- 
 maxillary division of the fifth pair ; they escape from the infra-orbital 
 foramen. 
 
 The infra-orbital foramen is about four lines below the lower edge 
 of the orbit, and nearly on a line extending from the bicuspid teeth 
 to the supra-orbital foramen. The nerve may be divided through the 
 mouth by first recognizing the location of the foramen, and placing 
 the finger upon it ; then make a narrow incision, beginning at the 
 fold of the cheek and maxilla, carrying it upward in the line before 
 indicated, till within a short distance of the foramen, when with a 
 sharp-pointed pair of scissors the nerves are divided as they emerge. 
 They may also be divided through an external incision made directly 
 down upon the foramen. 
 
 In the latter the incision should be crescentic with the concavity 
 upward, and be located about one-half inch below the lower border of 
 the orbit ; the muscles and cellulo-adipose tissue are displaced, nerves 
 isolated from the vessels and divided. The nerves may be divided 
 subcutaneously at this situation by a slender-bladed knife passed in 
 the line of their emergence, and its edge directed toward the inferior 
 wall of the canal. 
 
 The Superior Maxillary Nerve. This may be excised, divided, or 
 stretched in its course along the floor of the orbit, or at its exit from 
 the foramen rotundum. It may be reached on the floor by passing a 
 tenotome about an inch backward in the line of its course, turning 
 the edge downward, and cutting upon and through the thin floor of 
 the orbit. Its termination at the infra-orbital foramen can then be 
 exposed, and the severed portion pulled out (Langenbeck). 'Through 
 a narrow incision of the soft parts, in this situation, a blunt hook can 
 be introduced, the nerve caught up and stretched. The whole of the 
 nerve can be removed from the canal, and sometimes farther poste- 
 riorly, if an incision be made about an inch and a half in length along 
 the lower border of the orbit, the tissues elevated and the nerve iso- 
 lated from the artery, raised on a hook and divided ; or by pulling 
 out the central portion, either by a ligature previously applied, or
 
 OPERATIONS ON THE NERVOUS SYSTEM. 
 
 143 
 
 with a pair of forceps. If the more formidable operation of its division, 
 as it escapes from the foramen rotundum, be attempted, the initiatory 
 incision through the soft parts should be of a shape and extent to 
 best expose the site of the proposed operation ; the V, +, U, T shaped 
 ones are selected, according to the wish of the operator. In either 
 instance its central portion should correspond as nearly as possible to 
 the infra-orbital foramen. After the flap is raised, the crown of a 
 large trephine or drill is applied to the bone so as to open into the 
 antrum along the course of the nerve, which is carefully followed 
 backward to the spheno-maxillary fossa by cutting away the floor of 
 the canal with a sharp, delicate chisel. It is then carefully isolated 
 from the tissues in the fossa back to the foramen of exit, and divided 
 with a pair of curved scissors (Carnochan). The internal maxillary 
 artery runs through the fossa, and should be carefully avoided. If it 
 be cut, it should be ligatured if possible ; not infrequently firm pressure 
 will check the hemorrhage ; when other means fail, ligaturing of the 
 external carotid will become necessary. 
 
 The posterior wall of the antrum is quite vascular, and, when 
 broken, or cut through by the small trephine, it often bleeds vigor- 
 ously. There seems to be good 
 ground for the belief that quite 
 as gbod results follow an excision 
 made anterior to Meckel's gangli- 
 on as behind it. In either in- 
 stance the operation ought not to 
 be attempted unless a strong light 
 can be thrown upon the field of 
 action. 
 
 The second and third branches 
 of the fifth pair can be exposed 
 at their exit from the skull by 
 the ingenious method of Prof. 
 Pancoast. 
 
 Operation. Make an incision 
 the entire width of the perpen- 
 dicular ramus of the lower jaw 
 near where it joins the body; 
 connect to its extremities two par- 
 allel incisions carried upward to 
 the zygoma and malar bone, care- 
 fully avoiding Steno's duct (Fig. 
 213). Dissect this flap down to the bone, its upper border remaining 
 attached at the zygoma. The coronoid process is now sawn off, de- 
 tached from the temporal muscle and removed. The temporal muscle 
 is then pushed beneath the zygoma. The fatty matter now exposed is 
 
 FIG. 213. Pancoast's lines of incision.
 
 144 OPERATIVE SURGERY. 
 
 removed, and the internal maxillary artery within it is ligatured. The 
 upper head of the external pterygoid is detached from the greater 
 wing of the sphenoid bone by the finger, and all hemorrhage checked, 
 when the nerves within the zygomatic fossa are readily seen, and can 
 be easily excised. 
 
 If it be desired to expose the second branch as it crosses the spheno- 
 maxillary fossa, extend the incisions upward and seek the spheno- 
 maxillary fissure at the anterior lacerated foramen. The nerve should 
 now be carefully isolated and a strong ligature passed around it. This 
 last step is often attended with difficulty, especially when the fissures 
 leading to it are narrow. If more room be necessary, the posterior 
 wall of the antram can be crushed in. 
 
 The Inferior Dental Nerve. This nerve may be divided, excised, 
 or stretched, before it enters the jaw, in its course through it, and at 
 its exit from the mental foramen. In the first situation an incision 
 is made about an inch and a half in length along the anterior border 
 of the vertical ramus of the jaw, within the mouth down to the ante- 
 rior fibers of the internal pterygoid muscle ; the connective tissue be- 
 tween this muscle and the inner surface of the ramus is now pushed 
 aside, and the nerve detected as it enters the canal. The small spine 
 surmounting the opening for the entrance of the vessel and nerve can 
 be quite readily located, and will be a valuable guide to the nerve as 
 it enters the dental canal. It can now be isolated, hooked up, and 
 divided. About an inch and a half can be easily excised in this situ- 
 ation, if after its isolation a strong ligature be thrown around it and 
 tied. It is then divided by curved scissors as it enters the canal ; 
 traction by means of the ligature can then be made, which will not 
 only draw the nerve down to admit of the division of the proximal end, 
 but also add the good that may be derived from the stretching process. 
 
 It may be approached in this situation from without, by making an 
 incision from the sigmoid notch to the angle of the jaw. The parotid 
 gland is turned aside, and the masseter muscle detached from the 
 ramus sufficiently to allow the application of a trephine at a point 
 three fourths of an inch behind the last molar tooth. When the but- 
 ton of bone is removed, about half an inch of the nerve can be iso- 
 lated, exposed, and excised. 
 
 The nerve may be exposed in its course through the body of the jaw, 
 by raising the soft parts, by means of an incision through them, about 
 two inches in length, beginning in front of the facial artery. After the 
 bone is thoroughly exposed, a trephine is applied in two or more situa- 
 tions, and the bone removed down to the canal, when the intervening 
 portions may be chiseled out, and the whole nerve removed ; or it may 
 be excised at each of the openings. The former is the surer method. 
 
 It may also be divided as it emerges from the mental foramen by 
 turning the lower lip outward and making an incision about an inch
 
 OPERATIONS OX THE NERVOUS SYSTEM. 145 
 
 in length at the junction of the buccal fold, downward three fourths 
 of an inch, in the line of the bicuspid teeth, when a careful search will 
 disclose the filaments as they escape from the opening. Seize them with 
 the forceps, draw them slowly and carefully out, and cut them off. 
 
 The Lingual Nerve. This may be reached in two situations : 1. 
 As it passes just below the insertion of the pterygo-maxillary liga- 
 ment. 2. Beside the tongue and sublingual gland. 
 
 In the former) the mouth is opened widely, and the fold of mucous 
 membrane covering the ligament is readily seen behind the last molar 
 tooth. The nerve can be felt just below the insertion of the ligament, 
 close to the tooth. Make an incision backward from the tooth over 
 the course of the nerve, about one inch in length, carefully push aside 
 the submucous tissue, and the nerve will appear in the wound, when 
 it can be raised and cut. It has been successfully divided on several 
 occasions near this situation by entering the point of a curved bistoury, 
 three fourths of an inch behind, and below the last molar, cutting 
 downward and outward to the bone in an imaginary line extending 
 from the angle of the jaw to the last molar tooth. 
 
 In the second situation, the tongue is drawn forward and to the 
 opposite side, and an incision made about one inch in length, parallel 
 with the tongue, and about one fourth of an inch from the attach- 
 ment of the mucous membrane to it ; then push aside the submucous 
 tissue, and the nerve will be readily seen. 
 
 The Facial Nerve. This escapes from the cranium at the stylo- 
 mastoid foramen, passes through the parotid gland and divides into 
 the temporo-facial and cervi co-facial branches. 
 
 Operation. Make an incision about two and a half inches in length 
 along the anterior border of the mastoid process and sterno-mastoid 
 muscle. After the division of the integument and fascia, the parotid 
 gland is pushed forward with the handle of the scalpel, and the wound 
 carefully deepened by the same instrument. At about three fourths 
 of an inch from the surface the nerve will be seen passing forward 
 and outward from its foramen of exit. At about a fourth of an inch 
 to the inner side of its foramen the jugular foramen is located ; for 
 this reason caution is essential to avoid wounding the jugular vein. 
 The search should be carefully conducted in order not to injure the 
 parotid gland. The nerve is somewhat deeply situated, being separated 
 from the bone by connective tissue. The temporal branch can be di- 
 vided where it crosses the condyle of the jaw through an oblique incision 
 extending from the zygoma to the posterior border of its ramus. 
 
 Operations on Spinal Nerves. Great Occipital Nerve. This is a 
 large branch of the posterior cervical plexus arising from the internal 
 division of the second nerve. It pierces the complexus and trapezius 
 muscles near their attachment and supplies the integument as far for- 
 ward as the vertex of the skull. 
 10
 
 146 OPERATIVE SURGERY. 
 
 Operation. Locate the occipital protuberance and make an in- 
 cision one inch and a half in length downward, forward, and outward 
 at its outer side, beginning about an inch above the protuberance ; 
 carefully separate the tissues in the line of the incision and the nerve 
 will be exposed where' it escapes from beneath the trapezius muscle. 
 
 Auricular is Magnus Nerve. This nerve is one of the ascending 
 branches of the cervical plexus. It emerges at the posterior border of 
 the sterno-mastoid muscle near its middle, and ascends on that muscle 
 to the lobule of the ear. 
 
 Operation. Make an incision two inches in length obliquely up- 
 ward and backward, its center corresponding to the lower extremity of 
 the lobule of the ear. On dividing the skin and fascia the nerve will 
 be found resting on the sterno-mastoid muscle, from which it can be 
 raised with a hook and stretched or cut. 
 
 Spinal Accessory Nerve. This nerve is excised to overcome spas- 
 modic actions of the muscles which it supplies with filaments. It can 
 be found through an incision made behind (De Morgan, Fig. 214), or 
 
 in front of (Sands) the sterno- 
 mastoid muscle. The latter is 
 the better plan. 
 
 Operation. Make an incision 
 three inches in length along the 
 anterior border of the sterno-mas- 
 toid, beginning close to the mas- 
 toid process ; expose the sterno- 
 mastoid, pull it backward, and 
 the nerve will be found beneath 
 FIG. 214. De Morgan's operation, se. as it crosses the jugular vein, 
 Stemo-cleido-mastoid muscle, n. Spi- which should bc'cautiouslyavoid- 
 nal accessory nerve, s. Splemus mus- , , , , ., n 
 
 c i e- ed ; close and dress the wound 
 
 antiseptically. 
 
 Branches of the Brachial Plexus. It may become necessary, on 
 account of a severe neuralgia involving the branches of this plexus, or 
 located in a painful stump, to excise or stretch the cords near their 
 origin. It is best done prior to its division into its three terminal 
 cords ; that is, where only two cords are found. Place the patient 
 upon the back, raise the shoulders, and turn the head backward and 
 to the opposite side. The course of the external jugular is determined 
 by pressure just above the clavicle. Make an incision along the pos- 
 terior border of the sterno-mastoid, three inches in length, extending 
 down to the clavicle ; a second incision of the same length is now made 
 outward from this point, along the upper border of the clavicle, care- 
 fully avoiding the external jugular ; turn the flap upward and seek 
 for the posterior belly of the omo-hyoid ; when found, draw it upward 
 with a hook or ligature, push aside the loose connective tissue, and the
 
 OPERATIONS ON THE NERVOUS SYSTEM. 147 
 
 two cords will appear located above and to the outer side of the third 
 portion of the subclavian artery, which should be carefully avoided. 
 The inner cord is cautiously hooked up, and a ligature applied to it, 
 by which it can be raised from its bed and divided with a pair of scis- 
 sors near the outer border of the scalenus anticus muscle, being careful 
 to avoid the muscle and the phrenic nerve. If gentle traction be 
 made upon the ligature, the distal extremity will be raised, and can 
 be again divided an inch or so from the point of the first section, and 
 removed. The second or outer cord is then divided in the same 
 manner. 
 
 Musculo- Cutaneous Nerve. This can be exposed in two situations : 
 1. As it escapes from the axilla. 2. Near to the elbow joint. 
 
 Operation. To excise it in the first situation, carry the arm from 
 the body and rotate it outward ; make .an incision three inches in 
 length along the outer border of the coraco-brachialis muscle ; divide 
 the skin and fascia on a director, draw the muscle inward, and the 
 nerve will be easily found at its outer border. 
 
 In the second situation it is found by making an incision two and 
 one half inches in length, between the biceps and the supinator longus, 
 through the integument, fascia, and aponeurosis ; separate the mus- 
 cles and the nerve will be readily seen. 
 
 Musculo- Spiral Nerve. This can be exposed in two situations : 1. 
 By making an incision about four inches in length, between the outer 
 border of the triceps and the brachialis anticus muscles, beginning it. 
 two and one half inches above the external condyle. Divide the fas- 
 cia on a director, separate the connective tissues with the handle of a 
 scalpel or by the finger, and the nerve will be easily found. 2. Make 
 an incision, three inches in length, in the space between the supinator 
 longus and the brachialis anticus muscles ; divide the fascia, separate 
 the connective tissue beneath it, and the nerve will be readily exposed. 
 
 Median Nerve. It can be easily exposed in its course along the 
 arm and lower half of the forearm by modifying either of the incis- 
 ions for ligaturing the brachial to correspond to the relations of the 
 nerve to that vessel. 
 
 In the forearm, by making an incision about three inches in length, 
 along the inner border of the tendon of the flexor carpi radialis, be- 
 ginning about two inches above the wrist-joint. Divide the tissues in 
 the usual manner. Separate the tendons of the flexor carpi radialis 
 and palmaris longus, when the nerve will be discovered emerging from 
 beneath the fleshy fibers of the flexor sublimis digitorum. 
 
 The Radial and Ulnar Nerves like the median in the arm can 
 be reached readily through the same incisions employed to ligature 
 the vessels bearing similar names. 
 
 Branches of the Sacral Plexus. Or eat Sciatic Nerve. This is best 
 exposed just after its escape from beneath the lower border of the
 
 148 
 
 OPERATIVE SURGERY. 
 
 FIG. 215. Great sciatic nerve exposed, n, n. Sciatic 
 nerve, ffm. Gluteus maxiiEus. oh. Outer ham- 
 string muscle biceps flexor cruris. 
 
 glutens maximus. Place the patient on the abdomen and make an 
 incision three or four inches in length, beginning at the gluteal fold, at 
 a point midway between the tuber-ischii and the trochanter major (Fig. 
 123, #), or the vertical may be joined by a short horizontal incision 
 (Fig. 215) ; divide the integument and fascia on a director, separate the 
 
 connective tissue with the 
 fingers and handle of the 
 scalpel down to the nerve. 
 It can then be stretched 
 by passing one or two fin- 
 gers around it, and mak- 
 ing firm and steady trac- 
 tion upon it. Division or 
 excision can be done easily 
 through the same open- 
 ing. The wound should 
 be carefully closed and 
 dressed under antiseptic 
 precautions. 
 
 Bloodless Stretching of 
 the Sciatic. Administer 
 an anaesthetic and place 
 the patient on the back. 
 Extend the leg fully on the thigh, and hold the pelvis firmly. Flex 
 the thigh on the pelvis, while full extension of the leg on the thigh 
 is continued. This causes extreme tension of the muscles and other 
 structures on the posterior surface of the thigh, thereby stretching 
 the nerve. The manipulation must be firmly yet cautiously made to 
 attain the object, and at the same time not tear asunder the ham- 
 string muscles. 
 
 Results. -Obstinate sciatica has been relieved, and even apparently 
 cured, by this simple manipulation. Not infrequently the degree of 
 the resulting ecchymosis indicated rupture of the muscular struct- 
 ures. 
 
 Internal Popliteal Nerve. This can be reached by the same 
 method and with the same caution as the popliteal artery. It is, 
 however, less deeply situated and somewhat nearer the center of the 
 popliteal space than the vessels. Extreme caution should be exercised 
 in operating upon it, on account of its nearness to the popliteal vein, 
 which lies beneath it and to its inner side. 
 
 External Popliteal Nerve. It can be easily reached by making an 
 incision, two or three inches in length, along the inner side of the 
 tendon of the biceps cruris. when the nerve can be readily found be- 
 neath the fascia, surrounded by fat. 
 
 Tlie Small Sciatic, Anterior and Posterior Tibial Nerves can be
 
 OPERATIONS OX THE NERVOUS SYSTEM. 
 
 149 
 
 exposed through the incisions adopted in ligaturing the vessels of the 
 same names. 
 
 The Plantar Nerves. These are the terminal branches of the pos- 
 terior tibial, and are given off just after the nerve winds around the 
 internal malleolus. They can be exposed by making an incision about 
 three inches in length, beginning just in front of the center of a line 
 extending from the anterior border of the internal malleolus to the 
 inner tuberosity of the os calcis, and extended forward along the ex- 
 ternal border of the abductor pollicis. If the space between the short 
 flexor and the abductor be now opened at the posterior portion, the 
 nerves will be found accompanied by the arteries of similar name. 
 
 Perineal Nerve. This may be exposed in the perineum of the 
 male by making an incision along the rami of the pubes and ischium 
 in the same manner as directed for ligaturing the pudic artery at this 
 situation. In the female perineum the nerve may be exposed either 
 by an incision made without or within the vagina. In the former, 
 make it through the superficial tissues, about three inches in length, 
 in the groove between the labium and the perineum, just inside the 
 rami of the pubes and ischium. The nerve is surrounded by connect- 
 ive tissue, and it is difficult to find it in this situation ; however, if the 
 blade of the knife be turned inward and the outer coats of the vagina 
 be divided down to the inner one, the nerve will not escape section. 
 
 It is more easily severed from within the vagina. If the finger be 
 introduced an inch or more, and lateral pressure be made, the nerve 
 will be felt, cord-like in character and sensitive to touch. Make a 
 vertical incision through 
 the coats of the vagina, 
 and the nerve will be ex- 
 posed for division or ex- 
 cision. 
 
 Branches of Lumbar 
 Plexus. Anterior Cru- 
 ral Nerve. This nerve 
 is the largest branch of 
 the lumbar plexus, and 
 enters the thigh beneath 
 Poupart's ligament, 
 about three fourths of an 
 inch to the outer side of 
 the femoral artery (Fig. 
 216). 
 
 Operation. Make an 
 incision three inches in length directly downward, beginning about an 
 inch above Poupart's ligament, in the line of the nerve. The super- 
 imposed layers of tissue are then carefully divided on a director down 
 
 n 
 
 FIG. 216. Anterior crural nerve exposed, a. Fern-- 
 oral artery, n. Anterior crural nerve, pi. Psoas 
 and iliac muscles, s. Sartorius muscle.
 
 150 OPERATIVE SURGERY. 
 
 to the groove between the iliac and psoas muscles, in which it rests. 
 The pulsations of the femoral artery will always suggest the location 
 of the nerve. 
 
 The Internal or Long Saplienous Nerve is given off from the ante- 
 rior crural and supplies the inner surface of the leg. It is accompa- 
 nied by a vein of the same name in its course along the leg. It can be 
 reached easily in many situations, but practically, however, it is best 
 exposed at the inner side of the knee, where it escapes beneath the sar- 
 torius, and at the middle of the leg. In the former situation recognize 
 the tendon of the sartorius. Press upon the internal saphenous vein 
 above this point to distend it, make an incision two inches in length 
 close to and parallel with the vein, draw it aside, and the nerve will 
 be found emerging from beneath the tendons of the sartorius and 
 gracilis. At the middle of the leg make an incision three inches in 
 length, parallel with the properly distended vein, which should then 
 be pulled aside, and the nerve will be found beneath it. 
 
 The External or Short Saphenous Nerve arises from the internal 
 popliteal, escapes between the heads of the gastrocnemius, pierces the 
 fascia below the middle of the leg and becomes subcutaneous, passes 
 down on the fibular side of the posterior surface to the malleolus, ac- 
 ^ companied by the external saphenous vein. Distend the vein by press- 
 ure, make an incision close to and parallel with it, near the border of- 
 the tendo Achillis ; pull the vein aside, and the nerve will be seen be- 
 neath. 
 
 Suturing of Nerves. This is a procedure of modern introduction, 
 employed to unite the extremities of divided nerves. The earlier the 
 attempt is made the better, provided the tissues surrounding the nerve 
 be not inflamed. Every antiseptic precaution should be taken ; if 
 possible, it should be done under the douche of the bichloride solution. 
 
 Operation. A free incision is made down upon the ends of the 
 nerves to be united, being careful not to disturb unnecessarily the 
 surrounding soft parts. The extremities are refreshed by the removal 
 of a small portion, drawn in contact with each other, and retained in 
 apposition by fine antiseptic catgut passed through their respective 
 sheaths and tied. It is wise, owing to the easy absorption of the cat- 
 gut, .to re-enforce it by one or two horse-hair or fine silk asepticized 
 sutures. If it be necessary, a fine catgut suture can be passed through 
 the nerve structure and tied, in order to properly oppose and maintain 
 the extremities. If the distance between the extremities be too great 
 to allow a ready apposition of them, something may be gained by mak- 
 ing traction on them and by the relaxation of their associated soft 
 parts. If a sufficient amount of the nerve be present to admit of it, 
 the splicing should be made obliquely, since it offers a better oppor- 
 tunity to securely unite the ends. After the ends are united, close the 
 wound, dress antiseptically, and place the part in an easy position.
 
 OPERATIONS OX TENDONS, FASCLE, AND MUSCLES. 
 
 151 
 
 Results. The results thus far point to the entire feasibility of the 
 operation ; it hastens the resumption of nerve action by lessening the 
 distance between the divided extremities, and in no instance has it 
 been followed by neuritis or other untoward symptoms. 
 
 Nerve Transplantation. Nerve transplantation is, as yet, limited 
 to experimentation. Sections of nerves can be transplanted and union 
 will readily take place ; but nervous influence is not quickly estab- 
 lished. Future experimentation in this line will no doubt secure 
 some great practical advance in the surgery of the nervous system. 
 
 CHAPTER VII. 
 
 OPERATIONS ON TENDONS, FASCUE, AND MUSCLES. 
 
 Tenotomy consists in making a subcutaneous division of the ten- 
 dons of muscles to overcome or alleviate a deformity. In order to 
 accomplish this successfully, the exact location of 
 the offending structure must be known, together 
 with its important contiguous vessels, nerves, etc. 
 Many of the large tendons are easily located by 
 their natural prominence. Others that ordinarily 
 lie concealed become apparent if contraction has 
 occurred, and still more conspicuous if they be 
 placed upon the stretch. The principles governing 
 tenotomy should be well considered ere a tendon 
 be divided, otherwise an expedient of great good 
 becomes mischievous and even destructive in its 
 results. Muscles and fasciae, either singly or con- 
 jointly, are also the direct causes of, or may be in- 
 directly connected in, causing deformities. They, 
 too, are amenable to a similar treatment. 
 
 The instruments employed are few in number 
 and simple in character. Fig. 217 represents the 
 tenotomes used by Prof. L. A. Sayre. They are excellent instru- 
 ments for the purpose. Fig. 218 represents the ordinary tenotome 
 found in the pocket-cases of the day. It is too fragile to be safely em- 
 ployed in the division of tissues requiring any outlay of force. A 
 detailed description of either is unnecessary, since they can be ordered 
 from the instrument-maker by simply naming the designer. 
 
 The blade of the tenotome used for dividing fascise and muscles 
 (Fig. 219) is of necessity much longer than either of the former ; the 
 
 FIG. 217. Teno- 
 tomes.
 
 152 
 
 OPERATIVE SURGERY. 
 
 FIG. 218. Tenotome. 
 
 principles embodied in it, however, are substantially the same. A 
 cocaine solution may be injected near the point of division. An ob- 
 servance of the following simple rules will obviate the pos- 
 sibility of doing violence to other than the tissues directly 
 I concerned in the operation : 1. Mark the handle to indicate 
 the direction toward which the cutting edge looks. 2. Care- 
 fully note the length of the blade, that it may be inserted 
 only far enough to divide the contracted tissues. 3. Place 
 the structure to be divided upon the stretch (Fig. 220). 
 Pinch up, or press aside the skin over the part to be cut, so 
 that when it is released, after the completion of the opera- 
 tion, the opening will not correspond to the divided tissues. 
 4. The blade should be made aseptic before being used. 5. 
 Pass the knife-blade from important vessels and nerves. 6. 
 Insert the blade on the flat, close to the surface of the tissue 
 to be divided ; turn the edge toward it, and carefully sever 
 it by a guarded sawing motion, aided by pressing the tendon 
 upon the cutting surface of the knife. If unguarded force 
 be used, the tendon and its superimposed tissues may be di- 
 vided, which will seriously complicate the recovery. 7. 
 Withdraw the blade upon the flat, follow it by firm pressure 
 upon the parts with the thumb, which should finally rest 
 
 FIG. 219. 
 Fasciatome. 
 
 FIG. 220. Dividing a tendon.
 
 OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 153 
 
 upon the incision ; this will press out all blood and exclude the air. 
 8. Seal the wound carefully with adhesive plaster or collodion ; or 
 stitch it with asepticized silk, and apply the antiseptic dressing. 9. 
 Rectify the deformity and confine the part to which the tendon is 
 attached until repair shall have commenced. 10. Avoid the division 
 of a tendon as it passes through its sheath, if possible. 11. Divide 
 the offending tissue at the point of greatest forced prominence, pro- 
 vided it be consistent with its relation to important structures. If 
 reflex spasm results from " point pressure," the tendon should be 
 divided, and at the pressure-point inciting the reflex action. Cocaine 
 injections act admirably. 
 
 Tenotomy Upper Extremities. The tendons of the flexor sub- 
 limis and flexor profundus digitorum may be divided by a transverse, 
 subcutaneous incision carried through them down to the bone at about 
 the middle of the first row of anatomical phalanges. Antiseptic pre- 
 cautions should be observed carefully in this instance, otherwise severe 
 inflammation of the sheaths of the tendons may follow. After the 
 division of the tendons reduce the deformity and keep the parts quiet 
 for five or six days, till the danger from inflammation has subsided, 
 when they may be cautiously moved. 
 
 Extensor Communis Digitorum. The tendons of this muscle can 
 be readily divided as they pass along the carpus or upon the dorsum 
 of the phalanges. In the former instance, pinch up the skin, pass 
 the knife beneath the tendon as before directed, and cut toward the 
 surface. They may be divided by passing the blade above the tendons 
 and cutting down upon the bone. On the dorsum of the phalanges 
 the blade should be passed beneath the skin, and the tendons divided 
 upon the bone. In the division of the tendons of both flexor and ex- 
 tensor muscles, the joints and palm of the hand above the transverse 
 line should be avoided, also the course of the vessels and the spaces 
 between the metacarpal bones. 
 
 The Extensor Primi Internodii, Secundi Internodii, and Ossis 
 Metacarpi Pollicis Tendons can readily be made prominent by forcible 
 extension of the thumb in the living subject, with the forearm mid- 
 way between supination and pronation. The primi internodii and 
 ossis metacarpi pollicis tendons form the inner boundary of the " snuff- 
 box," at the apex of the styloid process of the radius, the ossis meta- 
 carpji pollicis being the innermost of the two. The tendon of the 
 extensor secundi forms its outer boundary. They can be divided in 
 this situation by first making them as prominent as possible, then in- 
 troducing the knife beneath from the anterior surface of the wrist 
 and cutting toward the integument. The radial artery is to be avoided 
 as it passes beneath them, and likewise the radicle of the radial vein 
 as it crosses the intervening space. 
 
 Flexor Carpi Radialis. The tendon of this muscle is situated
 
 154: OPERATIVE SURGERY. 
 
 immediately to the inner side of the radial artery, at the lower third 
 of the forearm, and can be readily divided by passing the knife from 
 the artery beneath the tendon. 
 
 Flexor Carpi Ulnaris. This is the most internal tendon on the 
 anterior surface of the forearm, and has the ulnar artery at the outer 
 border. It can be easily cut by passing the knife beneath it, from 
 without, inward. 
 
 Biceps Muscle at the Forearm. The tendon of insertion of this 
 muscle may be divided either above or below the giving off the bicipi- 
 tal fascia. The former is the safer. Make the veins in the region 
 prominent by constricting the arm above, extend the forearm to make 
 the tendon prominent and tense ; enter the knife at its inner border, 
 pass it cautiously between it and the brachial artery, and cut upward, 
 being careful not to injure the distended veins. 
 
 Tenotomy Lower Extremities. Tibialis Posticus. The tendon 
 of this muscle is intimately associated with the deformity of talipes 
 varus. It runs along the inner border of the tibia, behind the inter- 
 nal malleolus, in a separate sheath, being the innermost tendon at 
 this situation ; after leaving the internal malleolus, it passes beneath 
 the calcaneo-scaphoid articulation to its insertions. 
 
 In the normal foot it lies well concealed within its closely fitting 
 groove ; but it can be readily outlined between the tip of the malleolus 
 and the calcaneo-scaphoid articulation. 
 
 In talipes varus it is raised from its groove and becomes more 
 prominent above the tip of the internal malleolus, as well as below it. 
 It can be divided in either situation, but it is better done at a point 
 about an inch and a half above the tip of the malleolus in the adult, 
 and one inch in the child or infant. The tendon is made tense by 
 strongly abducting the foot, and the knife is passed with the usual 
 precautions between the posterior border of the tibia and the tendon ; 
 the division is made by cutting outward. 
 
 The section between the tip of the malleolus and the calcaneo- 
 scaphoid articulation is not advised, on account of the contiguity of 
 the ankle-joint and the internal plantar artery ; if, however, it be 
 thought advisable to operate at this situation, the foot should be 
 strongly abducted, and the point of the tenotome carefully insinuated 
 beneath the tendon, and between it and the internal plantar artery ; 
 the handle is then depressed so as to carry the point away from the 
 joint, and the section made from within outward. 
 
 Flexor Longus Diyitorum. The tendons of this muscle are some- 
 times productive of contraction of the toes, after the correction of the 
 deformity of the tarsus caused by the tibialis posticus. It lies imme- 
 diately posterior to the tendon of that muscle, behind the internal 
 malleolus, and is often divided by the same cut which severs the tendon 
 of the tibialis posticus. It can, however, be divided independently.
 
 OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 155 
 
 If, after the division of the posticus tendon, the influence of the 
 flexor longus digitorum be objectionable, it may be divided by intro- 
 ducing the tenotome beneath it through the same incision, and cut- 
 ting toward the surface as before. The posterior tibial artery and its 
 venae comites, which in the adult are often varicose in this situation, 
 must be carefully avoided by pressing them outward with the finger. 
 If from contraction of the toes, unassociated with deformity due to 
 the tibialis posticus, it be deemed advisable to sever its tendon, the 
 posterior tibial vessels must be first detected, pushed outward by the 
 thumb, which should then be pressed firmly between them and the 
 tendons at the inner side ; pass the tenotome perpendicularly through 
 the integument, midway between the posterior margin of the tibia 
 and the end of the thumb ; carefully insinuate it between the ten- 
 dons of the posticus and the flexor longus digitorum down to the 
 bone, turn the edge upward, and carefully divide it toward the surface. 
 
 Flexor Longus Pollicis. It may become necessary to divide the 
 tendon of this muscle, on account of the crippled action of the foot in 
 walking, dependent upon undue flexion of the great toe. 
 
 The toe should be forcibly extended, and the knife carefully in- 
 serted beneath it at the point of its greatest prominence, which will 
 be at the anterior and inner side of the foot. The instrument must 
 always be passed from the internal plantar artery. 
 
 The Tendo Achillis is the most prominent tendon of the human 
 system, and should be divided at its narrowest portion. . The posterior 
 tibial artery is at the front and inner side, but sufficiently remote to 
 be secure, if ordinary care be exercised. The short saphenous vein 
 lies superficially and closely to its outer border. 
 
 It can be readily divided if the foot be forcibly flexed, to render it 
 tense ; pinch up the skin, push it outward to protect the vein, enter 
 the knife beneath it from within outward, turn the edge toward the 
 tendon and carefully sever it with a sawing motion while the foot is 
 firmly flexed and the tendon pressed upon the edge of the knife by 
 the finger. Great care is necessary, else a sudden giving way of the 
 tendon may cause the knife to sever the superimposed tissues. All 
 the precautions enjoined in tenotomy should be carefully observed in 
 this instance. 
 
 Peroneus Longus and Brevis. Their tendons pass in a common 
 groove behind the external malleolus, and are inclosed by the same 
 sheath, the latter passing the most anteriorly. It leaves its fellow 
 after passing behind the malleolus, and is inserted into the base of the 
 metatarsal bone of the little toe on the outer side. The longus, after 
 passing behind the malleolus, gains the sole of the foot, enters the 
 calcaneo-cuboid groove, and is inserted into the base of the metatarsal 
 bone of the great toe at its outer side. The tendon of either may be 
 divided in two situations : 1. About one and one half inch above the
 
 156 OPERATIVE SURGERY. 
 
 tip of the malleolus. 2. Three fourths of an inch in front of it. 
 They are commonly divided in the former situation. They can be 
 severed connectedly or singly in either situation. 
 
 If it be decided to sever both simultaneously above the malleolus, 
 seek the anterior and external border of the fibula, about an inch and 
 a half above its tip, pass the knife between the bone and tendons, turn 
 the edge outward and cut toward the surface. The short saphenous 
 vein should be pushed inward to avoid injury. 
 
 If either is to be divided separately, push the integument back- 
 ward with the thumb, to protect the vein, then push the thumb firmly 
 down to the bone behind the tendons ; pass the tenotome perpendicu- 
 larly midway between the end of the thumb and the external border 
 of the fibula, carefully insinuate it between the tendons, after which 
 it is passed outward or inward, as the case may be, beneath the ten- 
 don to be severed, the edge turned upward, and the division made as 
 in the preceding instances. 
 
 If the division be made below the malleolus, make the tendons 
 tense, enter the knife about one half or three fourths of an inch in 
 front of the tip of the malleolus, between the tendons, when either or 
 both may be divided. 
 
 TiMalis Anticus. This muscle, like the posticus, is of importance 
 in connection with the deformity of talipes varus. 
 
 It is the innermost tendon of the leg and foot on its anterior sur- 
 face, and can be easily outlined unless the foot be fat and chubby, 
 when some difficulty may be experienced. 
 
 In well-marked cases of talipes varus it is displaced considerably to 
 the inner side, and, if the foot be abducted, will become quite promi- 
 nent. It is best divided about one inch above its insertion into the 
 internal cuneiform bone. Make the tendon tense, pass the knife from 
 without inward, to avoid the dorsalis pedis artery. 
 
 Extensor Proprius PolUcis. As it passes across the dorsum of the 
 foot, it can, like the preceding, be quite easily distinguished. It may 
 become necessary to divide it after the division of the extensors of the 
 tarsus, on account of its causing undue extension of the great toe. 
 The toe should be forcibly flexed, and the tenotome carried beneath it 
 from without inward, to avoid the dorsalis pedis vessels. 
 
 Extensor Longus Digitorum. The tendons of this muscle may 
 not only cause an obstinate extension of the toes, but aid in maintain- 
 ing the tarsus in a state of forced flexion. They can be divided sepa- 
 rately, as they pass along the dorsum of the foot, provided either 
 require it. If all be cut at once, it is done by flexing the toes, enter- 
 ing the knife beneath them, a little below the bend of the ankle, from 
 within outward, to avoid the dorsalis pedis vessels. 
 
 Peroneus Tertius. This may be divided together with the extensor 
 longus digitorum, of which it is a part ; or it can be done separately
 
 OPERATIONS ON TENDONS, FASCIA, AND MUSCLES. 157 
 
 before its insertion into the dorsum of the metatarsal bone of the little 
 toe, by extending the tarsus, and passing the knife beneath it, from 
 without inward. It is the most external tendon on the dorsum of the 
 foot, in front of the external malleolus. 
 
 Biceps of the Leg. This tendon forms the external hamstring, 
 and is inserted into the head of the fibula and the outer tuberosity of 
 the tibia. The external popliteal nerve is located immediately at its 
 inner side. To divide it, the leg should be extended, and the tenot- 
 ome passed from within outward, beneath the tendon about an inch 
 and a half above the head of the fibula. 
 
 The inner hamstring tendons are the semi-tendinosus, semi-mem- 
 branosus, gracilis, and sartorius ; the two first, however, are the ones 
 principally concerned. The tendon of the semi-tendinosus is felt as 
 the longest, smallest, and nearest to the median line of the popliteal 
 space ; that of the semi-membranosus is internal to it, somewhat less 
 superficial, and runs parallel with it. Either of these tendons can be 
 divided by extending the leg to make it tense, and entering the knife 
 beneath and from the outer side, at the most prominent portion, and 
 cutting toward the surface. Their division to relieve forced flexion 
 of the leg will not always admit of complete extension, due, among 
 other things, to the contraction of the heads of the gastrocnemius, 
 which are inserted into the condyles of the femur. The forced exten- 
 sion of the leg under these circumstances often causes a tearing asun- 
 der of the attachments of this muscle, especially in the inner head, 
 which is larger, stronger, and inserted higher than the external. The 
 hemorrhage resulting therefrom may be severe enough to infiltrate the 
 calf of the limb, even extending throughout the popliteal space. The 
 liability to this rupture and consequent bleeding may be lessened, if 
 not obviated, by first dividing the tendo Achillis ; or, what is per- 
 haps better, by first dividing the hamstring tendons, when, if, on at- 
 tempting to straighten the limb, the foot becomes extended, the tendo 
 Achillis can then be divided. 
 
 Gracilis and Sartorius. They may be divided, after forcible ex- 
 tension of the leg. Pass the tenotome close at the inner side of the 
 tendon of the semi-membranosus, between it and the gracilis, depress 
 the handle outward or inward, as the case may be, and divide these 
 structures toward the skin. 
 
 * The Quadriceps Extensor Tendon may be divided above the pa- 
 tella by making an incision down to the tendon parallel with the 
 base of the patella ; enter the point of the knife above it cautiously, 
 and with a sawing motion divide the tendon. A careful and continu- 
 ous attempt should be made to flex the leg while the tendon is being 
 cut, that its deepest fibers may be ruptured, thus avoiding, as far as 
 possible, entering the synovial extension of the knee-joint, which lies 
 beneath it. However, the limb should not be flexed farther than is
 
 158 OPERATIVE SURGERY. 
 
 necessary for this purpose, and after the division should be placed in 
 a comfortable position till repair is well advanced. 
 
 Pectineus. This muscle, which acts as a flexor and adductor of 
 the thigh, may require division on account of malposition of the limb. 
 The pelvis is steadied, thigh extended and abducted, which causes the 
 fibers to become tense and prominent. A long-bladed tenotome is 
 then introduced at the outer border, about an inch below its origin, 
 and carried inward and upward, till the division is complete. The 
 internal circumflex artery, which runs between the psoas magnus and 
 the outer border of the pectineus, is the only vessel of any size exposed 
 to injury. The danger to this is obscure, unless it arises higher than 
 usual. If the division be made downward and inward the femoral 
 vessels will be less exposed than when made in the opposite direction. 
 
 The Adductor Lonyus is situated farther to the inner side of the 
 thigh than the preceding, forming the inner border of Scarpa's tri- 
 angle. It is, however, located on about the same plane as the pecti- 
 neus. It is tendinous at its origin from the pubes, and can be easily 
 divided, when made tense, by passing the knife beneath its outer bor- 
 der, and cutting upward and inward. 
 
 The Tensor Vagina} Femoris can be severed without difficulty by 
 introducing a long-bladed tenotome beneath it, from either border of 
 the muscle, about an inch below its origin, and cutting toward the 
 surface. 
 
 The Sartorius forms the outer boundary of Scarpa's triangle, and 
 can be divided by making its fibers tense, by strong abduction ; then 
 introducing a long tenotome beneath it, at its inner border, two 
 or three inches from its origin, and cutting upward toward the sur- 
 face. 
 
 Muscles of the Trunk. The Multifidus Spinm lies on either side 
 of the spinous processes, in the groove formed by the spines and trans- 
 verse processes, from the sacrum to the axis. This muscle is quite su- 
 perficial in the sacral region, opposite to the posterior superior spinous 
 process of the ilium. Raise a fold of skin parallel with the long axis 
 of the muscle ; pass a long-bladed tenotome from the spine outward 
 to the outer border of the muscle, and cut toward the spine. 
 
 Latissimus Dorsi. The tendon of this muscle may be divided 
 separately at the lower border of the axilla, or conjointly with that of 
 the teres major, a short distance below their insertion into the hu- 
 merus. 
 
 In either instance the arm is forcibly raised to render them tense 
 and prominent, and a long, narrow-bladed tenotome is inserted along 
 the anterior border, and they are carefully severed by a sawing motion. 
 
 It may likewise be divided at the lower angle of the scapula. 
 Make the muscle tense as before, pass a long, strong tenotome beneath 
 it, and cut carefully outward ; close the opening with a compress.
 
 OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 159 
 
 The Erector Spince forms the principal portion of the muscular 
 prominence on either side of the spine to be seen in the lumbar re- 
 gion. This is a thick, strong muscle, which arises from the sacrum 
 and contiguous structures, and divides at the lower border of the last 
 rib into the longissimus dorsi and sacro-lumbalis, which are inserted 
 into the angles of the ribs and the transverse processes of the dorsal 
 vertebra?. The erector spinae can be divided by a long tenotome 
 passed from within outward, to the outer border of the muscle, just 
 below the last rib, and carried downward and inward toward the 
 spine. 
 
 Trapezius. This is a muscle possessing an extensive origin. The 
 portion which arises from the inner third of the superior curved line 
 of the occipital bone is often divided, on account of abnormal devi- 
 ations of the head. 
 
 This is readily accomplished by making the muscle tense, and 
 severing it with a tenotome entered beneath it, just below the occipi- 
 tal protuberance, the edge turned toward the integument. 
 
 Sterno-cleido-mastoid. Division of this muscle is often necessary 
 in cases of wryneck dependent upon abnormal muscular force. It 
 is divided at its lower extremity, either at its sternal or its clavicular 
 attachment ; often at both. For the division at either, the muscle is 
 put on the stretch by turning the head, and the blunt-pointed teno- 
 tome passed beneath it from the outer side, about half an inch above 
 its insertion, and divided toward the surface. The division of the 
 clavicular portion may be ample to correct the deformity ; if not, the 
 sternal portion should be severed in the same manner. It is necessary 
 to closely hug the under surface of the portions to be divided, else the 
 deep-seated and important vessels may be injured. It is not safe to 
 attempt a subcutaneous section of the muscle above this point, on 
 account of its relation to the common carotid artery and the internal 
 jugular vein. 
 
 Plantar Fascia. This tissue is an exceeding dense, white fibrous 
 membrane of great strength, with the fibers arranged longitudinally. 
 It is divided into three portions, the middle and two lateral. The 
 former is the one especially concerned in those deformities requiring 
 division. It is narrow behind and attached to the inner tubercle of 
 the os calcis ; broader and thinner in front, and divides into five pro- 
 cesses opposite the middle of the metatarsal bones, being one for each 
 of the toes. Each of these processes divides opposite the metatarso- 
 phalangeal articulations into two slips, which embrace the sides of the 
 flexor tendons, and are inserted into the sides of the metatarsal bones 
 and the transverse metatarsal ligament. It likewise sends prolonga- 
 tions between the groups of the plantar muscles. This fascia serves 
 the important function of assisting in maintaining the integrity of the 
 plantar arch.
 
 160 
 
 OPERATIVE SURGERY. 
 
 It is divided by placing it upon the stretch, and passing a teno- 
 tome beneath the inner border of the most prominent portion, and 
 cutting toward the sole. The deformity is then overcome as much as 
 is practicable, and the foot is placed and fixed in the corrected po- 
 sition. 
 
 Palmar Fascia. Like the plantar fascia, this is divided into three 
 portions two outer and a middle part, the middle division being one 
 of special significance. It is narrow above, and attached to the lower 
 border of the annular ligament ; below it is broad and thinner, and 
 opposite the heads of the metacarpal bones divides into four slips, one 
 for each finger. Each slip subsequently subdivides into two processes, 
 
 FIG. 221. Fascial contractions, a. Fascial contractions, b. Flexor tendons. 
 
 which inclose the tendons of the flexor muscles, and are attached 
 to the sides of the first phalanx, and to the glenoid ligament, and 
 
 extends upward over the flexor tendons 
 nearly to the tip of the finger. This fascia 
 is intimately connected with the integu- 
 ment of the palm, and sends vertical septa 
 between its muscles. From various causes 
 it may undergo structural changes, which 
 result in contractions of the fingers on the 
 palm, as well as shortening of the palm it- 
 self. The anatomical arrangement of the 
 fascia fully explains the mechanism of the 
 deformity. 
 
 Dupuytren's Contraction. This deform- 
 ity depends upon the contraction of the 
 prolongations of fascia of the palm, con- 
 nected with the digits ; the morbid process 
 more frequently manifests itself in the 
 ring and little fingers, causing them oft- 
 times to become opposed to the palmar 
 surface of the hand. 
 
 Operation. Anaesthetize the patient ; render the restricting bands 
 tense by a firm extension of the affected digits, and then, under anti- 
 
 FIG. 222. Transverse incisions 
 for Dupuytren's contraction.
 
 OPERATIONS ON TENDONS, FASCLE, AND MUSCLES. 
 
 septic precautions, divide the restraining bands at short intervals, 
 subcutaneously, with a narrow-bladed knife, its edge being directed 
 from the surface of the palm. When sufficiently liberated the digits 
 can be freely extended, in which position they are to be confined by 
 dorsal splints until repair is completed. Passive motion and forcible 
 extension until the tendency to contraction is overcome, comprise the 
 important elements of the after-treatment. Goyraud made longitu- 
 dinal incisions over the tense digital prolongations of fascia, dissected 
 the integument from them, after which they were divided sufficiently 
 to admit of extension of the digits ; the integumentary incisions were 
 closed and the fingers confined in a straight position until healed. His 
 success was gratifying. 
 
 Fallacy. This deformity may be confounded with that dependent 
 upon contraction of the flexor tendons. An examination of Fig. 221 
 will enable the surgeon to make a clear distinction between the two 
 conditions. 
 
 The fascia in other situations may become contracted, as the fascia 
 lata, at its upper or lower extremities. Whenever these contractions 
 cause a persistent deformity they should be divided, and upon the 
 same principles as like tissues in other portions of the body. The 
 employment of an anaesthetic is advisable in tenotomy, especially 
 when the section is to be extensive, or contiguous to important struct- 
 ures. In all instances antiseptic precautions should be taken. 
 
 Tendon Suturing. The uniting of divided tendons by catgut or 
 by fine silver wire is an accomplished fact. Hereafter the practical 
 surgeon, instead of assigning as a reason for the permanent immobility 
 of an extremity, that " The tendon was cut," should first make an 
 earnest effort to unite its extremities. The especial functions of the 
 divided tendons can be determined by causing movements of the car- 
 pus and fingers, independently of each other, and watching the effects 
 of these movements on the distal extremities of the divided tendons. 
 Some difficulty is often experienced in finding the respective ends of 
 the severed tendons, since they especially the ends connected with 
 the muscular belly are notably drawn into their sheaths. 
 
 Operation. Under full antiseptic precautions, flex the part so as 
 to produce the greatest relaxation of the muscles associated with the 
 divided tendons ; if necessary, open their sheaths sufficiently to catch 
 their extremities, draw them down and unite them by an oblique 
 splice, if possible, with catgut or fine silver wire, close the wound, 
 dress antiseptically, and confine the extremity in the position best 
 calculated to cause muscular relaxation and quiet during the healing 
 process. 
 
 Fallacy. If great care be not taken, in case more than one tendon 
 be divided, the tendons of muscles acting diversely will be united, 
 with manifest results. 
 11
 
 162 
 
 OPERATIVE SURGERY. 
 
 CHAPTER VIII. 
 
 OPERATIONS ON BONES. 
 
 THE injuries and diseases to which bones are liable, although not 
 differing in any essential particular from the same conditions when 
 occurring to the soft parts, require an independent consideration, on 
 account of the dissimilarity of the function and structure of the osse- 
 ous system. Tendons, muscles, nerves, and fasciae are divided and ex- 
 cised ; so are bones. The integument and soft parts generally, become 
 the seat of inflammation, ulceration, and gangrene. Bony tissue is like- 
 wise preyed upon by the same morbid processes, named, however, quite 
 differently ; ulceration of the soft parts being comparable to caries of 
 bone, necrosis of bone finds its synonym in gangrene of soft parts. 
 To preserve the function of a tissue unimpaired is the greatest end 
 that can be attained by surgery. To relieve a patient of the local 
 effects of an injury or disease constitutes conservative surgery in its 
 fullest sense. 
 
 The functions of bones being, in a practical sense, to support the 
 body, protect important organs, and act as levers for purposes of pre- 
 hension and locomotion, we have but to act with a knowledge of these 
 purposes, and of the methods to maintain them, to give to the patient 
 the full benefit of our art. 
 
 The operations upon bone are denominated gouging, sequestrotomy, 
 excision, osteotomy, and osteoplasty. 
 
 FIG. 223. Volkmann's scoop. 
 
 Fm. 224. Hebra's Scoop. 
 
 Gouging is applied to the removal of carious bone, and should not 
 be attempted until the process has become chronic. 
 
 FIG. 225. Chisel. 
 
 The instruments required to meet the exigencies of a case are 
 gouges (Figs. 204, 205, 206, 207), scoops and chisels (Figs. 223, 224,
 
 OPERATIONS ON BONES. 
 
 163 
 
 and 225), of various sizes and shapes, together with a suitable mal- 
 let (Fig. 208). 
 
 Operation. Having arranged the patient in a position suitable 
 for the convenience of the operator, administer an anaesthetic, apply 
 
 FIG. 226. Marshall's osteotrite. 
 
 the elastic bandage if practicable, carrying it lightly over the site of 
 the disease, and make a free incision down upon the carious bone ; 
 separate the soft parts with retractors ; then, with the drills, gouge, 
 osteotrite, etc., remove all the diseased structure. 
 
 It is important to be able to determine the line between the healthy 
 and diseased bone ; and this is often very difficult. If the portions 
 removed, when washed, present a whitish, grayish, or blackish appear- 
 ance, and are porous and fragile, instead of being vascular, red, and 
 tough, then the operation should be continued. If the gouged sur- 
 faces bleed freely from numerous points, and have a normal firmness 
 and color, then the operation should cease. 
 
 It is important in gouging the extremities of bones to use extreme 
 caution, or the joint cavity may be opened directly, or become second- 
 arily involved. After the removal of the elastic constriction, all 
 hemorrhage should be arrested, the wound washed thoroughly with 
 a suitable antiseptic 
 solution, good drain- 
 age secured, the soft 
 parts united, and 
 dressed antiseptic- 
 ally. 
 
 Sequestrotomy. This operation is employed to remove dead bone 
 en masse, and is therefore applicable to necrosis. The additional in- 
 struments necessary are small crown trephines, bone-cutting forceps 
 of various shapes (Figs. 227, 228, and 229), gnawing forceps, small 
 
 FIG. 227. Liston's straight forceps. 
 
 FIGS. 228, 229. Liston's curved forceps. 
 
 saws (Figs. 241, and 242, 230, 231) and periosteal elevators (Figs. 232 
 and 237), etc. There are two methods employed, depending on the 
 nature of the case viz., direct and indirect.
 
 164 
 
 OPERATIVE SURGERY. 
 
 The Direct Method. Having detected the situation of the necrosed 
 bone, and being satisfied, either from the long course of the disease, 
 or by movement of the dead portion, that detachment has occurred, 
 apply the elastic bandage, using care not to force deleterious matters 
 
 FIG. 230. Lente's saw. 
 
 into the circulation, select a strong scalpel (Fig. 234), and connect 
 the fistulous openings with each other, down to the bone ; choosing 
 
 FIG. 231. Langenbeck's key-hole saw. 
 
 such openings, of course, as will cause the connecting incision to be 
 consistent with good drainage, easy access to the diseased parts, and 
 safety to the underlying structures. The surfaces of the incision 
 
 FIG. 232. Sayre's 
 periosteotome. 
 
 FIGS. 233, 234. Strong scalpels. FIG. 235. Retractors. 
 
 should now be separated with retractors (Fig. 235), to fully expose 
 the openings in the involucrum. If the sequestrum can be drawn out 
 of the opening with suitable forceps, it should be done carefully ; oth- 
 erwise the reparative tissue upon which it rests will be injured, and 
 the process of recovery deterred. If it be too large, or be interlocked 
 with healthy bone, the opening must be enlarged sufficiently to admit 
 of its withdrawal ; or, if this be impracticable, an incision through
 
 OPERATIONS ON BONES. 165 
 
 the periosteum should be made, corresponding to the long axis of 
 the sequestrum. The periosteum should be carefully raised upon 
 either side of the incision to permit the application of a small crown 
 trephine, with which the involucrum should be perforated a sufficient 
 number of times to admit the easy removal of the dead portion, 
 either with or without the chiseling away of the irregular borders. 
 
 The gnawing forceps, chisels, the mallet, and even small saws, may 
 be used in lieu of or in conjunction with the trephine. 
 
 Should there be but one sinus, and evidences of disease exist above 
 and below it, the center of the incision should correspond to the sinus, 
 if the anatomical relations will admit of it. It is necessary to use great 
 caution in making these incisions in the vicinity of joints, or their 
 synovial pouches will be opened. After the removal of the dead bone, 
 the wound, through its whole extent, should be thoroughly cleansed, 
 suitable drainage provided, the lips of the wound closed, and anti- 
 septic dressing applied ; or, after washing, it can be lightly filled with 
 oakum saturated with balsam of Peru, or carbolic acid and oil, and 
 the whole confined in place by a mass of carbolized oakum, held in 
 position by a roller bandage. In the latter instance it should be 
 dressed frequently to secure proper cleanliness. If the antiseptic plan 
 be employed, the rules applicable to the method should be strictly ob- 
 served. When the portion of bone removed is large, or the remain- 
 ing part is small and fragile, the limb must always be supported by a 
 splint ; otherwise it may bend or break, and thereby complicate the 
 ultimate result. 
 
 If the sequestrum be as yet unseparated from the healthy bone, it 
 should be allowed to remain until the process of separation is com- 
 pleted, when it can be removed. 
 
 The indirect method is preferable when the bone is superficial and 
 its disease progressive, as in ostitis of the lower jaw, clavicle, bones 
 of the arm, forearm, or tibia ; in fact, all the long and many of the 
 flat bones can be reproduced by this method. It consists in making a 
 free incision down upon the diseased bone, through the surrounding 
 periosteum, and separating the membrane by means of the handle of 
 a scalpel, spatula, periosteal elevator, or any instrument of a like 
 character. This must be done at intervals, and not extend beyond 
 the diseased portion ; the length of the intervals will depend entirely 
 upon the rapidity of the" morbid process. This plan is necessarily te- 
 dious, both in detail and in time ; yet sooner or later the dead bone 
 can be raised from its new osseous trough, which will soon become 
 filled, and ofttimes serve the purposes of its predecessor. The free 
 incision necessary to expose the dying bone will provide good drain- 
 age ; nothing is necessary other than this, than to keep the wound 
 clean by ordinary means. 
 
 Excision. Excision of bone is a conservative operation, directed
 
 166 OPERATIVE SURGERY. 
 
 to the extraction of such portions of it as are inconsistent with its 
 future usefulness or the symmetry of the part, together with the re- 
 moval of the condition directly demanding the operation. It is em- 
 ployed in lieu of the more radical measure amputation. It may be 
 directed to the articular extremities or to the shaft of a bone ; and, in 
 either instance, it may be partial or complete. The articular extremi- 
 ties or joints are excised on account of injury, disease, or ankylosis 
 in a faulty position. In estimating the prognosis for life, the sur- 
 roundings of the patient, his previous habits, present condition, and 
 the existence of constitutional taints, must be considered ; also the 
 nature and extent of the cause demanding it. The prospective useful- 
 ness of the limb will depend on the ability to leave the muscular attach- 
 ments intact ; and also upon the condition of the nerves that animate, 
 and the blood-vessels that nourish them. If the patient be a manual 
 laborer, or be one over-sensitive of a deformity, it is well then to con- 
 sider if additional advantages can be derived from artificial limbs and 
 appliances, Avhen it may be deemed the wiser to sacrifice the offend- 
 ing member for the relief afforded by amputation. The incisions pre- 
 paratory to the necessary exposure of the parts to be removed should 
 be free, and, when possible, be made in the long axis of the bone. 
 They are often, however, varied, to suit the peculiar demands of the 
 individual cases. They are likewise varied for the different joints, 
 being in one instance longitudinal, in another U, H, or === shaped, 
 according to the proposed extent of the operation and the contiguous 
 anatomy of the part. In every instance, however, they should be 
 made with a view to good drainage, when the same incision will ren- 
 der the parts accessible, and not expose adjacent important struct- 
 ures to unwarranted danger. Future usefulness being one of the 
 most important factors to be gained, the insertion of all muscles, 
 having especially defined functions, as flexion or extension, must, if 
 possible, be carefully avoided. If it be necessary to divide tendons, they 
 should be incised obliquely, the better to facilitate subsequent union. 
 Should it be necessary to remove the bony surfaces, into which they 
 or the ligaments are inserted, the periosteum covering these surfaces 
 should be carefully peeled off, together with all tendinous attach- 
 ments. All diseased and loose pieces of bone should be removed, to- 
 gether with irregularities and isolated portions of articular cartilages. 
 The synovial membrane should be preserved, unless it be diseased, and 
 its diseased portions cut or scraped off. The removal of the entire 
 shaft of a bone may be necessary on account of injury or disease, 
 notably the latter. In such cases the incision should be free, and 
 made over its most superficial aspect, provided that important struct- 
 ures do not intervene ; the periosteum is then elevated proportion- 
 ately to the extent of the disease, gradually or rapidly, as the circum- 
 stances indicate, and the diseased bone removed, leaving, if possible,
 
 OPERATIONS ON BONES. lf,7 
 
 the epiphyseal extremities. If the epiphyseal cartilage be destroyed, 
 the growth of the bone in its long axis will be interrupted. This is 
 very important to observe in operations upon the bones of adolescents, 
 since to destroy this cartilage will cause a subsequent shortening of 
 the limb. The consultation of any standard work on anatomy will 
 enable the surgeon not only to accurately locate the epiphyseal junc- 
 tions, but likewise inform him of the age at which the shafts become 
 united to their epiphyses. 
 
 The time of operating must be governed by the condition of the 
 patient, and also by the part to be operated upon. If the patient be 
 
 suffering from shock, 
 reaction should take 
 place prior to oper- 
 FIG. 236. Retractor. ative interference. 
 
 Should inflamma- 
 tion of the bone have occurred, good drainage should be established, 
 and the operation deferred until the acute symptoms subside. If the 
 operation be for necrosis, the diseased bone should be allowed to sepa- 
 rate before the attempt is made. 
 
 The instruments required for excision are varied in number and 
 shape, and must be selected according to the peculiarity of the case. 
 The knives should 
 be broad and strong 
 (Figs. 233, 234). 
 The retractors (Fig. Fm 237 ._ Sands , periosteotome . 
 
 235) must likewise 
 
 be strong, and possess a hook-like curve, otherwise they will slip from 
 the wound. A sharp-hooked retractor may be employed (Fig. 236). 
 The periosteotomes, or elevators (Figs. 237, 232), vary in shape, but 
 should possess a blunt, non-cutting edge ; and if compactness be de- 
 sired, the elevator may be connected with the handle of the knife 
 (Fig. 234). However, it is not so handy or efficient as the independ- 
 ent instrument. These instruments must be used with care, other- 
 wise the function of the periosteum will be destroyed, and may even 
 be followed by sloughing. The bone-cutting instruments are forceps, 
 and saws of various sizes and shapes. The straight bone forceps are 
 the most available for general purposes. The blades should fit accu- 
 rately, and be sufficiently sharp to make as clean a out as possible. 
 In order that bone intricately located may be reached, the blades are 
 bent at various angles (Figs. 227, 228, 229). The gnawing forceps or 
 rongeur are of inestimable value in removing bony projections. 
 
 Bone-holding Forceps (Fig. 238) vary somewhat in their grasping 
 and holding powers ; consequently the surgeon will be governed in 
 his selection of an instrument by its suitability for the purpose. The 
 varieties of saws are numerous, among which are the chain-saw (Fig.
 
 168 
 
 OPERATIVE SURGERY. 
 
 239), the straight saw, with an adjustable back (Fig. 241), and the 
 curved, for right and left sawing. These are of use in removing por- 
 
 Langenbcck's. Ferguson's. 
 
 FIG. 238. Bone-holding forceps. 
 
 FarabceuPs. 
 
 tions of thin bones from flat surfaces. The chain-saw, as the name 
 indicates, is composed of numerous links or sections, having a handle 
 
 FIG. 239. Chain-saw. 
 
 for working it attached to each extremity. To apply the saw, remove 
 the handle from the hook and carry it beneath the bone, with the cut- 
 
 FIQ. 240. Chain-saw carrier.
 
 OPERATIONS ON BONES. 
 
 169 
 
 ting edge upward, by means of a thread and curved needle, or an in- 
 strument known as the " chain-saw carrier " (Fig. 240) may be employed 
 
 FIG. 241. Lifting-back metacarpal saw. 
 
 instead ; readjust the handle, and draw it from side to side at an angle 
 of about 45 with the bone. It should not be jerked, or be allowed 
 to kink, but should be kept taut while be- 
 ing used, for fear of clamping or breaking 
 it. This instrument is employed in divid- 
 ing those bones which are nearly surrounded 
 by the soft parts. Fig. 242 represents a saw 
 of great practical worth. The blade is ad- 
 justable, and its cutting surface can be 
 turned in any direction ; it has therefore a 
 universal application, which renders it su- 
 perior to the chain-saw, except in isolated 
 cases. The gouges, chisels, and mallet are 
 required to thoroughly remove all diseased 
 bone. They vary in size and shape, in 
 order that the intricacies of the wound may 
 be reached. The instruments to seize the 
 fragments of bone are also variously shaped, 
 to be better able to grasp them. 
 
 The Surgical Engine. This is the out- 
 come of the dental engine, the former being 
 the stronger and associated with suitably 
 constructed knives, trocars, burrs, and saws. 
 These instruments are connected by a hand- 
 piece which is attached to a flexible wire 
 cable that permits the easy holding and di- 
 recting of their rapidly revolving surfaces. 
 The rapidity of their action two to three 
 thousand revolutions per minute lessens 
 the pain and the injury done to important 
 parts. The engine can be used with advan- 
 tage in bone surgery. It is expensive and 
 somewhat cumbersome, and therefore bet- 
 ter fitted for hospital use than for general 
 practice. 
 
 The treatment of excision wounds is in nearly all instances sub- 
 stantially the same. Eest and thorough drainage, together with strict 
 antiseptic measures, constitute the basis of the future treatment. 
 
 FIG. 242. Szymanowski's saw.
 
 170 OPERATIVE SURGERY. 
 
 Eest can be secured by the various forms of splints, either movable 
 or immovable in character. The older dressings of these wounds con- 
 sisted of oakum, lint, marine lint, or a fine silken oakum, either with 
 or without saturation with carbolic acid and oil, or balsam of Peru. 
 If treated by this method, they should be dressed with sufficient fre- 
 quency to prevent any septic infection, once daily being usually 
 enough. If the antiseptic methods be adopted, the rules governing 
 the readjustment of the dressings should be enforced. 
 
 Excision of the Upper Jaw. This operation is done for various 
 diseases, connected either with the bone structure itself or the cavi- 
 ties with which it is associated. In all instances the periosteum should 
 be preserved, except those in which it is invaded by malignant disease. 
 
 The special instruments requisite in addition to those already 
 enumerated for excisions are a trephine, or a bone-drill and a strong 
 pair of forceps to turn or twist the bone out of its cavity, together 
 with forceps to draw the teeth in the line of section. The patient 
 is anaesthetized and placed upon the back, either with the head slight- 
 ly raised or markedly depressed. In the latter position the blood 
 does not escape into the larynx, but into the upper and posterior 
 part of the pharynx. This position, however, impedes respiration 
 by undue stretching of the tissues of the anterior cervical region. 
 However, this may be obviated, in a great degree, if the foot of the 
 table be raised, as for the reduction of the abdominal contents by 
 taxis. If the head be elevated, the blood can, with care, be kept from 
 the larynx, either by constant sponging or tamponing the pharynx 
 around a large catheter or rubber tube, or permitting the patient to be 
 suificiently conscious to dislodge it. Still another method is to confine 
 the patient in a rocking-chair, which can be tipped forward or back- 
 ward as circumstances require. The surest of all is to perform a pre- 
 liminary tracheotomy, and then tampon the floor of the pharynx. 
 This is not as a rule necessary unless the operation be complicated 
 with a very vascular morbid process requiring a separate removal. 
 If the important associated anatomy be carefully considered before 
 beginning the operation, it will save much time and not a little blood. 
 
 In complete removal, the bony connections which must be divided 
 are : 1. With the malar, below the outer angle of the orbit. 2. With 
 the fellow of the opposite side in the roof of the mouth. 3. The nasal 
 process of the bone, with its body below the inner angle of the orbit. 
 4. The slight connection between it and the palate bone and pterygoid 
 processes of the sphenoid. The internal maxillary artery in the spheno- 
 maxillary fossa and the branches of the facial artery running through 
 the external soft parts are the only vessels that will cause troublesome 
 hemorrhage. Steno's duct must be avoided, as it runs from the pa- 
 rotid gland to empty into the mouth opposite the second molar tooth, 
 on a line extending from the lobule of the ear to midway between the
 
 OPERATIONS ON BONES. 
 
 in 
 
 border of the lip and the ala of the nose. The superior branches of the 
 seventh pair of cranial nerves may be divided unnecessarily if the course 
 
 FIG. 243. Linear guides for removal of upper jaw. 
 
 or extent of the incisions be too great. All anticipated complications 
 should be carefully studied, and provisions made for their treatment. 
 Loss of blood, however, is the only one in addition to the shock com- 
 mon to all operations that requires close attention. Hemorrhage from 
 the facial and internal maxillary arteries, while often profuse, can be 
 easily controlled. 
 
 The Lines of Incision. They may be made within or without the 
 buccal cavity. 
 
 To attempt the removal from within is too tedious, the space being 
 limited and the ability to control hemorrhage entirely inadequate. 
 At the present time external incisions only are practical. These can 
 be classed as the outer, and the median. The former (Lizar's) com- 
 mencing at the angle of the mouth and passing in a curved course 
 upward and outward to the malar process (Fig. 243, a) ; if more room 
 be needed it may be supplemented by an incision through the upper 
 lip to the nostril, also by extending the first. This incision exposes 
 Steno's duct and the branches of the seventh nerve to injury, and is 
 followed by a conspicuous scar. 
 
 Listen made an incision from below the external angular process 
 of the frontal bone to the angle of the mouth ; if necessary, a sec- 
 ond was also made along the zygoma joining the first (Fig. 243, c), 
 and even a tbird from the nasal process of the maxilla downward to
 
 172 
 
 OPERATIVE SURGERY. 
 
 the lip in the median line. Velpeau, like Lizar, made a single curved 
 incision with the convexity downward from the angle of the mouth 
 to the malar bone, and even to the angle of the orbit if necessary. 
 The last (Ferguson's), and an admirable one, is made at the middle 
 of the upper lip, and, following the furrows between the cheek and 
 nose, terminates about half an inch below the inner angle of the 
 eye (Fig. 243, #). To this may be added an incision of an inch or so 
 in length, extending outward half an inch below the orbit, and at a 
 right angle with the vertical one, or it may be extended to the external 
 angle of the orbit and the zygoma if necessary. In this incision the 
 coronary and angular arteries only are divided. 
 
 Operation ly the Median Incision, with Removal of the Whole 
 Bone. The middle incisor tooth corresponding to the side to be oper- 
 ated upon is drawn, and the facial artery compressed on both sides by 
 an assistant. The incision is begun at the border of the lip, and in or- 
 der to prevent blood from entering the mouth, it is not carried through 
 it until later, from the upper attachment of the lip, through the re- 
 mainder of the course, the incision is rapidly made down to the bone, and 
 the flap dissected outward as far as the malar bone above, and the tuber- 
 osity of the maxilla below ; during the dissection the bleeding points 
 are controlled by the fingers of the assistant or by the serrefine forceps. 
 All vessels should be ligated with catgut before the bone is removed. 
 The cartilage of the nose is separated from the bone and turned inward, 
 the edge of the orbit gained, and the periosteum on the floor separated 
 
 and pushed backward 
 and upward by means 
 of an elevator or han- 
 dle of a scalpel to the 
 border of the spheno- 
 maxillary fissure. The 
 malar process is now 
 divided by sawing, or 
 cutting through it 
 with bone - forceps, 
 from the outer extrem- 
 ity of the spheno-max- 
 illary fissure. The thin 
 floor of the orbit is 
 divided with a scalpel 
 from the spheno-max- 
 illary fissure obliquely 
 forward and inward, 
 and the nasal process severed with forceps (Fig. 244). The mucous 
 membrane of the roof of the mouth is then divided transversely in- 
 ward to the center, on a line with the last molar tooth, then from the 
 
 FIG. 244. Division of processes of superior maxilla.
 
 OPERATIONS ON BONES. 
 
 173 
 
 center forward, in the median line, to the incisor teeth. The hard 
 palate is divided at the side of the septum, corresponding to the bone 
 to be removed, by a saw or bone-forceps, and the bone seized and pressed 
 downward to break up its posterior connections, after which it is raised 
 and twisted slightly from side to side and pulled out, bringing with it 
 some portions of the palate bone and pterygoid process of the sphenoid, 
 together with the muscular fibers connected with them. If the mucous 
 membrane of the mouth be not diseased, it can be saved by making an 
 incision through it along the alveolar border, and pushing it inward 
 together with the periosteum to the median line. After the removal 
 of the bone the periosteum can be stitched to the side of the cheek. 
 
 Excision Below the Floor of the Orbit. After the exposure of the 
 external surface of the superior maxilla, as in the preceding method, 
 perforate the anterior wall of the antrum with a drill or trephine ; 
 then, with the bone forceps or saw inserted into the opening, divide 
 the bone through into the nasal fossa, and separate it from its outer 
 connections by sawing or cutting through the malar bone. Aside from 
 this the steps of both are similar. 
 
 After the operation the wound is washed with carbolic acid, and 
 all bleeding points checked either by ligature, pressure, or cautery, 
 the first being the best. The external incision is then closed with 
 sutures or pins, and readily unites in three or four days. The raw 
 surfaces within should be kept thoroughly cleansed while repair is 
 taking place. These cases make a satisfactory recovery from the opera- 
 tion, although some deformity always remains. 
 
 The stitches are 
 removed from the 
 soft parts the third 
 or fourth day, un- 
 ion, as a rule, being 
 complete. 
 
 The results of 
 this operation are 
 good, so far as im- 
 mediate loss of life 
 is concerned. About 
 one in five or six 
 die. If the removal 
 be done for malig- 
 nant growths, the 
 prognosis for ulti- 
 mate recovery is un- 
 favorable. 
 
 8 u b p e r iosteal 
 Excision. This can be done with any of the median incisions, but an 
 
 FIG. 245. Subperiosteal excision of upper jaw.
 
 1T4 
 
 OPERATIVE SURGERY. 
 
 external one is preferred by some (Fig. 245). The external incision is 
 made from the middle of the malar bone to a point on the upper lip, 
 one third of an inch from the angle of the mouth (Oilier). It is some- 
 times necessary to make a second incision from the middle of the lip 
 upward to the nose (dotted line, Fig. 245), as in the preceding oper- 
 ation. The mucous membrane 011 the external surface of the alveolar 
 process is divided down to the bone ; beginning at the line of junction 
 between the lateral incisor and canine teeth and carried backward to 
 and around the posterior molar to the inner surface of the alveolar 
 process, forward parallel with the external incision to a point opposite 
 the commencement of the external incision, then obliquely backward 
 and inward on a line corresponding to the intermaxillary suture of that 
 side, to the median line. The anterior extremities of the external and 
 internal incisions are now connected with each other by a transverse 
 incision, carried on a line extending between the lateral incisor and ca- 
 nine teeth. The periosteum is then peeled off from the external and 
 orbital surfaces of the bone, and also from the inner surfaces of the al- 
 veolar process, and the hard palate of that side. The nasal and malar 
 processes are divided as before, the canine tooth drawn, and the inter- 
 maxillary bone separated, together with the hard palate of the maxilla 
 to be removed, from the contiguous bone, by the chisel, saw, or for- 
 ceps. The maxilla is then twisted out, and the periosteum from the 
 inner and outer surfaces of the alveolar process united. 
 
 FIG. 246. Removal of both superior maxillae. 
 
 The superior maxillse may be removed simultaneously by either 
 of two methods. 1. Make an incision from each angle of tho mouth
 
 OPERATIONS OX BONES. 1Y5 
 
 to the middle of the malar bone on the respective sides (Fig. 246, a), 
 and dissect upward the intervening flaps ; or, 2, make a vertical one 
 (Fig. 246, b) along the ridge of the nose through the lip, beginning 
 at a point one fourth of an inch below the lower border of the orbit 
 (Dieffenbach). To this may be added a transverse incision one fourth 
 of an inch below, and extending to opposite the middle of each orbit, 
 across the upper end of the vertical incision (dotted line, Fig. 246) ; 
 the outer bony attachments are divided as in the single operation ; the 
 nasal processes are divided either by forceps or the saw, and both bones 
 removed at once not separately. In all operations for the complete 
 removal, the superior maxillary nerve should be divided as far back as 
 possible. The bones may be removed separately in the manner de- 
 scribed for the removal of a single superior maxilla. 
 
 Results. About thirty per cent die from whom both bones are 
 removed simultaneously. 
 
 Excision of the Inferior Maxilla. The operations on the lower jaw 
 require no additional instruments ; the precautions referable to the 
 patient are almost of equal importance, and the contiguous anatomy 
 is even more important than for the upper. The facial artery runs 
 beneath and across its lower border and on its outer surface at the 
 anterior border of the masseter muscle ; the parotid gland lies behind 
 the ramus, and often overrides it. The external carotid artery, as it 
 passes through the gland, is closely associated with -its posterior bor- 
 der. The internal maxillary artery runs closely behind and to the 
 inner side of the neck of the condyle. The inferior dental artery runs 
 along the inner surface of the ramus to enter its canal. The superior 
 division of the seventh pair of nerves passes across the outer border of 
 the neck of the condyle. Steno's duct passes across the masseter 
 muscle to its opening opposite the second molar tooth, on a line par- 
 allel with and about an inch below the lower border of the zygoma. 
 The lingual nerve runs along the inner surface of the ramus, close to 
 the bone just below the last molar tooth. 
 
 The genio-hyo-glossus muscle is attached to the superior genial 
 tubercles, and, if incautiously detached, will permit the tongue to fall 
 backward and close the glottis. It is very important, when possible, 
 to preserve the attachments of the muscles of mastication, on account 
 of their action on the resultant tissues. The operation may be directed 
 to a complete or partial removal of the bone. A partial removal may 
 include any fractional portion of it. 
 
 The incisions for the removal may be made within the mouth or 
 on the external surface. If the whole or a lateral half is to be re- 
 moved, an external incision must be made. The portion in front of 
 the molar teeth, and even in front of the ramus, can be excised by in- 
 ternal incisions alone ; the latter is, however, often attended by vex- 
 atious difficulties, and is hardly warrantable, except in selected cases.
 
 OPERATIVE SURGERY. 
 
 The ramus and portions of the body behind the teeth can be removed 
 through an external incision without opening into the buccal cavity, 
 provided the periosteum be carefully raised from its surface. In the 
 same manner the body, or any portion of it, may be taken away if the 
 teeth be absent. If the teeth be present, the periosteum may be care- 
 fully detached, and the bone with the teeth removed, after which the 
 openings of the buccal cavity, caused by the withdrawal of the teeth, 
 can be closed by sutures applied internally. If the jaw be the seat of 
 phosphoric or other necrosis, it may be gradually enucleated, through 
 an external opening, from its surrounding involucrum, by the indi- 
 rect method, and the teeth may even remain in the new growth. Un- 
 fortunately, however, when processes of a malignant nature call for 
 the operation, these conservative methods are of no avail, since the 
 operation must be directed to the removal of all the diseased tissues. 
 When possible, the incision in the buccal lining should be closed, and 
 the wound drained externally. This will keep the mouth clean, and 
 prevent swallowing the discharges. 
 
 Excision of the Central Portion. Pass a stout ligature through 
 the tongue well behind its tip, to prevent tearing out, and tie the ends 
 to form a loop, which will be convenient for keeping it from falling 
 backward. The assistant stands behind the head of the patient, holds 
 the loop firmly, at the same time compressing the facial arteries where 
 they pass across the jaw ; or seizes the lower lip at the angles between 
 the thumbs and fingers, rendering it tense, and at the same time arrest- 
 ing its circulation. The operator, standing in front, makes a vertical 
 incision through the median line down to the bone, extending to the 
 lower border of the symphysis mentis, raises the periosteum from its 
 surfaces, if practicable, to the extent of the proposed section, draws a 
 tooth at each point where the bone is to be divided, saws it at these 
 points, and draws the fragment forward and separates the attachments 
 of the muscles as closely as possible to their insertion. The flaps are 
 then united with silver wire, extending through the mucous membrane. 
 The vermilion border of the lip is carefully adjusted, and united with 
 pins or silver sutures. If the tongue fall backward, its severed mus- 
 cular attachments can be drawn forward, and connected with the in- 
 cision in the median line by a deep suture passed through the lip. 
 The bone can be easily reached through a curved incision made along 
 its lower border, or by an internal one corresponding to the fold of the 
 buccal membrane. The lip is depressed over the symphysis mentis, 
 and the bone is removed. 
 
 Excision of the Lateral Portion of the Body. Make an external 
 incision along the under border of the portion to be removed, down to 
 the bone. If necessary, the incision may be turned upward at a right 
 angle toward but not through the lip. If the condition of the parts 
 will permit, the periosteum is reflected off, the bone divided in front.
 
 OPERATIONS ON BONES. 
 
 177 
 
 external to insertion of the genio-hyo-glossus muscle, and if possible 
 turned outward, and the tissues separated back to the point of posterior 
 section ; it is then removed with a 
 chain-saw, and dressed as before. 
 Excision of Half of the Lower 
 Jaw. Commence the incision 
 about an inch and a half below 
 the arch of the zygoma, and carry 
 it downward along the posterior 
 border of the ramus, and beneath 
 the body of the jaw to the sym- 
 physis mentis, carefully exposing 
 the facial artery and tying it. 
 If the operation be for necrosis, 
 this incision will be sufficient ; 
 if for other disease, the lower lip 
 is cut perpendicularly through 
 its center to meet the longitudi- 
 nal incision (Fig. 247). The 
 bone is exposed in front by peel- 
 ing off the periosteum or other- 
 wise, and sawn through just to 
 the outer side of the insertion of 
 the genio-hyo-glossus muscle if 
 
 FIG. 247. Linear guide for removal of half 
 the lower jaw. 
 
 possible, the end pulled outward, and the remaining attached tissues 
 separated either by cutting or by a periosteotome, back to the begin- 
 ning of the incision. Depress the fragment forcibly, and if possible 
 
 detach the temporal 
 muscle with scissors 
 or the periosteotome, 
 then turn the bone 
 outward, and divide 
 the insertions of the 
 pterygoid muscles in 
 the same manner, care- 
 fully avoiding cutting 
 the lingual nerve, draw 
 the bone forward for- 
 cibly and twist it from 
 its socket (Fig. 248). 
 
 If it be impossible 
 to accomplish its re- 
 moval in this manner, 
 extend the incision up- 
 ward to the neck of the 
 
 FIQ. 248. Severin; 
 12 
 
 connections of inferior maxilla.
 
 178 OPERATIVE SURGERY. 
 
 bone (dotted line, Fig. 247), avoiding if possible the division of Steno's 
 duct and the cervico-facial branch of the seventh pair of nerves, and 
 enucleate the condyle. In this situation the condyle must be closely 
 followed, otherwise the internal maxillary artery may be injured, as it 
 passes immediately behind it. If the primary incision be sufficient to 
 expose the bone above the seat of the disease, it should be sawn through 
 at this point and the upper portion allowed to remain. 
 
 Excision of the Entire Lower Jaw. Remove the left half first, or 
 the right if it best suits the convenience of the operator, in the manner 
 before described. A ligature is then passed through the tongue, given 
 to an assistant, and the remaining half of the bone excised in a similar 
 manner. Arrest all hemorrhage, and close the wounds with sutures 
 in such a way as to accurately coaptate the divided buccal borders. 
 
 In all situations, when the nature of the disease will permit, the 
 periosteum should be reflected by a careful yet vigorous use of the 
 elevator. The insertions of ligaments and tendons will offer the only 
 obstacle, and these should be carefully detached by a sharp knife, that 
 a continuity of the periosteal and fibrous tissues may remain. 
 
 The periosteum in young subjects may reproduce enough bony 
 material to give a fair outline to the face and serve an important func- 
 tion in mastication. 
 
 If bone be not reproduced, the periosteum will furnish a firm 
 fibrous base, which may be utilized for artificial appliances. If the 
 anterior portion of either or both sides be removed, the gap may be 
 filled in by an artificial dental appliance, which will often happily 
 maintain the symmetry of the face and become useful in mastication. 
 
 Excision of the Alveolar Process. When the extent of the disease 
 will permit, the alveolar process can be removed down to the body of 
 the jaw through either an external or internal incision, the former be- 
 ing the better. The diseased part is then removed, and the wound closed 
 as before. After recovery, the body of the jaw will form an excellent 
 foundation for a compensatory dental appliance. Whenever the disease 
 is malignant, the periosteum should be removed with the bone, and care 
 taken that none of the diseased membrane remains in the wound. It is 
 also necessary in such cases to remove all associated structures when 
 diseased such as glands, floor of the mouth, and even the tongue itself. 
 
 Results. Out of two hundred and forty-six excisions in the con- 
 tinuity, forty-six died. Of one hundred and fifty-three disarticula- 
 tions of one half the bone, thirty-six died. In twenty operations for 
 removal of the entire jaw, one died. It will be seen that death has 
 followed in twenty per cent, of all the cases. Pyaemia, erysipelas, and 
 exhaustion were the principal causes. 
 
 Operation for Anchylosis of the Inferior Maxilla. This consists in 
 establishing a false joint in front of the cause of the immobility, which 
 is usually dependent on cicatricial contraction, irreducible dislocation,
 
 OPERATIONS ON BONES. 179 
 
 or anchylosis. The removal of a wedge-shaped piece from the lower 
 border of the jaw, or from the alveolar process, has been practiced ; 
 or a transverse section of the ramus with a sharp chisel introduced 
 through the mouth, or even fracture of the neck when the condyle is 
 involved, has relieved the condition. 
 
 Operation for Removal of a Wedge-shaped Piece (Esmarch). 
 Make an incision two inches in length down to the bone, along the 
 lower border of the jaw, beginning at or in front of its angle, depend- 
 ing upon the location of the cause of the immobility. Avoid or tie all 
 important vessels in the course of the incision ; expose both surfaces 
 of the bone up to the summit of the alveolar process, and pull a tooth 
 if necessary. Divide the bone with a chain-saw at one extremity of 
 the exposed surface, force the other extremity through the wound, and 
 remove the wedge-shaped piece with the rongeur or saw, the base of 
 which should not exceed a third or half an inch. While the patient 
 is still under the influence of the anaesthetic and before the wound is 
 closed, ascertain the distance the liberated portion can be separated 
 from the upper jaw with moderate force. Provide suitable drainage, 
 close the wound, and prevent union of the bones by passive motion. 
 
 Kizzoli, of Bologna, recommends a simple section of the bone in- 
 stead of the removal of a wedge-shaped piece ; however, the results of 
 this method do not warrant its substitution for the former. If the 
 cause of the immobility be due to anchylosis of the temporo-m axillary 
 articulation, the condyle should be removed, or the ramus be so di- 
 vided as not seriously to impair the functions of the masseter muscle, 
 that is, divided beneath that muscle. The division of the neck of the 
 bone by a straight chisel introduced through the mouth (Grube) has 
 been practiced. After either operation it may be necessary to divide the 
 masseter muscle before the full benefit can be experienced from the di- 
 vision or the removal of the bone. If it be determined to remove the 
 condyle, a curvilinear incision, corresponding to the location of the por- 
 tion of bone to be removed, is made down to it, when, by means of a 
 chisel, saw, or forceps, the neck of the bone is divided at the proper, 
 place, the fragment turned outward by forceps, its attachments divided, 
 and the bone removed. Passive motion should follow the same as before. 
 
 Excision of the Sternum. No definite plan for this operation can 
 be outlined. The form and length of the incisions must be governed 
 by the location and extent of the disease. The diseased bone should 
 be freely exposed, and removed in the usual manner. Care must be 
 observed, else the pleural cavity will be opened. When possible, sub- 
 periosteal excision should be done, as the bone is quite readily repro- 
 duced. The entire sternum is reported to have been removed by 
 Konig on account of a sarcomatous tumor involving its structure, and, 
 even though the pericardium and pleural cavity were opened, the pa- 
 tient ultimately recovered.
 
 130 OPERATIVE SURGERY. 
 
 Results. Partial excision, cautiously done, results most favorably ; 
 only one in eighteen died. 
 
 Excision of a Portion of a Rib. This may be done for the removal 
 of necrosed bone, or to make a permanent opening into the thorax for 
 the escape of pus. If for diseased bone, make an incision in the mid- 
 dle of the long axis of the rib of sufficient length to include the dis- 
 eased portion. This may be crossed at the middle by a transverse 
 incision. Separate the periosteum along with the superimposed tis- 
 sues, liberate the bone, and raise it from its bed. If the sequestrum 
 be not loose, time should be allowed for its separation. If the opera- 
 tion be for pyo-thorax, select the sixth or seventh rib ; make an incis- 
 ion in a line with the axilla about two or three inches in length down 
 upon the middle of the rib, through the periosteum ; bisect this by a 
 horizontal one of the width of the rib, expose the bone on both sur- 
 faces by raising the periosteum together with its surrounding tissues, 
 being careful as yet not to open into the pleural cavity ; exsect one 
 half or three fourths of an inch of the bone, dividing it with a chain- 
 saw. If the intercostal artery, which lies beneath its lower border, 
 be cut, tie it ; then make a suitable opening through the' intervening 
 structures into the pleural cavity. 
 
 It is well to make the first incision corresponding to the long axis 
 of the rib, and thus the more surely avoid the intercostal vessels and 
 nerves. The wound should bq dressed antiseptically. 
 
 Excision of the Clavicle. This operation is performed for necrosis 
 and for morbid growths of the clavicle. The patient is placed on the 
 back, with the shoulders elevated from the table and the head turned 
 to the opposite side. 
 
 Contiguous Anatomy. The muscular and ligamentous attachments 
 of the clavicle must be carefully studied, for it is by a knowledge of 
 them that the surgeon is enabled to raise the bone safely from its 
 more important relations. 
 
 In front. 
 
 Attachments of 
 Pectoralis major muscle. 
 Sterno-mastoid muscle. 
 Trapezium and deltoid muscles. 
 Above. 
 
 External jugular vein. 
 
 Branches of thyroid axis. i ) Below. 
 
 Subclavian artery. ( V1 ' J Cephalic vein. 
 
 Brachial plexus. 
 
 Behind. 
 
 Internal mammary artery sternal half. 
 Subclavian vein, " 
 
 External jugular vein. 
 Innominate vein at the right. 
 Thoracic duct at the left. 
 Pleura.
 
 OPERATIONS OX BOXES. 181 
 
 The intimate association of the clavicle to important arteries, 
 veins, nerves, etc., surrounds its removal with great difficulties and 
 dangerous complications ; especially, if it be attempted for a well- 
 developed malignant or other morbid growth. With the patient in 
 the proper position for the operation, the foregoing plan shows the 
 important anatomical relations of the clavicle. 
 
 The whole or a portion of the bone can be removed. If the whole 
 bone is to be removed, it may be raised by its scapular extremity, or 
 divided at its middle, and each half taken away separately. 
 
 Excision of the entire Clavicle. Anaesthetize and place the patient 
 in the position above described ; if the operation be for necrosis, make 
 an incision the whole length of the bone parallel with its long axis. If 
 necessary, a short transverse incision is added ; expose the clavicle, 
 divide the periosteum, and with the elevator enucleate the diseased 
 bone from the surrounding tissues. The clavicle can be divided 
 through the center and each half removed separately, or the acromial 
 end can be detached and the entire bone raised from without inward. 
 In either instance, the articular ends and their connecting ligaments 
 should be preserved if possible. 
 
 If the involucrum be weak and liable to bend or break after the 
 bone is removed, the shoulder must be held outward, backward, and 
 upward by means of the method employed in treatment of fracture of 
 that bone. The indirect method of sequestrotomy can be performed 
 in some instances. 
 
 If the operation be for the removal of a tumor of this bone, espe- 
 cially of one acutely malignant, and involving any considerable portion 
 of its surrounding tissues, it is certain to be an exceedingly tedious 
 and bloody procedure. 
 
 The smaller the size of the tumor and the less its vascularity, the 
 easier will be its removal. 
 
 Operation. Make an incision 'in the long axis of the bone, from 
 its sternal to its acromial extremity ; if necessary, this is crossed by a 
 vertical incision, extending from the posterior border of the sterno- 
 mastoid muscle to the upper third of the pectoralis major muscle. 
 Make these incisions as deep as the nature of the growth will permit, 
 and dissect the flaps from the tumor ; .separate the insertions of the 
 deltoid and the trapezius muscles on a director, cutting them either 
 with a knife or strong curved scissors, being careful to avoid the 
 cephalic vein which lies at the inner border of the deltoid muscle. 
 Divide the coraco- and acromio-clavicular ligaments ; raise the acro- 
 mial extremity of the clavicle, and thus elevate the morbid growth, 
 which should then be cautiously separated from the surrounding tis- 
 sues. The nearer the approach to the sternal extremity of the clavi- 
 cle, the greater will be the necessity for caution, since the growth may 
 be connected with the important structures located in this situation ;
 
 182 
 
 OPERATIVE SURGERY. 
 
 finally, divide the insertions of the sterno-mastoid and the pectoralis 
 major muscles, and rhomboid ligament, and carefully disarticulate the 
 sternal extremity while the tumor is lifted upward and inward to- 
 gether with the clavicle. 
 
 Either extremity of the clavicle may be excised by making a cru- 
 cial incision down to the bone corresponding to the portion to be 
 removed, exposing and dividing it with a chain-saw, and removing the 
 fragment with the same precautions as before described. 
 
 The results of the operation of complete excision have been quite 
 favorable ; of thirty-four cases, six proved fatal. Exhaustion, due to 
 loss of blood, erysipelas, etc., were the principal causes of death. 
 
 Partial excisions give a death-rate of about eight per cent from all 
 causes. 
 
 During the operation the entrance of air into the veins of the neck 
 is especially to be guarded against. 
 
 Excision of the Scapula. This bone is excised on account of gun- 
 shot injuries, necrosis, and morbid growths. 
 
 The whole bone may be removed, or its body, angles, and spine 
 may be removed separately. Its contiguous anatomy is extensive, but 
 not of the dangerous character of that associated with the clavicle. 
 To its spine, borders, and surfaces numerous and powerful muscles are 
 attached. 
 
 At the upper border are found the supra-scapular vessels and 
 nerves ; the posterior scapular artery passes down its vertebral bor- 
 der ; while at the axillary border the subscapular, and dorsalis scap- 
 ulas arteries, and even the axillary 
 artery itself, and the brachial plex- 
 us, are in close connection with the 
 bone. 
 
 Excision of the entire Scapula 
 (Fig. 249). Make an incision from 
 the tip of the acromion process along 
 the spine to the posterior border of 
 the scapula, a, b. Join it by a second 
 incision extending from near the 
 middle of the spine, c, to the inferior 
 angle of the bone; dissect up and 
 turn aside the flaps thus formed. 
 
 Divide the attachments of the 
 deltoid and trapezius ; disarticulate 
 the acromio-clavicular articulation ; 
 secure the subscapular artery ; divide 
 
 the ligaments and tendons around the glenoid cavity ; raise the cora- 
 coid process and carefully sever its ligaments and muscular attach- 
 ments ; raise the scapula by the inferior angle and divide its remain- 
 
 Em. 249. Excision of entire scapula.
 
 OPERATIONS ON BONES. 
 
 183 
 
 ing muscular attachments with a knife or strong pair of scissors, care- 
 fully avoiding the subscapular and posterior scapular vessels ; tie all 
 the bleeding points ; wash with an antiseptic solution ; thoroughly 
 drain and close the wound, and dress antiseptically. Sir "W. Fergu- 
 son and Mr. Pollock thought it better to raise the vertebral border of 
 the scapula first, that the subscapular artery might be the better con- 
 trolled. Spence thought that the anterior angle should be raised first, 
 the better to control the subclavian artery. All danger of hemorrhage 
 during the operation is easily obviated by pressure on the subclavian 
 artery above the clavicle by means of a short crutch or a large key, 
 also by direct pressure on the subclavian after the anterior angle of 
 the scapula is elevated. 
 
 The results of this operation are good. Of sixty-six cases of com- 
 plete excision, fourteen died. The 
 rate of mortality from the opera- 
 tion is about eight per cent ; it is 
 greater when due to traumatic 
 causes than when due to disease. 
 
 Excision of the Body of the 
 Scapula (Fig. 250). Make an in- 
 cision the whole length of the 
 spine, a, b ; begin a second incis- 
 ion at the posterior superior spine, 
 and carry it along the posterior 
 border of the bone to its inferior 
 angle, c, d ; dissect the resulting 
 triangular flaps from their corre- 
 sponding fossae, carefully avoiding 
 the supra - scapular artery and 
 nerve ; saw through the acromion 
 process close to the body, divide 
 the muscles attached to the anterior and superior borders of the 
 scapula ' raise the bone upward and saw through the anterior superior 
 angle behind the coracoid process, turn the bone outward and sever 
 its posterior connections with a knife or strong scissors. 
 
 The Acromion Process and Angles of the Scapula may be sepa- 
 rately removed. To remove the former, make an incision, which 
 may be curved if necessary, along its upper border expose the 
 process, divide the muscles attached to it, and with a pair of 
 bone-forceps remove the desired amount. This process can be re- 
 moved by making a curved or crucial incision over it ; exposing its 
 upper surface, dividing the muscles connected therewith, disarticulat- 
 ing the clavicle, and removing the requisite amount with a chain- 
 saw. 
 
 To remove an angle, make a V-shaped incision over it, dissect off 
 
 FIG. 250. Excision of body of scapula.
 
 184 
 
 OPERATIVE SURGERY. 
 
 FIG. 251. Subperiosteal excision. 
 
 the flaps, separate the muscles from the bone, and divide the exposed 
 portion with the bone-forceps. 
 
 Subperiosteal Excision of the Scapula (Oilier) (Fig. 251). Make 
 an incision from the outer extremity of the acromion process along the 
 
 spine of the scapula to its posterior 
 border, a, b. Make a second in- 
 cision from the posterior superior 
 angle of the scapula along its poste- 
 rior border, crossing the former, to 
 the inferior angle, c, b, d. Sever 
 the muscular attachments to the 
 acromion process and spine ; divide 
 the periosteum at the posterior 
 border of the scapula between the 
 attachments of the rhomboideus 
 major and infra-spinatus muscles, 
 and separate it from the infra- spi- 
 nous fossa. Remove the muscular 
 attachments of the superior border 
 of the scapula. The periosteum is 
 then raised from the supra-spinous 
 fossa, being careful to not injure the supra-scapular vessels, as they 
 pass in close contact with the supra-scapular notch ; disconnect the 
 muscles attached to the borders of the scapula, closely hugging the bone; 
 raise it upward by its inferior angle, denude the subscapular fossa, 
 leaving its periosteum connected with the subscapularis muscle ; lib- 
 erate the posterior border, allowing its cartilaginous portion to remain 
 when present. Turn the bone upward and forward, and remove 
 the remaining periosteum from its under surface up to the neck of the 
 scapula, and divide the neck with the chain-saw. If the extent of the 
 disease will not permit this, the neck can be enucleated, leaving the 
 ligaments connected with the periosteum. 
 
 Excision for Malignant Growths. Make an incision from the pos- 
 terior superior angle to the lower border of the tumor, carrying it 
 downward, forward, and inward, with the convexity posteriorly. A 
 second incision, beginning five inches or so in front of the preceding 
 incision, is carried downward and backward, crossing the other at or 
 near its middle, and terminating at the lower border of the growth. 
 The flaps are then reflected from the tumor, and the muscular at- 
 tachments are separated from the spine of the scapula, and the acro- 
 mion process sawn through behind the clavicle ; expose the su- 
 perior and posterior borders of the scapula, and free them of their 
 attachments ; raise the bone upward and forward by its posterior 
 border, and sever the serratus magnus muscle from it ; free the 
 axillary border, and divide the neck of the bone with a saw, if prac-
 
 OPERATIOXS OX BOXES. 
 
 185 
 
 ticable. When necessary, complete the entire removal by disarticula- 
 tion. 
 
 It is not possible to lay down definite rules to govern the number, 
 extent, or direction of the incisions ; each of these must depend on 
 the size and situation of the growth, together with the amount of 
 bone to be removed, and the ease and safety with which it can be 
 done. After the removal, arrest hemorrhage, provide good drainage, 
 unite the cut surfaces, and dress antiseptically. 
 
 The results of the operation are nattering : nineteen per cent died 
 from entire removal of the scapula due to disease. The mortality was 
 twenty-six per cent in partial excisions for disease, and about twenty 
 per cent when done for injury. 
 
 Excision of the Humerus. The humerus can be removed entirely 
 or in part. 
 
 The Important Associated Anatomy. The insertions of the mus- 
 cles acting upon the upper end of the bone, the course of the superior 
 profunda and circumflex arteries, the relations of the circumflex, 
 musculo-spiral, and ulnar nerves ; the points of insertion of the liga- 
 ments of the joints, together with the 
 connections of the important muscles, 
 must be carefully considered before 
 attempting the operation. This oper- 
 ation has been done for the relief of 
 old dislocations, caries, necrosis, gun- 
 shot injuries, arthritis, malignant dis- 
 ease, etc. 
 
 Excision of the Upper End of the 
 Humerus (Langenbeck). Place the 
 patient upon the back, with the shoul- 
 ders raised ; make an incision about 
 four inches in length downward from 
 the anterior border of the acromion 
 process, close to its articulation with 
 the clavicle, in the line of the bicipi- 
 tal groove (Fig. 252). The bone at 
 this region is quite superficial ; liber- 
 ate the long head of the biceps tendon 
 from the groove, by carrying the point 
 of the knife upward in the groove at 
 the outer side, through the capsule to 
 the acromion, and raise the tendon out 
 of the groove (Fig. 253) ; rotate the FIG. 252. Excision of upper end of 
 arm outward and divide the subscapu- humerus. 
 
 laris tendon and inner portion of the 
 capsule ; then rotate the arm inward, and cut the external rotators
 
 186 
 
 OPERATIVE SURGERY. 
 
 and posterior portion of the capsule (Fig. 254) ; force the head of the 
 bone through the opening in the soft parts (Fig. 255), seize it with a 
 strong pair of forceps, divide the inferior portion of the capsule, and 
 remove the head of the bone with a chain- or a small straight saw. 
 
 b - 
 
 -d 
 
 FIG. 253. Rai.sin<r tendon. 
 
 FIG. 254. Attachments to tuberosities of humerua. 
 a. Tcrcs minor muscle, b. Infra-spinatus mus- 
 cle, c. Supra-spinatus muscle. d. Subscapu- 
 laris muscle, f. Tendon of long head of biceps 
 muscle in the groove. 
 
 Subperiosteal Excision of Head of 
 Humerus (Langenbeck). Expose the 
 bicipital groove and split up the capsu- 
 lar ligament as in the preceding opera- 
 tion. Divide and raise the periosteum 
 from the inner border of the bicipital 
 groove, passing inward and separating it together with the subscapu- 
 laris and the fibrous capsule from the lesser tuberosity. Eotate the 
 humerus outward and complete the separation to the required extent 
 with the elevator and knife ; rotate the arm inward, displace the ten- 
 don of the biceps to the inner side of the head of the humerus, and 
 separate the periosteum from it in connection with the capsule and 
 the insertions of the external rotators, being very careful not to sever 
 its connection with the bone below. To force the head of the bone 
 
 FIG. 255. Sawing head of hu- 
 merus.
 
 OPERATIONS ON BONES. 
 
 187 
 
 through the external opening is practically impossible without de- 
 stroying the periosteal connections ; it is necessary, therefore, to divide 
 the bone in its position with a chain or nar- 
 row-bladed suw. 
 
 Partial removal of the upper extremity of 
 the humerus is often necessary on account of 
 disease or injury. The variety and extent of 
 the incisions to reach the part must be gov- 
 erned by the amount of the disease. 
 
 Either the vertical, V-or U-shaped incision 
 can be selected as best suits the exigencies of 
 the case. 
 
 Excision of the Glenoid Angle of the Scap- 
 ula. This operation is only applicable to 
 those conditions of injury or disease that are 
 limited to the glenoid articular surface of the 
 scapula. If a penetrating wound exist, its 
 course should be followed to reach the bone ; 
 if not, then a curved incision is made around 
 the posterior border of the acromion process 
 dividing the fibers of the deltoid, and expos- 
 ing the posterior and upper surface of the 
 joint (Fig. 256). A second incision is then 
 made, commencing at the center of this one, 
 at the upper margin of the glenoid cavity, 
 and, passing downward through the capsule, 
 
 upon the center of the greater tuberosity, between the tendons of 
 the supra- and infra-spinatus muscles through the deltoid in the di- 
 rection of its fibers. Open the wound widely by means of retractors 
 and divide the tendons of the biceps at their origin ; separate the 
 periosteum from around the neck of the scapula, if possible leaving 
 the attachments of the capsular ligaments. Cut through the exposed 
 bone with a chain-saw, and remove it carefully to avoid injury to the 
 periosteum. 
 
 Excision of the Shaft of the Humerus. In this operation, unless 
 great caution is observed, the musculo-spiral nerve and the superior 
 profunda artery will be injured in their course along the rnusculo- 
 spiral groove, as well also as the circumflex nerves and vessels, if the 
 incision be extended (Fig. 257) upward too far. The upper portion of 
 the shaft is easily exposed by making an incision of sufficient length 
 through the outer surface of the deltoid, commencing at its lower 
 third and dividing it carefully upward, to avoid the circumflex nerve 
 and artery ; the bone is then denuded of its periosteum, or the morbid 
 growth connected with it is circumscribed and removed. If the lower 
 portion of the shaft is to be operated upon, make the incision along 
 
 FIG. 256. Excision of gle- 
 noid angle.
 
 188 
 
 OPERATIVE SURGERY. 
 
 the outer border of the brachialis anticus muscle, carefully avoiding 
 the musculo-spiral nerve ; expose the bone and remove it as before. 
 
 b 
 
 FIG. 257. Musculo-spiral and circum- 
 flex nerves. 
 
 FIG. 258. Relation of ulnar nerve 
 to elhow-joint. a. Inner condyle 
 of humcrus. b. Ulnar nerve, c. 
 Olccranon process. 
 
 Excision of the Lower Extremity of the Humerus. The relation 
 of the ulnar nerve (Fig. 258, b} to the internal condyle, a, and of the 
 brachial artery to the anterior surface, must not be forgotten. Make 
 an incision on the posterior and external surface of sufficient length to 
 thoroughly expose the bone ; elevate the periosteum and divide the 
 bone with a chain-saw ; pull the upper end of the fragment down- 
 ward and disarticulate it from without inward. 
 
 If it be necessary to remove the entire humerus, make incisions as 
 if to remove the upper and lower portions, observing the same precau- 
 tions relative to the anatomy of these parts. The musculo-spiral 
 nerve in this operation is to be most cautiously avoided. 
 
 In all the preceding operations, substantially the same after-treat- 
 ment is required : arrest the hemorrhage, irrigate the exposed surfaces 
 with an antiseptic solution, provide drainage, close the lips of the 
 wound, envelop the entire limb with antiseptic dressing, and place it
 
 OPERATIONS ON BONES. 
 
 189 
 
 1)1 
 
 upon a splint affording an easy support at the 
 proper angle. Extension is often necessary to 
 maintain the limb at a suitable length during the 
 healing process. 
 
 The results depend much upon the nature of 
 the injury, the period of the operation, and the 
 employment of antiseptics. Of gun-shot wounds 
 of the shoulder-joint requiring excision, about 
 thirty-five per cent die ; the rate of mortality be- 
 ing increased when the inflammatory stage exists 
 at the time of operation. When excised for dis- 
 ease eighty-two per cent recovered, of which the 
 limb was useful in three fourths of the cases. 
 Thorough antisepsis will lessen this death-rate at 
 least fifty per cent. 
 
 Excision of the Elbow-Joint (Hitter). With 
 the forearm extended make a slightly curved in- 
 cision about an inch in length down upon the tip of the internal 
 condyle, and carefully separate the muscular and ligamentous at- 
 
 FIG. 259. Hiker's in- 
 cision. 
 
 FIG. 260. Ligaments of elbow-joint. 
 
 FIG. 261. Langcn- FIG. 262. Liston'a 
 beck's incision. incision. 
 
 tachments to the condyle ; make a 
 second longitudinal incision from three 
 to four inches in length down to the 
 head of the radius (Fig. 259). Draw 
 aside the soft parts and cut the exter- 
 nal lateral and orbicular ligaments (Fig.
 
 190 OPERATIVE SURGERY. 
 
 260). Expose the head of the radius and cut it off with a saw or 
 bone-forceps. Separate the capsular ligament from its attachments 
 on the anterior and posterior surfaces of the humerus ; force the ex- 
 tremity of the bone out of the external wound. This movement 
 admits of its division, and at the same time raises the ulnar nerve 
 from its bed and away from the bone. Saw off the lower end of the 
 humerus, and carefully expose and remove the olecranon. 
 
 Subpcriosteal Excision of Elbow- Joint (Langenbeck). Make a lon- 
 gitudinal incision down to the bone, three or four inches in length, a 
 little to the inner side of the middle of the olecranon process, about two 
 thirds of its length extending below the tip of the olecranon, carefully 
 avoiding the ulnar nerve (Fig. 261). Eemove the periosteum from the 
 portion of the olecranon process and ulna at the inner side of the incis- 
 ion. Separate by short parallel incisions the attachments of the inner 
 half of the triceps tendon to the olecranon process. Push the tissues 
 at the internal condyle, together with the ulnar nerve, inward toward 
 the tip of the condyle, and elevate the periosteum from the inner con- 
 dyle sufficiently to separate the internal lateral ligaments and the at- 
 tachments of the muscles from the bone, and leave them connected 
 with the periosteum. The liberated tissues are now permitted to 
 return to their former position, and the outer portion of the tendon 
 of the triceps is drawn outward and disconnected from the olecranon 
 process by short transverse incisions, closely hugging the bone and 
 allowing it to remain continuous with the periosteum which is reflect- 
 ed upon the inner surface of the olecranon and shaft of the ulna ; 
 expose the external condyle by separating the capsular ligament at its 
 attachment, above the trochlea and capitulum ; the tissues, including 
 the detached periosteum and tendon of the triceps, are separated well 
 from the bone by retractors. Flex the forearm and force the extremi- 
 ties of the bones through the opening ; saw off the head of the radius, 
 then the lower end of the humerus, and finally the- olecranon process. 
 It is necessary to remember in all cases of excision about the elbow- 
 joint, to respect the insertions of important muscles, such as those of 
 the brachialis anticus, biceps, triceps, etc. To unnecessarily destroy 
 the power of one of these, is to be guilty of an unpardonable oversight. 
 Variously formed incisions, other than the longitudinal, have been 
 employed ; as the H, with the horizontal portion corresponding to the 
 articulation ; the T, with the horizontal on a line with the condyle ; 
 U-shaped or semilunar, with the convexity downward. 
 
 Excision of the Elboiv-Joint by the I Shaped Incision (Liston, Fig. 
 262). Flex the elbow to an obtuse angle, the operator facing its pos- 
 terior surface, open the capsule between the olecranon process and In- 
 ternal condyle by a longitudinal incision about four inches in length 
 along the inner border of the olecranon, dissect and draw the soft 
 parts over the internal condyle with the thumb (Fig. 263), increasing
 
 OPERATIONS ON BONES. 
 
 191 
 
 the flexion gradually till the condyle is fully exposed, divide the in- 
 ternal lateral ligament, extend the arm and carry a transverse incision 
 
 FIG. 263. Exposing internal condyle. 
 
 from the point of articulation of the radius with the humerus directly 
 across to the center of the former incision. 
 
 The periosteum on the inner surface of the olecranon process and 
 ulna is raised and left connected with the tendon of the triceps, which 
 is carefully separated from the bone. Open the flaps wide and divide 
 the external lateral ligament, flex the forearm, and the articular sur- 
 faces will separate. Seize and saw off the lower extremity of the 
 humerus, the olecranon process, and finally the head of the radius. 
 
 Results. Excision of the elbow-joint has been performed with 
 such good success that its high rank is thoroughly established. Al- 
 though when due to injury the rate of mortality is about twenty per 
 cent, when due to disease it is less than eleven per cent. Partial excis- 
 ions are followed by better results, so far as motion is concerned, than 
 complete excisions.
 
 192 OPERATIVE SURGERY. 
 
 It would appear that the saving of the synovial membrane exerts a 
 more conservative influence upon the usefulness of the joint than the 
 saving of bone ; provided, of course, that the bony insertions of the 
 muscles acting directly upon the joint be respected. The amount of 
 bone removed will determine the usefulness of the joint. If too little, 
 the movement will be limited and insufficient ; if too great, it will 
 dangle, and be of little use except for prehension. If the operation be 
 for traumatism, remove the fragments ; if for disease, remove the dis- 
 eased portion ; in both conditions trim the extremities of the bones so 
 as to afford symmetrical support to opposed bony surfaces. The wounds 
 should be washed with a suitable antiseptic solution, closed with proper 
 drainage, dressed antiseptically, and kept extended until repair is be- 
 gun ; when the limb should from time to time be placed at various 
 angles for a day or so. By this course the newly formed tissue will 
 thereafter conform more readily to the various movements of the joint. 
 
 Excision of the Ulna. An incision is made along its posterior sur- 
 face of sufficient length to expose the diseased bone, the periosteum 
 is pushed aside, and section is made at the requisite point and the dis- 
 eased bone is removed. 
 
 If it be a partial excision of its upper extremity, expose that por- 
 tion by an incision in the same line, as for removal of the entire bone, 
 elevate the periosteum, leaving, if possible, the attachments of the 
 brachialis anticus and triceps muscles, and avoid the ulnar nerve, at 
 the inner condyle. 
 
 Excision of the Radius. Make an incision, extending from the 
 styloid process of the radius, along the outer border of the anterior 
 surface of the forearm to the radio-humeral articulation, through the 
 integument and fascia. Seek the outer border of the supinator longus, 
 pass upward, separating it from the flexor longus pollicis, and going 
 down to the bone, divide the supinator brevis, also the periosteum in 
 the long axis of the radius ; elevate the periosteum ; divide the bone 
 in the center, and remove each half separately. The insertion of the 
 biceps and pronator radii tores should be carefully preserved. If an 
 extremity of the bone is to be excised, expose the portion to be re- 
 moved by an incision made in the same line as the preceding ; raise 
 the periosteum with equal caution, and remove the diseased portion. 
 
 The results of this operation are good ; a patient seldom dies, and 
 fair use of the extremity is secured. 
 
 Excision of the Lower Extremities of the Bones of the Forearm 
 (Bourgary). Make an incision two inches in length along the inner 
 border of the ulna on the dorsal surface, from just below the apex of 
 the styloid process (Fig. 264). Divide the periosteum at the inter- 
 space between the extensor and flexor carpi ulnaris muscles in the 
 same line, and reflect it from the dorsum of the bone inward to the 
 interosseous membrane. A second longitudinal incision is made along
 
 OPERATIONS OX BONES. 
 
 193 
 
 the outer side of the radius from just be- 
 low the apex of the styloid process two or 
 three inches upward ; the periosteum is 
 divided through the same incision, the at- 
 tachment of the supinator longus sepa- 
 rated, and the periosteum raised on the 
 dorsal surface together with the sheaths 
 of the extensor tendons. 
 
 The periosteum is then elevated from 
 the like portions of 'the palmar surface 
 of the lower ends of both bones around to 
 the interosseous membrane. Protect the 
 soft parts carefully while the bones are 
 being sawn through. The operation can 
 be extended to the bones of the carpus if 
 necessary, by continuing the lateral incis- 
 ions downward. 
 
 Excision of the Wrist-Joint This 
 joint properly consists of the radius, ar- 
 ticulated with the outer two of the first 
 row of carpal bones. In cases where ex- 
 cision is necessary, it is not usual to find 
 the disease or injury limited entirely to 
 these structures. It, therefore, becomes 
 necessary to remove all bony structures 
 involved, even though they include the 
 
 two rows of carpal and the contiguous extremities of the metacarpal 
 
 bones. The intimate relation exist- 
 ing between the carpal bones and 
 the continuity of their synovial sur- 
 roundings, renders tjhem especially 
 liable to progressive disease as well 
 as to inflammatory processes (Fig. 
 265). They are intimately bound to- 
 gether by strong ligaments admit- 
 ting of but limited movement be- 
 tween their surfaces (Figs. 266 and 
 267). Since these bones are in close 
 relation to the tendons of important 
 muscles, the sheaths of which should 
 be scrupulously preserved together 
 with themselves, this operation is 
 surrounded with difficult and tedi- 
 ous details. 
 
 FIG. 265. Synovial membranes of carpus. All diseased or detached bone 
 13 
 
 FIG. 264. La eral incisions.
 
 194 
 
 OPERATIVE SURGERY. 
 
 should be removed. If a portion of a carpal bone be diseased, it is 
 better that the entire bone be removed. The insertions of all muscles 
 acting on the carpus should be preserved, if possible. 
 
 FIG. 206. Ligaments of dorsal surface 
 of carpus. 
 
 FIG. 267. Ligaments of palmar surface 
 of carpus. 
 
 A tendon is not to be divided, except it forms an insurmountable 
 obstacle to the incision necessary to the removal of the bones, and it 
 should afterward be sutured. If the tendons be divided at a distance 
 from the immediate seat of the operation, and subsequently sutured, 
 the chances of union will be enhanced. The radial and ulnar arteries 
 and the branches associated with the carpus should be cautiously 
 avoided. 
 
 Complete Excision of the Wrist-Joint (Langenbeck). Place the 
 forearm and hand of the patient with the palm downward on a table 
 of convenient height for the operator and his assistant. An incision is 
 then made through the integument, beginning at the middle of the 
 metacarpal bone of the index-finger at its ulnar border, and extending 
 longitudinally to three fourths of an inch above the lower extremity 
 of the radius, at its middle (Fig. 268). The deeper course of the in- 
 cision passes to the radial side of the extensor indicis without opening 
 its sheath, upward, over the tendon of the extensor carpi radialis 
 brevior, to the inner side of its insertion ; then, if the tendons going 
 to the index-finger be pushed to the ulnar side, the incision extends 
 upward to the beginning of the tendons of the extensor secundi inter- 
 nodii pollicis and the extensor indicis, dividing the lower portion of 
 the posterior annular ligament. Draw the tissues apart with suitable 
 retractors and separate from the bone with a periosteal elevator the
 
 OPERATIONS ON BONES. 
 
 195 
 
 -b 
 
 fibrous sheaths of the extensors of the carpus on the posterior surface 
 of the radius ; the insertion of the supinator longus muscle, and the 
 annular and capsular 
 ligaments are then dis- 
 connected and drawn 
 to the radial side to- 
 gether with the perios- 
 teum; the tendons, liga- 
 ments, and periosteum 
 on the posterior surface 
 of the ulna are sepa- 
 rated in the same man- 
 ner and drawn to the 
 ulnar side. Open well 
 the radio-carpal joint, 
 flex the carpus and ex- 
 pose the articular sur- 
 faces, and separate the 
 bones of the first row 
 from their connection 
 with each other, leaving 
 the periosteum if pos- 
 sible. Liberate the sca- 
 phoid from the trape- 
 zium and trapezoid, 
 the semilunar from the 
 os magnum, and the 
 cuneiform from the un- 
 ciform ; lift them out, 
 leaving their perios- 
 teum if possible to- 
 gether with the trape- 
 zium and pisiform 
 bones. The bones of the second row are taken out after severing the 
 connections between the trapezium and trapezoid, and the heads of 
 the metacarpal bones. The extremities of the radius and ulna can 
 now be forced through the wound, carefully exposed and sawn off, 
 avoiding the radial and ulnar vessels. The divided tendons should be 
 sutured and the resulting wound treated by antiseptic measures. Con- 
 tinuous extension from the fingers should be early and constantly em- 
 ployed during the after-treatment. 
 
 There are other incisions intended to meet the indication- (Lis- 
 ter) : Begin the incision on the dorsal aspect of the radius, opposite the 
 styloid process, and carry it toward the inner side of the metacarpal 
 articulation of the thumb parallel with the secundi internodii pollicis 
 
 FIG. 268. a. Extensor carpi radialis longior. b. Extensor 
 longus pollicis. c. Extensor carpi radialis brevior. d. 
 Posterior annular ligament. /. Langenbeck's incision.
 
 196 
 
 OPERATIVE SURGERY. 
 
 FIG. 2G9. Lister's incisions. 
 
 tendon (Fig. 2C9, a). When at the radial border of the second meta- 
 carpal bone, carry the incision along one half the length of that bone ; 
 
 separate the soft parts on the ra- 
 dial side, divide the tendon of 
 the extensor carpi radialis longior 
 at its insertion, raise it, together 
 with the extensor carpi radialis 
 brevior and secundi internodii 
 pollicis tendons, open the wound 
 well, and disconnect the trapezi- 
 um from the remaining bones, 
 which are to be taken away. Ex- 
 tend the carpus and separate the 
 soft parts on the dorsum at the 
 ulnar side of the incision. 
 
 Make a second incision along 
 the anterior and internal border 
 of the forearm on the inner side 
 of the flexor carpi ulnaris, begin- 
 ning it about two inches above 
 the styloid process and extending 
 it to the middle of the metacar- 
 pal bone of the little finger (Fig. 
 
 269, V). Expose the dorsum of the ulna, divide the tendon of the ex- 
 tensor carpi ulnaris at its insertion, separate it from the groove in the 
 ulna, raise the extensors of the fingers from the carpus, leaving their 
 attachments to the radius intact ; expose the anterior surface of the 
 ulna, hugging the bone closely ; separate the pisiform bone with the 
 flexor carpi ulnaris ; flex the hand and separate the flexor tendons in 
 the same cautious manner ; divide the remaining ligaments connecting 
 the bones of the forearm with the carpus ; separate the process of the 
 unciform bone, also the carpus from the metacarpus with cutting for- 
 ceps ; expose the extremities of the radius and ulna through the ulnar 
 incision, remove with the saw or forceps the diseased portions, care- 
 fully avoiding the grooves for the passage of the tendons ; remove the 
 trapezium without injury to the tendon of the flexor carpi radialis. 
 All articular surfaces of bones metacarpal bones, pisiform, and be- 
 tween lower extremities of radius and ulna should be removed, as 
 well as all diseased portions of bone. Many other incisions may be 
 made through which to effect the removal of the wrist-joint ; but only 
 such as admit of it being done through longitudinal incisions are ad- 
 visable, since transverse incisions may sacrifice the tendons which im- 
 part usefulness to the remaining portion of the carpus. 
 
 All hemorrhage having ceased, suture the divided tendons, close 
 the wound, allowing the most dependent incision to remain open for
 
 OPERATIONS ON BONES. 197 
 
 drainage. Envelop the limb in antiseptic dressings, causing the whole 
 to be properly supported by a splint. The subsequent treatment con- 
 sists in cleanliness, extension, and passive motion. 
 
 Results. Ten per cent die after excision for disease, and fifteen 
 per cent for gun-shot injuries without antiseptic treatment. In about 
 thirty-three per cent of those who recover, the operation has been of 
 no service ; in about eleven per cent, entirely satisfactory ; in the re- 
 mainder, useful. The prognosis for usefulness is better when excision 
 is performed for injury than for disease. 
 
 Excision of the Metacarpo-phalangeal Joints. This operation can 
 readily be done by making an incision about one inch and a half in 
 length at one side of the extensor tendons and along the dorsum of 
 the bones composing the joint. The tissues in contact with the bone 
 are carefully raised and turned aside, the joint exposed, and the re- 
 quisite amount of bone removed by the chain-saw, cutting forceps, or 
 dental engine. 
 
 Excision of the Phalangeal Joints. These articulations may be ap- 
 proached either through a longitudinal incision made along the side 
 of the joint, or by a curved incision at the same situation with the 
 convexity downward. In either instance separate the tissues carefully 
 down to the extremities of the bones, which, when properly exposed, 
 can be caused to protrude through the incision by lateral flexion and 
 the extremities can then be removed. 
 
 The after-treatment consists in placing the fingers in an immov- 
 able position properly protected by an antiseptic dressing, and when 
 repair begins passive motion is made and continued until the recovery 
 is complete. 
 
 Excision of the Joints of the Lower Extremities. The phalangeal 
 joints of the tarsus are removed in a similar manner to those of the 
 upper extremity. 
 
 The Metatarso-phalangealJoints are removed through longitudinal 
 incisions, made over the dorsal surface of the bones constituting the 
 joints, at either side of the extensor tendons, which are pushed aside 
 together with the remaining surrounding soft parts, the bones ex- 
 posed, and their extrem- 
 ities severed by the chain- 
 saw or bone-forceps. The 
 removal of the metatarso- 
 phalangeal articulation 
 of the great toe can be 
 and often is done by a 
 different method. Make 
 a curved incision with 
 the convexity downward, 
 of sufficient length to FIG. 270. U-shaped incision.
 
 198 OPERATIVE SURGERY. 
 
 freely expose the bones to be removed, at the inner side of the joint, 
 its center corresponding to the joint center (Fig. 270). Dissect the 
 soft parts from around the bones, carefully pushing aside the tendons ; 
 expose and remove the necessary amount of the articulation with a 
 chain-saw or forceps. If the operation be done for the correction of 
 the deformity caused by prominence of the head of the metatarsal 
 bone, enough bone should be removed from its extremity to permit 
 the easy return of the displaced toe to its natural position ; where it 
 is to be retained quietly till repair is well advanced, and then passive 
 motion is to be commenced. 
 
 The Tarso-metatarsal Joints can be excised through a straight in- 
 cision or by raising a semilunar flap over their dorsal surfaces, avoid- 
 ing division of the extensor tendons, which are raised and pushed 
 aside, while the dorsal ligaments connecting the bones are divided and 
 the joint cavity exposed by forced flexion, after which the bones of 
 the distal row can be divided with a saw or bone-forceps. The corre- 
 sponding extremities of the tarsal bones can be treated likewise. 
 
 Tar sal Joints. When separate tarsal joints become involved by 
 disease or traumatic violence, they can be removed by making an in- 
 cision over the injured or diseased portions, often following in the 
 line of the course of the violence, or in the tracks of sinuses leading 
 from the disease. 
 
 This treatment is, however, better adapted to those joints having a 
 limited synovial membrane, than to those where that membrane ex- 
 tends between several contiguous bone surfaces ; in the latter case it 
 is often better to remove the bones entire by aid of the chisel, saw, or 
 gouge. In either instance curved incisions are preferable, provided 
 they do not divide important tendons and vessels. 
 
 Excision of the Calcaneum. It is important that as much as pos- 
 sible of this bone be saved, as it forms the posterior pillar of the arch 
 of the foot, and also gives attachment to the tendo Achillis, which 
 exerts a powerful influence in locomotion. When gouging fails to 
 remove the diseased bone, excision becomes the final resort. A horse- 
 
 FIG. 271. Excision of os calcis. 
 
 shoe-shaped incision is begun a little in front of the calcaneo-cuboid 
 articulation and carried around the base of the os calcis along the side
 
 OPERATIONS OX BONES. 
 
 199 
 
 of the foot to a corresponding point on the opposite side. This flap, 
 with the knife hugging the bone, is dissected up, exposing the entire 
 under surface of the os calcis (Fig. 271). A second perpendicular in- 
 cision about two inches in length is then made through the middle of 
 the tendo Achillis down to the preceding one ; the resulting flaps are 
 dissected off close to the bone, and the posterior articulation between 
 the calcaneum and the astragalus opened, the ligamentous connections 
 severed, together with those between it and the contiguous bones, the 
 os calcis taken away, and any additional diseased bone removed. 
 
 Results. A large majority of these cases recover with useful 
 limbs. 
 
 Excision of the Astragalus. This is accomplished through a semi- 
 lunar opening, with the convexity downward, extending between the 
 malleoli in front. The tendons of the extensor muscles must be care- 
 fully pushed aside ; its ligamentous connections with the tibia, fibula, 
 and os calcis are severed, finally, those with the scaphoid ; then, with 
 the foot extended, the bone is pulled from its site and the calcaneum 
 placed in the resulting gap between the malleoli. 
 
 Results. About seventy-five per cent of these cases recover with 
 useful limbs. 
 
 Excision of the Ankle-Joint. This articulation is a hinge-joint, 
 having no lateral movement, except the foot is well extended, and 
 then it is very limited. The indications calling for the operation are 
 numerous, and should be well considered before it is attempted. As 
 in all excisions those incisions which best preserve the tendons, ves- 
 sels, nerves, and periosteum are to be adhered to, consequently those 
 of a longitudinal character are the best to be employed. 
 
 Operation, Subperiosteal (Langenbeck). Make an incision, about 
 three inches in length, along the posterior border of the lower extrem- 
 ity of the fibula down to the bone (Fig. 272), carrying it forward in a 
 hooked shape around the lower end 
 and then upward along its ante- 
 rior border about an inch. The 
 periosteum is reflected from the 
 bone together with the tissues in 
 contact with it, thereby exposing 
 the lower extremity of the fibula 
 without opening the tendinous 
 grooves of the peronei muscles 
 (Fig. 273). The fibula is then di- 
 vided at the upper end of the in- FIG. 272. Excision of ankle-joint, 
 cision with a narrow saw, pulled 
 
 outward, and the ligamentous attachments along its inner border and 
 surfaces severed (Fig. 274), and the bone removed. An incision is 
 then made about an inch and a half in length down to the bone,
 
 OPERATIVE SURGERY. 
 
 h- 
 
 f- 
 
 around the lower end of the inner malleolus (Fig. 275). A third and 
 vertical one is next made about two inches in length, down to the 
 
 bone through the 
 center of the tibia, 
 connecting with 
 the semicircular 
 one first made. The 
 triangular flaps, in- 
 cluding the perios- 
 teum, are turned 
 aside with the ele- 
 vator, using care to 
 raise the sheaths of 
 all tendons from 
 their grooves (Fig. 
 276), and, pushing 
 them aside, the 
 tibia is divided at 
 the upper end of 
 the cut with a 
 chain-saw, the frag- 
 ment pulled out- 
 ward with the for- 
 ceps, freed from 
 the interosseous 
 membrane, and re- 
 m o ved. If it be ne- 
 cessary to remove 
 the articular sur- 
 face of the astragalus, it can be done through either incision ; the 
 better, however, through the internal one, on account of the greater 
 amount of room. If the 
 excision is to be performed 
 for chronic disease of the 
 ankle and contiguous 
 points, Vogt recommends, 
 with the view of getting a 
 more extended insight into 
 the diseased portions, that 
 
 an incision be made anteri- 
 orly, midway between the 
 tibia and fibula, beginning 
 about two inches above the 
 articulation of the ankle 
 and extending downward to FIG. 274. Removing lower end of fibula. 
 
 FIG. 273. Outer side of ankle, a. Tendo Achillis. 6. Pe- 
 roneus longus. c. Peroneus brevis. d. Peroneus tertius. 
 c. External malleolus. /. Extensor longus digitorum. g. 
 Crucial ligament, h. Extensor longus pollicis.
 
 OPERATIONS ON BONES. 
 
 the'inedio-tarsal joint on the dorsal surface of the foot. The long 
 extensor tendons are carefully drawn to the inner side, the tendons of 
 the short extensor are divided and 
 drawn to the outer side ; the blood- 
 vessels carefully tied between two 
 ligatures and the capsule of the 
 joint opened by a vertical incis- 
 ion ; then detach the anterior liga- 
 ment and expose the head and 
 neck of the astragalus. If the 
 superior astragalo-scaphoid liga- Fm. 275. Internal incisions, 
 
 ment be divided, the anterior and 
 
 inner surfaces of this bone will be better exposed. A transverse in- 
 cision is now made at right angles to the primary one, extending out- 
 
 b 
 
 FIG. 276. Inner side of ankle-joint, a. Tibialis anticus muscle, b. Tendo Achillis. 
 c. Tibialis posticus muscle, d. Flexor longus digitorum. e. Flexor longus pollicis. /'. 
 Posterior tibial artery, g. Tuberosity of scaphoid bone. 
 
 ward to the tip of the external malleolus, leaving the tendons behind 
 it intact. Divide the three fasciculi of the external lateral ligament 
 close to the malleolus, also cut the interosseous or internal calcaneo- 
 astragaloid ligament, force the articular surface of the astragalus out- 
 ward, seize it with lion-tooth forceps, separate its remaining connec- 
 tions, and remove it. All diseased portions can now be easily exam- 
 ined and removed with a minimum degree of disturbance of the 
 healthy tissues. 
 
 The method recently practiced by Busch is a very ingenious one, 
 serving as it does to remove the diseased joint without impairing its 
 tendons or their sheaths. It is open to the objection, however, of
 
 202 OPERATIVE SURGERY. 
 
 weakening the arch of the foot, on account of the division of the long 
 calcaneo-cuboid ligament and the plantar fascia. 
 
 Buscli's Operation. An incision is made down to the bone, across 
 the sole of the foot, from one malleolus to the other ; the sides of the 
 joint are exposed by drawing the tissues forward. The os calcis is now 
 sawn through from below upward and forward to the anterior margin 
 of the calcaneo-astragaloid articulation, and pulled backward after the 
 division of the opposing ligamentous structures. The entire astragalus 
 can now be removed through the opening, and also the lower extremi- 
 ties of the tibia and fibula. 
 
 After the removal of the dead bone and the establishment of good 
 drainage, the fragments of the os calcis are placed in position and 
 held there by silver wire. The wound should be dressed antiseptically 
 and no weight allowed upon the foot until the tissues are firmly 
 united. 
 
 The after-treatment for excision of the ankle-joint consists in ap- 
 plying an immovable dressing around the joint under antiseptic pre- 
 cautions. 
 
 Results. When done for disease, about ten per cent die ; for gun- 
 shot wounds, about twenty-seven per cent ; for other injuries, about 
 thirteen per cent. The results are better from complete than from 
 partial excision. 
 
 The prognosis for life is most favorable between one and fifteen 
 years of age ; most unfavorable between thirty and forty years. A 
 large proportion of the recoveries from this operation results in a more 
 or less useful limb ; about nine per cent being useless. 
 
 Excision of the Bones of the Leg. If it be desired to remove, by 
 excision or otherwise, portions of either of the bones of the leg, the 
 external incision is governed, as to its location and extent, by the 
 situation and degree of the injury or disease of the bone. The bone 
 should, however, be reached by the shortest course, which usually is 
 between the individual muscles, rather than through their structures. 
 After its removal, which should always be subperiosteal, the limb must 
 be so confined as to permit the new structure, when completed, to ful- 
 fill the functions of its predecessor. The patient must not be per- 
 mitted to bear weight on the limb till the new bone becomes firm, 
 else distortion or fracture will occur. 
 
 Excision of the Knee-Joint. This joint can be excised with com- 
 parative safety to the patient, and with a fair prospect of recovery 
 with a useful limb. As in the preceding, the nature of the cause de- 
 manding the operation exercises a marked influence on the result. 
 
 Results. The mortality, when due to disease, is about thirty per 
 cent ; when dependent upon injury, about forty per cent ; when 
 done with all antiseptic precautions, the rate is less than fifteen per 
 cent.
 
 OPERATIONS ON BONES. 203 
 
 If it be for a gun-shot injury, the mortality is increased to seventy- 
 five per cent. The age of the patient is a consideration not to be un- 
 derestimated ; the results are best from five to ten years of age, when 
 due to injury or disease ; fifteen to twenty per cent die when done for 
 gun-shot wounds. Partial excision gives a higher rate than complete, 
 when due to disease. The removal of about three inches of bone in- 
 sures the best prognosis for life. A lesser or greater amount increases 
 the percentage of deaths. The removal of the patella, when not dis- 
 eased, increases the rate of mortality slightly. The usefulness of the 
 limb after the operation can be briefly summed up as follows : 
 
 When due to disease, fourteen per cent were perfect, forty-two 
 were useful, and the remaining useless, of which eighteen per cent 
 were amputated. 
 
 For injuries, about eighteen per cent were perfect, about sixty-five 
 per cent useful, and about twelve per cent were amputated. 
 
 "When due to gun-shot injuries, about sixty per cent were useful and 
 twenty-four per cent were amputated, the remaining not accounted for. 
 
 When done for deformity, nineteen and a half per cent of the 
 results were perfect, and about sixty-eight per cent of the patients 
 had useful limbs ; the remainder not reported. 
 
 It appears that the degree of usefulness does not depend upon the 
 amount of bone removed. 
 
 The removal of the patella seemed to increase the degree of use- 
 fulness of the limb. In excision of the knee-joint for all causes, before 
 the growth of the patient is completed, great care should be taken to 
 preserve intact, if possible, the epiphyseal cartilage, especially of the 
 lower end of the femur (Fig. 277). This precaution markedly lessens 
 
 FIG. 277. Epiphyseal cartilage and line of section in excision of knee-joint. 
 
 the failure of the development of the length of the femur upon the 
 diseased side thereafter, because this epiphyseal junction provides for 
 much more than its proportionate share of the growth of the length 
 of the femur normally.
 
 204 OPERATIVE SURGERY. 
 
 Contiguous Anatomy. The articular vessels and those which oc- 
 cupy the popliteal space are the ones to be preserved. The latter are 
 removed from all danger by the dense and unyielding ligamentum 
 posticum Winslowii. The former can be avoided by limiting the in- 
 cisions to the space between the origin and insertion of the lateral 
 ligaments. There are two well-known methods of excising this joint : 
 1, the non-subperiosteal, or the ordinary method ; and 2, the sub- 
 periosteal. The former is employed when the tissues are too exten- 
 sively destroyed or diseased to admit of the saving of the periosteum. 
 
 Non-subperiosteal Excision of the Knee- Joint (Mackenzie). Flex 
 
 FIG. 278. Mackenzie's anterior curved incision. 
 
 the leg to a right angle and make a curved incision, from the pos- 
 terior border and upper portion of one condyle, around to the same 
 point on the outer, with the convexity downward and correspond- 
 ing to the insertion of the ligamentum patellae (Fig. 278). This in- 
 cision divides the tissues down to and opens the anterior portion of 
 the capsular ligament. The limb should now be still more strongly 
 flexed and the lateral and crucial ligaments divided. A retractor 
 is then passed between the ligamentum posticum Winslowii and the 
 posterior surface of the femur, the bone pushed forward and cut off 
 on a line parallel with the articular surface, provided the extent of 
 the diseased bone will admit of it. The head of the tibia is then 
 treated in the same manner, being careful to avoid the articulation of 
 the fibula. 
 
 In this operation it is better to remove the patella, since its means 
 of attachment (the ligamentum patellae) has been severed. All in- 
 flamed or degenerated synovial membrane should be dissected away. 
 
 The bony surfaces should now be united by passing two annealed 
 iron or silver wires anteriorly through to their posterior borders. The 
 wound is then washed with the strong carbolic or a bichloride solu-
 
 OPERATIONS ON BONES. 
 
 205 
 
 FIG. 279. Corresponding 
 lines of division. 
 
 tion and a drainage-tube passed from side to 
 
 side through the joint behind the bones ; the 
 
 whole enveloped in the antiseptic dressing, 
 
 and the limb immovably fixed in a bracketed 
 
 plaster splint, and properly suspended. In 
 
 sawing through the exposed extremities of 
 
 either bone, the line of incision can be made 
 
 to include the whole of the diseased osseous 
 
 tissue. If carious bone or an abscess cavity 
 
 extend in an isolated manner into the sawn 
 
 extremity of the femur or tibia, it can be 
 
 scooped out and the resulting cavity drained 
 
 by making an opening through its bottom 
 
 with a bone-drill to the external surface of 
 
 the limb, thereby saving the surrounding 
 
 healthy bone-tissue and contributing to the 
 
 length of the diseased limb. Deeply con- 
 gested cancellous 
 bone -tissue should 
 be preserved if to 
 remove it be to im- 
 pair the epiphyseal 
 
 cartilage, since it not infrequently makes a 
 good recovery, but offers in addition thereto 
 the only opportunity of preserving the nor- 
 mal growth of the femur. The line of sec- 
 tion through the bone last sawn must corre- 
 spond in direction to, and be parallel with, 
 the line of section through the bone to 
 which its sawn surface is to be applied (Fig. 
 279), otherwise the union of the sawn sur- 
 faces will cause an angular deformity. This 
 applies more particularly to those cases where 
 anchylosis in the straight position is sought. 
 If for any reason it be thought better to an- 
 chylose the limb with slight flexion, then the 
 thicker portion should be taken from the pos- 
 terior parts of the bones. 
 
 Subperiosteal Excision of Knee-joint 
 (Langenbeck). Extend the limb and make 
 a curved incision on the inner side five or six 
 inches in length, with the convexity down- 
 ward, corresponding to the posterior border of the condyles, and its 
 
 center to the line of the articulation, commencing at the inner border 
 
 of the rectus femoris and terminating below at the crest of the tibia 
 
 FIG. 280. Langenbeck's in- 
 cision.
 
 206 
 
 OPERATIVE SURGERY. 
 
 FIG. 281. Tendons at inner side of knee- 
 joint, a. Vortus interims muscle, b. Rec- 
 tus femoris muscle, c. Sartorious muscle. 
 d. Adductor mugnus muscle, e. Gracilis 
 muscle, f. Semi-membranosus muscle, g. 
 bemi-tendonous muscle. h. Gastrocne- 
 rnius muscle. 
 
 (Fig. 280). If the flap be now raised, the vastus interims muscle and 
 the tendons of the adductor magnus and sartorius will be seen (Fig. 
 
 281), and should be carefully 
 avoided. Divide the internal 
 lateral ligament on a line with 
 the articulation ; with the peri- 
 osteal elevator, separate the cap- 
 sular ligament and the perios- 
 teum from the anterior and 
 posterior surfaces of the inner 
 condyle of the femur, and the 
 tibia outward to the median line 
 of the bones together with the 
 internal semilunar cartilage ; 
 flex the leg, then extend it 
 slowly, and at the same time dis- 
 locate the patella outward by 
 the thumb applied to the inner 
 border ; divide the crucial liga- 
 ments, also the external lateral, 
 and the corresponding portion 
 of the capsular ligament by a 
 semilunar incision carried a few 
 lines below the tip of the external condyle. Eemove the periosteum and 
 its associated tissues from the outer portion of tibia and femur, the 
 same as at the inner side. Divide the posterior portion of the capsule 
 and force the extremities of the femur and tibia successively through 
 the wound, and saw them as before. The patella remains unmolested, 
 except it be diseased, when the diseased portion is removed with a 
 gouge, or the bone can be enucleated from the periosteal surroundings 
 by the elevator and scalpel. A small opening should now be made at 
 the outer and inner sides of the joint posteriorly, for the purpose of es- 
 tablishing thorough drainage. A drainage-tube can be passed through 
 the upper synovial pouch, or firm compression be made thereon to 
 prevent the collection of inflammatory products within it. The sur- 
 faces are then cleansed, all hemorrhage arrested, the flaps united, and 
 the limb surrounded by antiseptic dressing, and immovably fixed till 
 future dressings become necessary. 
 
 The Subperiosteal Excision of Oilier is made through an incision 
 commencing two inches above and to the outer side of the patella, 
 carried down to its upper and outer angle, along the outer border to 
 the apex and to the outer side of the ligamentum patellae, below its 
 insertion, through the soft parts (Fig. 282). The outer condyle of the 
 femur is denuded of its periosteum together with the lateral and cap- 
 suTar ligaments and the outer head of the gastrocnemius ; the anterior
 
 OPERATIONS ON BONES. 
 
 20T 
 
 FIG. 282. Ollier's 
 incision. 
 
 and internal surfaces of the femur are denuded, the crucial ligaments 
 cut, patella displaced inward over the inner condyle, the leg is then 
 flexed and carried inward, causing the femur to protrude, when it is 
 isolated and sawn off. The Tipper end of the tibia is then denuded of 
 its periosteum from above downward, pushed through 
 the opening and likewise divided. If the patella be 
 diseased, remove it, leaving its periosteum behind. 
 
 Excision ~by a Transverse Incision. Ascertain the 
 line of junction of the articulation with the limb ex- 
 tended, if the joint will permit ; make a transverse 
 incision from one condyle directly across to the other, 
 passing across the middle of the patella or at its 
 apex ; if the former, saw the patella through in the 
 line of the incision, remove the fragments, after which 
 the joint surfaces are exposed and removed as in the 
 preceding operations. This incision affords good 
 drainage, and exposes the joint by a minimum injury 
 of the soft parts. In all instances the diseased syno- 
 vial membrane should be carefully dissected away be- 
 fore the wound is closed. In all forms of excision 
 of this joint care must be taken to prevent the soft 
 parts posterior to the bones from being caught be- 
 tween their sawn surfaces, since this will hinder union by preventing 
 a proper contact of their surfaces. If the two wire sutures be carried 
 through to the posterior borders of the bones, this accident can not 
 occur. If the patella be permitted to remain, its severed ligament 
 may be united by suturing, or, if the bone have been sawn across, the 
 bony fragments may be united by strong catgut or silver wire. It is 
 thought, in cases of imperfect union of the tibia and femur, that the 
 presence of the patella gives greater stability to the limb. 
 
 Excision of the Patella. It may be necessary, on account of ne- 
 crosis or injury, to remove the patella independently of the tibia and 
 femur. In such cases the deep incisions must correspond in extent to 
 the diseased bone, for if they be greater, the synovia! cavity may be 
 opened. The periosteum should be raised, and the dead bone care- 
 fully removed, -if possible, without entering the joint. When the joint 
 is not involved, recovery will be speedy and satisfactory, if the limb 
 be confined in the extended position till sufficient repair has taken 
 place to warrant flexion without fracture of the bone. 
 
 The results in eleven cases are two deaths and nine recoveries, of 
 which eight were complete and three partial excisions. 
 
 Excision of the Great Trochanter. This is occasionally required on 
 account of caries. A longitudinal or curved incision is made down 
 upon the bone, and the diseased portion removed with the usual in- 
 struments. The branches of the circumflex vessels and the capsular
 
 208 OPERATIVE SURGERY. 
 
 ligament are to be avoided. The periosteum should be saved when 
 possible. 
 
 Excisions of the Hip-Joint. It is well before attempting this opera- 
 tion to give a brief survey of the important ligamentous and muscular 
 attachments to be respected. The extent of this book is too limited 
 to describe them in detail, and even to do so would hardly be in keep- 
 ing with the scope of the work. 
 
 The ilio-femoral, capsular, cotyloid, and even the teres ligaments, 
 should be carefully considered in connection with their origin and in- 
 sertion, in order that their relations to the involucrum or periosteum 
 may be maintained. Those muscles which are connected with the tro- 
 chanters major and minor should likewise be preserved intact, in 
 order that their association with the new bone-growth may give to the 
 new joint, so far as possible, the normal functions of the old. 
 
 The results of this operation are substantially as follows : When done 
 for gun-shot injuries, about ninety-two and a half per cent die from 
 the primary ; about ninety-one per cent from the intermediary, and 
 ninety and a half from the secondary operation. AVhen done for dis- 
 ease, the mortality is reported variously from thirteen (Sayre) to forty- 
 five per cent. The most favorable age is between five and ten years ; 
 the best results are said to occur when the disease has existed several 
 months. The rate is about three per cent greater from complete than 
 partial excisions. The rate of mortality is but little improved by the 
 removal of the trochanter major, and the upper portion of the shaft ; 
 it is diminished, however, from the head of the femur downward, in 
 proportion to the amount of diseased bone removed, and is increased 
 in proportion to the extent of the disease of the ilium. About ninety- 
 four per cent secure useful limbs, when excised for disease. Complete 
 excision is followed by a more useful limb than partial excision. 
 
 The hip-joint may be removed with or without the preservation of 
 the periosteum, by two quite distinct methods of operating : 1. The 
 simple, when no effort is made to save the periosteum, and the mus- 
 cular and ligamentous attachments about the joint are freely' sacri- 
 ficed. This method is applicable for malignant disease of the bone, 
 and for injuries causing extensive comminution and laceration. 2. 
 The conservative, in which conscientious care will often be repaid 
 in peeling off the periosteal tissue and muscular attachments worthy 
 of preservation. Under all circumstances the acetabulum should be 
 closely scrutinized for the presence of dead bone, which should, in all 
 instances, be removed with care, otherwise the pelvic contents may be 
 injured by the manipulation. 
 
 Operation (White). The simple method is performed by placing 
 the patient on the healthy side, and making a deep curved incision 
 (Fig. 283), commencing at a point midway between the anterior supe- 
 rior spinous process of the ilium and the trochanter major, and pass-
 
 OPERATIONS ON BONES. 
 
 209 
 
 ing backward around the top of the trochanter major, down its pos- 
 terior border about three or four inches, with a strong knife ; then 
 dividing the insertions of the muscles connected to the great trochan- 
 ter (Fig. 284), drawing them 
 aside with a spatula, and expos- 
 ing the posterior surface of the 
 neck of the femur and the ace- 
 tabulum. The exposure will be 
 still more complete if the femur 
 .be rotated strongly inward. If 
 the cotyloid and capsular liga- 
 ments be now divided, and the 
 
 FIG. 283. White's posterior curved in- 
 cision. 
 
 FIG. 284. Sciatic nerve and external 
 rotator muscles. 
 
 thigh be flexed and adducted, the head of the bone will be raised 
 from the acetabulum sufficiently to admit of the division of the liga- 
 mentum teres, when the complete escape of the head of the femur will 
 take place. The soft parts are then protected by a spatula, the bone 
 exposed the required extent, and sawn off (Fig. 285). 
 
 Sulperiosteal Excision of the Hip- Joint (Langenbeck). Place the 
 patient on the sound side with the thigh flexed at an angle of 45 ; 
 make an incision five or six inches in length in the long axis of the 
 great trochanter (Fig. 286) upward and backward toward the posterior 
 superior spine of the ilium, through the fibers of the gluteus maxi- 
 mus, fascia lata, and periosteum of the trochanter ; separate the sur- 
 faces of the wound with retractors, and with the elevator and knife 
 raise the periosteum and the attachments of the muscles inserted into 
 the trochanter major and the contiguous surfaces, being careful to 
 14
 
 210 
 
 OPERATIVE SURGERY. 
 
 FIG. 285. Sawing off head of femur. 
 
 preserve their connections with each other ; next make a longitudinal 
 incision along the neck of the femur, through the capsular ligament 
 and the periosteum. The 
 periosteum of the neck is 
 then separated in connec- 
 tion with the attachments 
 of the capsular ligament 
 and the obturator externus 
 in a careful manner. If an 
 incision be now made 
 through the cotyloid liga- 
 ment, and the thigh be ro- 
 tated outward and ad- 
 ducted, the head of the 
 bone will be elevated from 
 the floor of the acetabulum 
 sufficiently to admit of the 
 division of the ligamentum 
 teres, when the head of the 
 bone can be pushed through 
 the opening and sawn 
 off. FIG. 286. Langenbeck's longitudinal incision.
 
 OPERATIONS ON BONES. 
 
 211 
 
 Sayre's Operation. The following admirable method of excision is 
 recommended by Professor Lewis A. Sayre. It is subperiosteal in all 
 essential particulars, and possesses an advantage over the one just de- 
 scribed in that the primary incision is better fitted for drainage. Place 
 
 the patient on the sound side and make an 
 incision with a strong knife down to the 
 bone, commencing at a point midway be- 
 tween the anterior superior spinous pro- 
 cess of the ilium and top of the trochanter 
 major ; carry it in a curved course upon 
 the bone to the top of the great trochanter 
 midway between its posterior border and 
 center ; complete it by carrying the 
 knife forward and inward, making the 
 length of the incision from four to six or 
 eight inches, depending upon the size of 
 the thigh (Fig. 287). If it be not cer- 
 tain that the periosteum of the trochan- 
 ter has been divided by the first incis- 
 ion, the knife should be carried along 
 the same line a second, and even a third 
 time if need be. The soft parts are now 
 drawn apart, exposing the great tro- 
 chanter, when, with a narrow, thick 
 
 knife, a second incision is made through the periosteum only, at right 
 angles with the first, about an inch or an inch and a half from the top 
 of the trochanter. At the junction of the periosteal incisions introduce 
 the blade of the elevator, and carefully peel the periosteum from either 
 side as far as possible, together with the ligamentous attachments, un- 
 til the digital fossa is reached. The insertions of the rotators into the 
 trochanter major and digital fossa are so firm that it will be impossible 
 to peel them off ; they must, therefore, be carefully separated by short 
 parallel cuts, so directed as to remove the periosteum with which they 
 are blended. After the separation of the tendinous insertions, con- 
 tinue to elevate the periosteum upon either side of the neck, using 
 great care not to rupture it. Its integrity is important to prevent in- 
 filtration into the surrounding tissues, provide attachments for the 
 important ligaments and muscles, also as the basis for the reproduc- 
 tion of bone which it is hoped will take place, each of which will 
 exert an important influence in the preservation of a useful joint. 
 Having separated the periosteum as far as can be done safely, adduct 
 the thigh carefully, raise the head of the bone from the acetabulum, 
 and the remaining portion can be detached. Adduct and depress the 
 femur slightly, being careful not to tear the periosteum, lift the head 
 of the bone out far enough to admit of a division just above the tro- 
 
 FIG. 287. Sayre's line of incision.
 
 212 OPERATIVE SURGERY. 
 
 chanter minor. Care should be taken not to expose a greater surface 
 than is necessary, since necrosis will follow and hinder recovery. It is 
 better to remove the trochanter major, even though it be not dis- 
 eased, since it will impede the escape of discharges, and is not essen- 
 tial to a useful limb if its periosteal covering and muscular attach- 
 ments have been preserved. In all cases after the operation, the 
 wound should be well irrigated with a strong solution of carbolic acid, 
 thoroughly smeared with balsam of Peru, and loosely filled with fine, 
 well-shaken oakum ; good drainage provided, and extension applied 
 to the limb either by the Buck's apparatus or the wire breeches. 
 
 Excision of the Coccyx. This is ofttimes done, though sometimes 
 ineffectually, for the relief of coccydynia. The operation exposes the 
 patient to no danger, and can but remove a comparatively useless 
 appendage. 
 
 Operation. Place the patient on the side and expose the bone by 
 a straight incision in the middle of its long axis ; isolate it carefully 
 and remove it with bone-forceps. 
 
 OSTEOTOMY. 
 
 In a liberal acceptation, osteotomy may be defined as a section of 
 bone. 
 
 In a limited sense, however, it is applied to the divisions of bone 
 that may be made for the relief of deformities dependent on anchylosis, 
 rickets, badly united fractures, etc. It may be performed either with 
 or without antiseptics. The former, however, is by far the safer plan. 
 
 The Instruments employed consist of especially designed saws, 
 chisels, osteotomes, mallets, scalpels and blunt hooks, and sand-pil- 
 lows. 
 
 There are variously formed saws employed, named usually after 
 the one who designed them, as Langenbeck's (Fig. 288) and Adams' 
 
 FIG. 288. Langenbeck's saw- 
 
 saws (Fig. 289). The blades are short and strong ; one fourth of an 
 inch in width and an inch and a half in length, connected to the 
 handle by a strong shank three inches long. The deviations from
 
 OPERATIONS ON BONES. 213 
 
 these are to meet especial indications, rather than to abrogate their 
 
 use. 
 
 The objections to the use of the saw not only apply to the danger 
 
 FIG. 289. Adams' saw. 
 
 of lacerating the contiguous tissue, but more forcibly to the retention 
 in the wound of the bone-dust, which, failing to be absorbed, is apt 
 to be followed by suppuration. The saw devised by Dr. George F. 
 Shrady, of this city, is the best, and is described by himself as follows : 
 Figs. 290 and 291. " The instrument consists of a trocar (1) and 
 a staff (2), with a handle and blunt extremity. A portion of this 
 
 FIG. 290. Shrady'a saw. 
 
 shaft at a short distance from the extremity is flattened, one edge (B) 
 being made into a knife-blade, and the other (C) being provided with 
 saw-teeth. This shaft is intended to replace the trocar in the canula 
 after the latter is introduced. When in position (3) either the saw 
 (C) or the knife-edge of the shaft, according to the way the latter is 
 turned, corresponds with the opening of the canula. The saw or 
 
 FIG. 291. Shrady's modified saw.
 
 214: OPERATIVE SURGERY. 
 
 knife can then be worked to and fro within the caimla by a piston- 
 like movement, the canula being steadied by grasping the flange (D) 
 at its base. If it be necessary to work the instrument as an ordinary 
 blunt-pointed sheathed saw or knife, the shaft can be fixed in the 
 canula, and made into one piece by a thumb-screw in the handle. 
 The portion of the canula at the back of the opening is made extra 
 strong, and is of the same thickness as the blade, so that in sawing 
 there is no stoppage of the passage of the instrument through any 
 thickness of the bone. The soft parts are protected from injury, no 
 matter which way the instrument may be worked. The saw-blade is 
 blunt at its extremity, and is guarded on all sides except in its limited 
 cutting surface. The same may be said of the knife. The working 
 of the saw to and fro in the canula is sufficient in sweep to insure the 
 division of any bone having a diameter less than the cutting edge. 
 Still, as this process is much slower than when the saw is used in the 
 ordinary way, it is perhaps better to restrict its employment to opera- 
 tions on the smaller bones, to cramped localities, and to situations 
 where there is special danger of wounding some neighboring vessels. 
 All that is necessary in using this saw is to thrust the trocar and 
 canula into the limb, the fenestrum of the canula being alongside of 
 the bone upon which the operation is to be performed. The trocar is 
 then withdrawn, the staff introduced in its place, and worked as 
 already described." 
 
 Since the above description was written, the instrument has been 
 slightly modified by lessening the size of the fenestrum through which 
 the teeth of the saw are seen ; this strengthens the canula and facili- 
 tates its progress through the bone (Fig. 291). 
 
 The Chisel is like that of the carpenter in form, but differs from 
 it in temper ; it has two parallel sides extending to its cutting edge. 
 The cutting surface has one side straight and the- other beveled, and 
 should be one eighth of an inch thick at the base of the bevel ; if 
 thicker, it may splinter the bone. The breadth varies according to 
 the size of the bone ; half an inch is suitable in the majority of cases. 
 For narrow bones one fourth inch is better (Fig. 292). The width 
 should always be less than the bone to be operated upon. 
 
 The temper given to the tools of the hard-wood or ivory turner is 
 best suited for the purpose, and its efficacy should be tested upon the 
 thigh-bone of an ox or like animal before using the instrument. 
 
 The chisel should be sharp, and leave a smoothly cut surface. This 
 instrument is employed only to remove a wedge-shaped piece from the 
 bone, since the shape of its cutting extremity will, like that of the 
 carpenter's chisel, cause it to go awry if a straight section be at- 
 tempted. 
 
 The Osteotome. This instrument is beveled on both edges, resem- 
 bling a slender wedge ; the handle and the blade forming one piece.
 
 OPERATIONS ON BONES. 
 
 215 
 
 FIG. 292. Chisels and osteotomes. 
 
 The top should have a round head, against which the thumb is pressed 
 to steady it. One border of the blade should be delicately marked in 
 inches to determine the depth of the incision. The edge should be 
 sharp enough to cut the finger-nails, and the temper of a character to 
 withstand the strain required. It can be tested upon the thigh-bone 
 of the ox, when, if it neither turn nor chip, it is calculated to with- 
 stand the test of human bone. Osteotomes vary in thickness, in order 
 that a section begun by one of a given thickness may be continued on 
 its withdrawal, by the substitution of another of a less thickness. 
 
 The Mallet is made of hard wood, and can be constructed for the 
 purpose ; or, an extemporized one may be employed. 
 
 The Scalpel is an ordinary one, with a sharp point suitable for 
 penetrating at once to the bone. Blunt hooks are employed to draw 
 the edges of the incision apart without force. 
 
 The Sand-Pillow. Its dimensions are usually about eighteen 
 inches by twelve ; made of stout cloth, and filled with sufficient fine 
 sand to permit its contents being moved from one part of the bag to 
 another, without leaving any portion empty. It should be dampened 
 before being used, covered with carbolized cloth, and the limb laid 
 upon, or rather imbedded in it. It forms an efficient support, and 
 prevents the force imparted to the bone by the mallet injuring the 
 soft parts. 
 
 The opening through the soft parts leading down to the point of 
 proposed section should be limited in extent, and so located as to 
 avoid the division of vessels, or injury to a joint. It should be made 
 when practicable in the long axis of the fibers of the muscle through 
 which it passes down to, but not through, the periosteum. The blade 
 of the scalpel should remain in the incision till the danger of muscu- 
 lar contraction ceases, and then the chisel or osteotome is passed into
 
 216 
 
 OPERATIVE SURGERY. 
 
 the incision by the side of it, as a guide, after which the blade can 
 be withdrawn. 
 
 It is better that the wound be large enough to admit the finger, or 
 even to permit inspection of the bone, than that the tissues around a 
 small incision be treated with violence, in the effort to accomplish the 
 purpose. 
 
 If chips of bone are to be removed, a larger incision is required 
 than if a simple section be intended. The patient should in all in- 
 stances be anaesthetized and the limb rendered bloodless by the elastic 
 bandage of Esmarch or Martin. All cutting instruments employed 
 must be rendered aseptic, and in all other respects the operation must 
 be performed with antiseptic care. 
 
 Subcutaneous Division of the Neck of the Femur (Adams). Place 
 the patient upon the side, with the bone to be operated upon upper- 
 most. Introduce a long slender scalpel or tenotome above the top of 
 the great trochanter, straight down to the neck of the femur ; divide 
 the muscles and open the capsule freely on the anterior and upper sur- 
 face ; pass the small saw by the side of the knife along the track down 
 to the anterior surface of the neck, which is then sawed transversely 
 through (Fig. 293) from before backward suf- 
 ficiently to be easily broken. The limb is then 
 placed in position, the wound irrigated with 
 an antiseptic solution, to render it aseptic and 
 to wash out the bone-dust ; hemorrhage is 
 checked, a small drainage-tube introduced, the 
 remaining portion of the incision closed, the 
 whole enveloped in antiseptic dressing, and 
 the limb placed in an immovable apparatus. 
 The tendinous contractions, that prevent the 
 limb being placed properly, should be divided 
 subcutaneously. 
 
 Results. This operation has been success- 
 ful in thirty-one out of thirty-four cases. 
 
 Maunder, Billroth, and others have used 
 the chisel for forcible fracture with good re- 
 sults. Another method (Volkmann) consists in forming a false joint 
 in the following manner : 
 
 Make an incision along the posterior surface of the great trochan- 
 ter four or five lines in length down to the bone. The femur is then 
 cut through about an inch below the point of the great trochanter, 
 with a chisel, the wall of the cervix femoris broken, and this portion 
 of the bone removed. The thigh is then adducted to make the upper 
 end of the femur more accessible then it is cut across and rounded 
 off to fit the new socket which is made by chiseling out the head of 
 the femur and increasing the area of the acetabulum by the same 
 
 FIG. 293. Sawing neck 
 of femur.
 
 OPERATIONS ON BONES. 217 
 
 process, being careful not to open into the pelvic cavity. The upper 
 end of the femur is placed in the newly-formed cavity, and extension 
 is applied to the limb to keep the cut surfaces sufficiently separated 
 to prevent bony union. Early passive motion should be made. Volk- 
 mann has performed this operation several times, resulting in useful 
 limbs in each instance. 
 
 Inter-troclianteric Osteotomy. This operation consists in exposing 
 the anterior, outer, and posterior surfaces of the femur through an in- 
 cision about six inches in length, beginning just above the tip of the 
 trochanter major, and carried longitudinally through the center of its 
 outer surface. A short, transverse incision is then joined to the cen- 
 ter of the posterior lip of the first ; the respective surfaces are then 
 exposed with an elevator until the trochanter minor can be felt, when 
 a chain-saw is passed around the bone immedi- 
 ately above this process. The uppermost or 
 curved section (Fig. 294) is made by first saw- 
 ing upward and outward, until the bone is 
 half severed, then changing the direction 
 downward and outward and completing the 
 section. 
 
 The second section is made by sawing direct- 
 ly through the bone in its transverse axis, re- 
 moving a piece one eighth of an inch thick at 
 its outer and posterior border, and three 
 fourths of an inch of its central part. 
 
 The upper end of the lower fragment is 
 then rounded to fit the concavity above. The FIG. 294. Sayre's lines 
 limb is straightened out and the wound treated of section, 
 
 like a compound fracture. 
 
 This method was practiced by Professor L. A. Sayre some time 
 since with eminent success. 
 
 The removal of a disk of bone in this situation has been quite fre- 
 quently done, but with indifferent success. Out of the seventeen 
 cases reported, seven died. While this method displayed great ingenu- 
 ity and resource on the part of the originator, the fatality attending 
 it, together with the introduction of the chisel and osteotome, render 
 it at the present time impracticable. 
 
 The modification introduced by Volkmann in 1873 consists in 
 making an incision along the posterior surface of the great trochanter 
 and removing the periosteum from two thirds of its circumference, 
 when with chisels and gouges a triangular piece is taken from just 
 below the trochanter (Fig. 295), the bone broken, straightened, and 
 placed in proper position until union takes place. 
 
 Results. Of the twelve operations thus performed, all recovered. 
 
 Osteotomy for Bony Anchylosis of Knee-Joint (supra-condyloid).
 
 218 
 
 OPERATIVE SURGERY. 
 
 FIG. 295. Volkmann's 
 section. 
 
 Make a longitudinal incision, sufficient to admit the osteotome, at the 
 outer side of the rectus tendon, one finger's breadth above the upper 
 portion of the outer condyle. The osteotome is 
 introduced, and turned so that its cutting sur- 
 face corresponds to the transverse axis of the 
 bone at the point to be divided ; with the limb 
 resting upon the sand-bag, the bone is two 
 thirds divided and the remainder broken or 
 bent. If performed from the inner aspect, the 
 incision is made along the anterior border and 
 half an inch in front of the tendon of the ad- 
 ductor magnus, beginning one inch above its 
 insertion. The remaining steps of the opera- 
 tion are similar to the preceding. It may be 
 necessary to supplement the section of the fe- 
 mur with that of the tibia, in order to suffi- 
 ciently correct the deformity. This is done by 
 making an incision through the skin over the 
 tibial crest just below the tuberosity. Through 
 this opening, the subcutaneous and posterior surfaces of the tibia are 
 divided sufficiently to admit of a fracture of the bone and the conse- 
 quent correction of the 
 deformity. The fibula, 
 owing to its mobile asso- 
 ciation with the tibia, 
 does not require division 
 at this situation. It is 
 often necessary, how- 
 ever, to cut the ham- 
 string tendons before 
 the deformity can be 
 properly corrected. 
 
 Supra - Condyloid 
 Osteotomy for Genu Val- 
 gum (Macewen) (Fig. 
 29G). In this operation 
 care is taken to avoid 
 the popliteal vessels, 
 anastomotica magna, 
 superior internal articu- 
 lar arteries, and the syn- 
 ovial pouch of the knee- 
 joint on the anterior surface of the femur. The incision in the soft 
 parts is made at the inner side of the limb, beginning a finger's 
 breadth above the insertion of the tendon of the adductor magnus into 
 
 FIG. 296. Genu valjmm.
 
 OPERATIONS ON BONES. 
 
 219 
 
 the spine at the upper portion of the internal condyle and half an 
 inch in front of it, and carrying it up sufficiently to admit the osteo- 
 tome ; or, its lowest limit is made to correspond to a line drawn trans- 
 versely across the limb in front, beginning an inch above the external 
 condyle, which will, if the internal condyle be much elongated, pre- 
 vent the osteotome being driven into the exter- 
 nal condyle, instead of above it. The course 
 of this incision avoids as far as possible any in- 
 terference with the anastomotica magna and 
 the articular arterial branches. The osteotome 
 may be applied to the bone transversely at the 
 point indicated by the faint transverse undotted 
 line in Fig. 297, and so directed that its course 
 will correspond to a line extending across the 
 posterior surface of the femur to a point one 
 finger's breadth above the external condyle. 
 The extent of the osseous incision will depend 
 upon the density of the bone ; if the subject 
 be young, and if the bone be cut through two 
 thirds of its diameter, it can be bent or broken. 
 If it be dense, it will be necessary to carry the 
 
 incision to the outer wall. The posterior and inner surfaces of the 
 bone are first cut, when, if necessary, a thinner chisel is employed to 
 
 FIG. 297. Line of bone 
 section. 
 
 FIG. 298. FIG. 299. FIG. 300. 
 
 FIGS. 298, 299, 300. Macewen's method. 
 
 FIG. 301. FIG. 302. 
 
 FIGS. 301, 302. Ogsten's method. 
 
 complete the operation. When the bone is sufficiently divided, the 
 limb is straightened, all hemorrhage arrested, and the limb treated 
 as before indicated. The above figures will aid in explaining the 
 method. 
 
 Fig. 298 shows a long internal condyle in genu valgum ; Fig. 299, 
 a section through about three fifths of its diameter ; Fig. 300, the ap- 
 pearance of the bone with the limb placed in position, showing the
 
 220 OPERATIVE SURGERY. 
 
 curvature rectified. The prognosis of this operation, with refereace 
 to usefulness of the limb, cure of the deformity, and danger to life, 
 is most flattering. 
 
 Results. In about six hundred and fifty supra-condyloid osteoto- 
 mies, but three fatal cases are reported that can be attributed to the 
 operation ; one each from septicsemia, hemorrhage, and carbolic-acid 
 poisoning. All the patients were benefited, and many were able to 
 take an active part in affairs from which they had been debarred. 
 
 Osteo-Arthrotomy (Ogsten). This method consists in dividing the 
 elongated condyle of the femur by sawing (Ogsten), or cutting 
 (Reeves), sufficiently to admit of the rectification of the deformity 
 (Figs. 301, 302). 
 
 Operation by Sawing. Place the patient in the dorsal position ; 
 administer an anaesthetic ; flex the leg upon the thigh, fully. At a 
 point two or three inches above the tip of the inner condyle, introduce 
 a tenotome upon the flat, carry it downward, forward, and outward 
 until its point can be felt in the inter-condyloid space. The cutting 
 edge is then turned downward and the tissues divided down to the 
 bone as it is withdrawn. A small Adams' saw is then introduced 
 along the course of the incision and the condyle is sawn, from above 
 downward, through about three fourths of its thickness. If the limb 
 be now straightened, the remaining portion is fractured and the de- 
 formity is rectified. 
 
 'Results. In forty-six operations two patients have died of septi- 
 casmia. 
 
 Operation l>y Cutting. By this method the elongated condyle is 
 divided or loosened with a chisel or osteotome ; the intention being to 
 divide the condyle to the greatest depth without opening into the 
 joint. Even though the cut be made to meet this indication, the 
 joint is no doubt involved (except possibly in the very young) by the 
 displacement upward of the fragment necessary to correct the de- 
 formity. 
 
 C'hicne's Method. Mr. Chiene, instead of sawing or cutting off the 
 condyle, corrected the deformity by the removal of an oblique trans- 
 verse wedge of bone from the body of the condyle which, when pressed 
 upward by straightening the limb, remained attached by its apex to 
 the shaft. Not infrequently, however, the fragment is detached by 
 this manipulation, and the joint opened into. The details attending' 
 this method are omitted, since it can not be compared favorably with 
 the much simpler and equally efficient one, supra-condyloid osteotomy. 
 
 Osteotomy for Genu Varum. In this deformity the operative pro- 
 ceedings are directed to the outer instead of the inner side of the 
 bones of the leg and thigh. The procedure, precautions, and treat- 
 ment are similar. The division of the bones through a small external 
 opening can be made almost indiscriminately in such as present this
 
 OPERATIONS ON BONES. 221 
 
 deformity, always remembering that thorough and complete antiseptic 
 precautions should be taken. The results are most flattering, and 
 commend it to the consideration and practice of the profession. 
 
 Bow- Legs. Genu varum may depend on an outward curvature of 
 the bones of the leg, wholly or in part. In either instance the de- 
 formity can be corrected by a subcutaneous osteotomy of the tibia. 
 If the patient be young enough, a green-stick fracture of the fibula 
 will obviate the use of the osteotome upon it. 
 
 Operation. Cleanse the part thoroughly with soap and brush ; 
 apply the elastic bandage ; place the limb on the sand-bag, and at the 
 point of the greatest curvature make a longitudinal incision down to 
 the periosteum, midway between the borders of the subcutaneous 
 bone at the point of proposed division, of ample length to admit the 
 osteotome, which is then turned so as to divide the bone transversely, 
 sufficiently to admit of its being fractured. Cut or bend the fibula, 
 correct the deformity, close the wound in the soft parts with catgut, 
 dress antisepticaily, and confine the limb in a temporary dressing 
 until all danger of hemorrhage, inflammation, etc., has subsided, 
 when it may be placed in an immovable plaster-of- Paris dressing, and 
 retained until union has taken place. If a double section is to be 
 made at different points, an antiseptic sponge should be bound over 
 the incision in the soft parts of the first while the second operation is 
 being made. This affords an opportunity to determine the severity of 
 the hemorrhage and the ease with which it can be controlled. If it 
 be necessary to divide one bone in two situations to correct a deform- 
 ity, the second division should be deferred until the former has healed, 
 when it should be done at the remaining point of greatest convexity. 
 If the bones be much curved, it may become necessary, in order that 
 the deformity be properly corrected, to remove a wedge-shaped piece 
 (cuneifom ostreotomy). For this purpose the chisel alone should be 
 employed. In all instances when the bichloride gauze is to be applied, 
 the skin must be protected from its irritant effects by smearing it 
 with a mixture of glycerin and salicylic acid, or by placing between 
 the bichloride gauze and the skin one or two thicknesses of carbolic- 
 acid gauze ; the latter plan is the better. 
 
 All osteotomies should be performed under strict antiseptic precau- 
 tions, and the incision of the soft parts closed with a catgut suture. 
 The limb must be immovably fixed and the patient kept quiet ; in 
 fact, the measures applicable to a compound fracture are in order, 
 since it resembles that condition more nearly than any other. 
 
 Results. The results of all osteotomies performed with antiseptic 
 precautions are extremely flattering. As yet, I have no personal 
 knowledge of a death from the operation, and of fourteen hundred 
 osteotomies but about one per cent are reported to have died in con- 
 sequence of it.
 
 222 OPERATIVE SURGERY. 
 
 Hallux Valgns. This deformity is practically limited to the great 
 toe, and is usually caused by improperly fitted boots and shoes. Fig. 
 468 represents the condition more graphically than* words can do it. 
 The first phalanx (anatomical) articulates with the inner portion of 
 the distal extremity of its metatarsal bone and is rotated inward on 
 its long axis. The principal portion of the head of the metatarsal 
 bone projects inward, and its extremity is surrounded by a sensitive 
 bunion. The indication is to place the toe in its normal axis and 
 retain it in that position. If the deformity be great, little else than 
 an operation on the bone will be of any practical value. Two methods 
 can be recommended : 
 
 1. The removal of the head of the metatarsal bone, with enough 
 of the shaft to permit the great toe to be easily returned and held in 
 its normal axis (Fig. 270). Under strict antiseptic precautions this 
 operation results in quick recoveries and useful toes. 
 
 2. The deformity can be corrected by removing a V-shaped piece 
 from the inner portion of the distal extremity of the metatarsal bone, 
 as near the head as possible without involving the joint cavity. This, 
 too, must be done under strict antiseptic precautions, and is accom- 
 plished through an incision made along the inner side of the meta- 
 tarsal bone. The soft parts are retracted and the V-shaped piece of 
 the bone is removed, without dividing more than three fourths its 
 diameter. The thickness of the base of the triangular piece to be 
 removed is estimated by the degree of the deflection of the toe from 
 its normal position ; it should correspond as nearly as practicable to 
 about one third the distance which the extremity of the toe will trav- 
 erse to regain its normal relation to the foot. 
 
 The wedge can be removed by means of a saw or chisel and the toe 
 brought into position, which will fracture the inner undivided por- 
 tions of the bone. Horse-hair drainage and immobility under anti- 
 septic dressing will be followed by speedy union and a satisfactory 
 recovery. 
 
 Osteoplasty, or transplantation of bone, has not gained the promi- 
 nence as a surgical expedient that the knowledge of the laws govern- 
 ing the growth of bone bids fair to attain for it. 
 
 Bone associated with its periosteal and fibrous connections, has 
 been transferred, as in the case of the operation on the hard palate for 
 the closure of the fissure, also the closure of the spaces between the 
 ununited fragments of bone, by filling them with freshly sawn sections 
 from the main shaft. The conditions necessary to a successful issue 
 of this operation are exceedingly numerous and exacting, the chief 
 one of which is a most rigid adherence to the antiseptic methods. 
 The feasibility of bone transplantation as a practical measure is not, 
 as yet, sufficiently established to warrant its being considered an 
 accomplished fact.
 
 AMPUTATIONS. 223 
 
 CHAPTER IX. 
 
 AMPUTA TIONS. GENERAL CONSIDERA TION. 
 
 AMPUTATION" consists in the removal of a limb either in its con- 
 tinuity or at its articulation, although the latter is often termed dis- 
 articulation. The aims sought to be gained by an amputation are : 1. 
 The saving of the life of the patient. 2. The securing of a serviceable 
 stump. 
 
 If the prospects of recovery be annulled by the presence of a badly 
 diseased or mangled limb, it is no opprobrium upon the art to remove 
 it. If a limb be so badly injured or diseased as to require removal, it 
 is entirely proper that the ability of the designer of compensative ap- 
 pliances be considered, that the patient may reap the combined benefit 
 of the art of the surgeon and the ingenuity of the mechanic. A 
 stump, to be serviceable, should be sound, unirritable, with a good 
 circulation and abundant leverage. The first three qualities depend, 
 all things being equal, very largely upon the length, shape, and vascu- 
 lar supply of the flaps ; the last depends entirely upon the length of 
 the bone. The flaps should be movable over the extremity of the 
 stump after healing is completed, not tightly drawn and smooth like 
 a base-ball cover. Flaps that are tightly drawn at the initial dressing 
 soon become more so, on account of the inflammatory action. The 
 increased tension causes pain, and early and rapid ulceration at the 
 seat of the ligatures, followed by separation of the flaps, union by 
 granulation, and finally a troublesome stump ; or, the normal shrink- 
 age of the integument draws the flaps against the end of the bone, to 
 which they, together with the cicatrix, become immovably united, and 
 cause a similar difficulty. The proper length of the flaps, then, be- 
 comes an important point in estimating the prospective usefulness of 
 the limb and comfort of the patient. In cases where each flap can be 
 made of a similar length, its extent should correspond to about one 
 fourth the circumference of the limb at the point where the bone is to 
 be divided. If one flap only be employed, it should be made double 
 the length of each flap when two are employed. Any increase in the 
 length of one flap should be accompanied by a proportionate decrease 
 in the length of the other. The shape of the flaps largely controls 
 the site of the cicatrix. It is advisable that the cicatrix be so placed 
 as not to be subjected to pressure or friction. If, however, the flaps 
 be made of sufficient length to admit of the formation of a non- 
 adherent or movable cicatrix, its location is a matter of secondary 
 importance. The length and location of the flaps also largely control 
 their circulation. If they be too long, the circulation will be en- 
 feebled ; if, on the contrary, they be too short, the tension will be- 
 come an impediment, causing a blue, cold, and shiny surface, sensitive
 
 224 
 
 OPERATIVE SURGERY. 
 
 to the slightest injury. The circulation in the normal limb, or a por- 
 tion of it, may be such as to predispose to a small and sluggish blood- 
 supply in flaps constructed from it. 
 
 Flaps are classified, according to the tissues entering into them, 
 as the cutaneous, integumentary or skin flaps, musculo-cutaneous, 
 and periosteal, either variety of which may be made either single or 
 double. The integumentary variety is commonly employed in this 
 country. 
 
 Flaps are also classified, according to their shape, into circular, 
 modified circular, oval, rectangular, hood, etc. The oval may be 
 either unilateral, bilateral, anterior, or posterior. Many of the pre- 
 ceding forms may be composed of integument alone, or combined with 
 muscular tissue, and even with periosteum. 
 
 Circular Method (Fig. 303). This method is followed by an ad- 
 
 FIG. 303. Circular method. 
 
 mirable stump, is easiest of performance, and consequently very fre- 
 quently practiced. It is especially to be recommended in the field 
 operations of military surgery, since the lightness of the flaps permits 
 the transportation of the wounded with the minimum degree of dis- 
 turbance of the seat of the amputation. It is done by making a circu- 
 lar incision transversely around the long axis of the limb, through the 
 integument and subcutaneous tissue down to the muscles, at a distance 
 below the proposed division of the bone, corresponding to about one 
 fourth the circumference of the limb at that point. The flap is then 
 dissected up from the muscles with an ordinary scalpel ; the edge of 
 the knife being directed toward the muscles (Fig. 304) rather than
 
 AMPUTATIONS. 
 
 225 
 
 parallel with them (Fig. 305), as the latter severs the capillary con- 
 nection between the integument and the deeper tissues. The djssec- 
 
 FIG. 304. Dissecting up the flap. 
 
 tion should be done by circular sweeps, rather than by mincing cuts, 
 which hack the tissues and provoke suppuration. This careful man- 
 
 FIG. 305. How not to do it. 
 
 ner of raising the flap applies equally to all the varieties which involve 
 the separation of similar tissues. 
 
 If the limb be conical, much difficulty will be experienced in turn- 
 ing over the sleeve of integument ; this, however, can be obviated by 
 a longitudinal cut made usually at the most dependent portion of the 
 flap. 
 
 15
 
 226 
 
 OPERATIVE SURGERY. 
 
 The flap should be turned upward to the point where the bone is 
 to be divided ; then with suitable knife make a circular division of the 
 
 FIG. 306. Circular division of the muscles. 
 
 muscles down to the bone, beginning far enough fielotu the reflection 
 of the flap to allow for the retraction of the divided muscles. No 
 definite law can be assigned to this element, 
 still they will contract according to their size, 
 length, degree of irritability, etc. The suita- 
 ble points of section will be stated in connection 
 with the description of the special amputations. 
 Not infrequently the muscles are cut just below 
 the reflection of the flap, as in Fig. 306 ; this 
 is not, however, as good a plan as the former, 
 since sensitive stumps are more liable to result 
 therefrom. The bone should be sawn at its 
 highest point of exposure. 
 
 The Modified Circular Method (Fig. 308). 
 This plan was suggested by Mr. Liston, who 
 made semilunar flaps, which he dissected up to 
 their point of junction with each other, at 
 which point the muscles and bone were divided, 
 as in the circular method. This method was 
 FIG. 307. stump after ' afterward modified by Mr. Syme, who dissected 
 the circular operation. a short distance above the point of juncture of 
 the flaps, and divided the muscles and bone, as 
 
 before. In either instance, however, it amounts to slitting up the cuff 
 of a circular flap, and trimming off the angles caused thereby.
 
 AMPUTATIONS. 227 
 
 The Oval Method. This is in reality a modified circular amputa- 
 tion, the flap being slit up at one side and the angles trimmed off. It 
 
 FIG. 308. Modified circular flap. 
 
 is employed principally in disarticulations, and will be described in 
 connection with those operations. 
 
 The Single-Flap Method. This is adapted to those cases where 
 the tissues of one side of the limb only are suitable for the purposes 
 of a flap ; as in the case of lacerations, ulcerations, etc. This flap 
 may be composed of the muscular tissues and integument, or of in- 
 tegument alone ; and can be made either by transfixion, or division 
 from without. If possible, a short convex flap is made on the opposite 
 surface of the limb. 
 
 The Double-Flap Operation is performed by transfixion, and includes 
 the muscles down to the bone on either side of the limb (Figs. 309 
 and 310). The tissues to be transfixed are raised slightly by the left 
 hand of the operator, who then enters the point of the knife at the 
 side nearest himself, pushing it through slowly, in close contact with 
 the anterior surface of the bone, slightly raising the handle as it 
 passes in front of the bone, thereby causing its point to emerge at the 
 opposite side of the limb at a point exactly opposite to its entrance ; 
 the flap is then made by cutting obliquely upward with a sawing mo- 
 tion. It is pulled backward by an assistant, and the knife is reinsert- 
 ed at the original point of entrance, carried behind the bone, handle 
 depressed to cause the point to emerge at the same situation as at the 
 anterior transfixion, and the posterior flap made by cutting obliquely 
 downward. Each flap should correspond in length to at least one 
 half the diameter of the limb. The retractor is then applied, and all
 
 228 
 
 OPEKATIVE SUKGERY. 
 
 the soft tissues are drawn well upward ; the remaining fibers in con- 
 tact with the bone are severed by a circular sweep of the knife, and 
 
 FIG. 309. FIG. 310- 
 
 FIGS. 309, 310. Flap by transfixion. 
 
 the bone is carefully sawn through. If lateral flaps be made, the outer 
 should be formed first. The flap containing the large vessels is to be 
 divided afterward. 
 
 The Mixed Double Flap is a modification of the preceding, and 
 sometimes called Sedillot's method. The flaps are made by trans- 
 fixion, as before, but are more superficial, the knife not being brought 
 in contact with the bone. The remaining muscles and vessels are di- 
 vided by a circular incision, and the amputation completed as before 
 described. In this instance the flaps are thinner and shorter than in 
 the preceding. 
 
 Langenbeck's Method. This differs from the last only in the man- 
 ner of obtaining the result ; the flaps being cut from the surface 
 toward the center of the limb, which affords a better opportunity to 
 shape them. Another modification of the method consist in cutting 
 the anterior flap from the surface, and making the posterior flap by 
 transfixion. 
 
 TJie Rectangular Flap, or Teale's Method (Figs. 311 and 312). 
 In this two rectangular flaps are employed, one being four times longer 
 than the other ; both flaps include the structures down to the bones. 
 The longer flap is taken from the side of the limb, where the bone is 
 most superficial. The shorter contains the important vessels. The 
 length and breadth of the long flap correspond to half the circumfer- 
 ence of the limb at the point of proposed amputation. The width of 
 the short flap is a half, and its length an eighth, of the circumference 
 of the limb. Both flaps should be carefully marked out before begin-
 
 AMPUTATIONS. 
 
 229 
 
 ning the operation. This method makes an admirable stump, but 
 sacrifices fulcrumage, and brings the bone section nearer the body 
 
 FIG. 311. FIG. 312. 
 
 FIGS. 311, 312. Teale's method. 
 
 than is consistent with the additional dangers incurred. Mr. Lister 
 recommends that the longer flap be made a third and the shorter flap 
 a sixth of the circumference of the limb, which brings the cicatrix at 
 the edge of the stump. Also that the posterior flap shall consist of 
 the integument and subcutaneous tissues alone. This, like Teale's, 
 may be employed when the loss of tissues is greater upon one side 
 than upon the other. 
 
 The Hood Flap. There is no substantial difference between this 
 and the circular method, if the latter be slit up at the 
 most dependent part, and the resulting corners rounded 
 off. This method meets the indications requisite to 
 form a good stump as well as any other variety of flap. 
 
 Equilateral Flaps (Fig. 313) consist of equilateral 
 skin-flaps, oval in outline, the posterior angle being 
 made somewhat farther up the limb, to improve the 
 drainage. The muscles are cut by a circular sweep at 
 a suitable distance below the point of reflection of 
 the integumentary flaps, and the bone is sawn above 
 the anterior point of junction of the flaps. 
 
 Periosteal Flap. This is made by raising the pe- 
 riosteum in conjunction with the tissues which rest 
 upon, or are attached to it, sufficiently to cover the 
 end of the divided bones, when it is allowed to fall 
 into place. It is best adapted to those bones subcuta- 
 neously located, like the tibia, and will be again re- 
 ferred to in connection with amputations of the leg. 
 
 A periosteal flap will, if it becomes adherent to 
 the end of the bone, preserve it from atrophy, and 
 lessen the danger of the formation of a conical stump ; 
 it likewise prevents the adhesion of the cicatrix to the stump, thereby 
 forming the basis for a movable cicatrix. 
 
 FIG. 313. Equi- 
 lateral flaps.
 
 230 OPERATIVE SURGERY. 
 
 If the patient be young, new bone may be developed ; this lessens 
 the sensibility and increases the usefulness of the stump. It is claimed 
 by some that the bony spiculae often shoot into the soft tissues on the 
 end of the stump, and require a second operation for their removal. 
 It is my opinion, however, that if the periosteum be removed entire 
 and in connection with its superimposed tissues, and be so placed that 
 the force of gravity will aid in holding its bone-producing surface in 
 contact with the divided extremity, this danger will be obviated. 
 
 Comparative Merits of Different Forms of Flaps. The ends sought 
 to be gained in making flaps are : 1. To secure good drainage. 2. To 
 make them of suitable length, that the circulation and movement of 
 the integumentary cushion at the end may be unrestrained. 3. To 
 place the cicatrix beyond the point of friction, and prevent its adhesion 
 to the end of the bone. 4. To guard against any danger of undue 
 sensibility, by making the flaps of proper length, and by drawing 
 down and cutting off the cutaneous and other nerves of larger size 
 that may exist in them. 
 
 With these aims in view, it will be seen that the old-fashioned cir- 
 cular flap affords equal advantages to the others, and is further com- 
 mendable for its simplicity. It is true that in this method the scar 
 will fall on the end of the stump, but with proper precautions as to 
 the length of the flaps and suitable surgical attentions, any danger 
 from this source is reduced to a minimum. 
 
 The Agents required for an Amputation may be classed as those for 
 arresting hemorrhage ; for the division and trimming of the soft parts 
 and the bone ; and those for uniting and dressing the wound. The 
 preparation of the patient for the operation ; the agents for controlling 
 and arresting hemorrhage, together with the various methods of secur- 
 ing and maintaining the coaptation of the cut surfaces, drainage, and 
 various forms of dressing, antiseptic and otherwise, have herein been 
 previously considered; therefore, there remain to be enumerated, 
 under this heading, only those instruments especially adapted to the 
 requirements of the operation. 
 
 Amputating Knives (Fig. 314). The modern amputating knives 
 can be used for making circular flaps, or, for those made by trans- 
 fixion. They should be double-edged (catlin) entirely or for an inch 
 or two from the point. The length of the knife selected will depend 
 upon the size of the limb to be operated upon, and should be about 
 one and a half times its diameter. It may be inconsistent with good 
 taste, but it is entirely consistent with good judgment and economy, 
 to amputate an arm or forearm with the knife intended for the thigh, 
 and the result will be equally satisfactory. 
 
 The Manner of grasping the Amputating Knife, prior to and during 
 the division of the soft parts, adds much to the optical effect of an 
 operation. It should be, at first, lightly grasped, with the edge for-
 
 AMPUTATIONS. 
 
 231 
 
 FIG. 314. Amputating knives. 
 
 ward, between the thumb and first two fingers, near enough to the shank 
 to admit the upper end of the handle to play between the heads of the 
 metacarpal bones of thumb and finger, when it 
 is swung backward and forward (Fig. 315). 
 There are two methods employed of carrying 
 it entirely around the limb : 1. Stand with the 
 left side toward the patient, seize the limb above 
 the point of intended operation with the left 
 hand, an assistant holding its distal extremity ; 
 place the left foot forward, slightly bend the 
 right knee, and with the catlin held by the right 
 hand, as before described (Fig. 315), stoop 
 downward and forward sufficiently to carry the 
 knife and arm under, and the knife over the 
 limb, placing its heel as near to the upper sur- 
 face of the limb as is convenient, when, with a 
 sawing motion, it is drawn toward the operator 
 beneath the limb, then upward between it and 
 the operator, and so on around, until it joins 
 the beginning of the cut, making a complete 
 circle (Fig. 316). If the knife be properly 
 grasped, it will pass readily between the thumb 
 and forefinger, as the hand passes around the limb ; enabling the sur- 
 geon to make the section with perfect ease, and without the least 
 manifestation of stiffness. 2. The method may be reversed by pass- 
 ing the hand and knife over instead of under the limb (Fig. 317) ; 
 otherwise the manipulations are the same. The latter, however, is 
 less natural, besides which it exposes the arm of the operator, and the 
 integument to be divided last, to the flow of blood. Still, either of 
 these methods is far superior to the one commonly employed and fig- 
 ured in text-books (Fig. 318). 
 
 The Catlin (Fig. 321). This is chiefly employed to divide the tis- 
 sues in the interosseous space, in amputations of the leg and forearm. 
 It can be readily supplemented for this purpose by the single-edged 
 narrow knife, provided the latter be withdrawn to complete the divis- 
 
 J 
 
 FIG. 315. How to grasp 
 the amputating knife.
 
 232 
 
 OPERATIVE SURGERY. 
 
 FIG. 316. How to carry the knife around the limb. 
 
 V 
 
 ' FIG. 817. Another method. 
 
 ry broad-bladed saw (Fig. 320) 
 and the bow-backed (Fig. 322) 
 are in common use. The first 
 meets all requirements except in 
 certain excisions, when either the 
 chain-saw (Fig. 239) or Butcher's 
 saw (Fig. 323) must be employed. 
 The narrow, movable-backed saw 
 
 ion of the interosseous 
 tissues, instead of chang- 
 ing the direction of the 
 cutting edge, while it 
 remains between the 
 bones. The latter act 
 will bruise and tear the 
 interosseous tissues. 
 
 Two or three ordina- 
 ry scalpels should be 
 added for raising the in- 
 tegument, etc. 
 
 A knife with a long, 
 narrow blade is the bet- 
 ter for amputating at 
 the phalangeal articula- 
 tions (Fig. 219). 
 
 Saws. The ordina- 
 
 FIG. 318. A common method.
 
 AMPUTATIONS. 
 
 233 
 
 FIG. 319. FIG. 320. Broad-bladed FIG. 322. Common bow-saw. 
 Metacarpal saw. 
 
 knife. 
 
 (Fig. 241) is of use in sawing small bones and removing 
 spiculae. 
 
 The Proper Method of using a Saw should be given some 
 attention (Fig. 324). After the division of the soft parts, 
 
 FIG. 321. 
 Catlin. 
 
 FIG. 323. Butcher's bow-saw.
 
 234 
 
 OPERATIVE SURGERY. 
 
 FIG. 324. Sawing the bone. 
 
 FIG. 326. Fara- 
 beuf s forceps. 
 
 FIG. 327. Catching bleeding points. 
 
 FIG. 325. Ferguson's lion-jaw for- 
 ceps. 
 
 the surgeon grasps the saw 
 firmly, places its heel close 
 to the border of the re- 
 tracted muscles, in a line 
 made through the perios- 
 teum by the knife, and, 
 while guided by the thumb- 
 nail, slowly and carefully 
 draws it toward himself 
 along the first four or five 
 
 inches of its edge, raises it from 
 the track, and places it as before ; 
 repeating the operation until a track 
 of sufficient depth is made to re- 
 tain it during the to-and-fro move- 
 ments of sawing, which should be 
 done by quick, sharp strokes, until 
 the bone is nearly severed, when 
 care must be taken, or the saw will 
 be clamped and the remaining por- 
 tion be broken off. If the handle 
 of the saw be raised and the re- 
 maining portion be divided at a 
 different angle with the bone, the 
 danger of breaking is lessened. 
 When two bones are to be sawed off,
 
 AMPUTATIONS. 235 
 
 the saw should be started in the less movable bone, and then turned 
 so as to include both. If the movable one clamp the saw, cut off 
 the more solid one first, then complete the other. The proximal and 
 distal portions of the limb should be supported and steadied during 
 the sawing of the bone. 
 
 Bone-Forceps. Liston's cutting forceps (Fig. 227) are used for 
 trimming off rough prominences. Ferguson's lion-jawed (Fig. 325) 
 and Farabceufs forceps (Fig. 326) are excellent instruments for grasp- 
 ing the bone to steady the part. They are also used for removing 
 bone by twisting, when great force is required. 
 
 How to operate. Before beginning an amputation, the operator 
 should rehearse in his mind, at least, the entire procedure as he con- 
 templates it ; by doing this he will be confident, and be certain to 
 anticipate the unimportant as well as the important details. The 
 preparation of the patient and administration of the anaesthetic, and 
 methods of dressing, are given on the pages in the fore part of this 
 work. The surgeon should always plan his work with careful precis- 
 ion, even to marking out upon the limb the outlines of the flaps, and 
 such other incisions as may be required. I am aware that this is sel- 
 dom practiced, even by the most experienced surgeons ; but, within 
 my own observations, had it been done more frequently better results 
 might have been secured. The young surgeon, too, often fancies that 
 to do this announces him as ignorant and inexperienced ; such, however, 
 is not always the case ; it rather serves to emphasize his cautious and 
 painstaking qualities. An operation should be done without haste, 
 when the safety of the patient will permit, remembering that it is done 
 quickly when done well. 
 
 The operator should stand in such a relation to the patient that the 
 left hand can readily control any undue hemorrhage by compressing 
 the artery, or otherwise. 
 
 The primary incision should be so located, if possible, that the 
 escaping blood will not obscure the course of the incisions to be subse- 
 quently made. 
 
 The incision which will divide the important vessels should be 
 made last when practicable. 
 
 In circular amputations the tissues should not be retracted until 
 after the division of the integument. 
 
 In flaps by transfixion, the tissues to constitute the flap can be 
 raised or depressed, according to the aspect of the limb from which 
 they are to be made. 
 
 After the limb is removed, the open mouths of the vessels should 
 be caught by serrefines, forceps, etc. The tourniquet, or Esmarch's 
 band, is then loosened slowly, and all bleeding points controlled by 
 suitable means (Fig. 327). The surgeon can then proceed carefully to 
 ligature the vessels thus secured.
 
 236 
 
 OPERATIVE SURGERY. 
 
 FIG. 328. Retractor for two bones. 
 
 FIG. 329. Retractor for one bone. 
 
 The Retractor is made of linen, or ordinary muslin, torn according 
 to the size and anatomical arrangement of the limb to which it is to 
 
 be applied. If for two 
 bones, one extremity of 
 the retractor should be 
 torn into three strips 
 (Fig. 328), the middle 
 one to pass between the 
 bones (Fig. 330). If 
 for one bone, the re- 
 tractor is torn partial- 
 ly through the middle 
 (Fig. 329), and applied 
 as shown in Fig. 331. 
 
 FIG. 330. Three-tailed retractor applied. 
 
 AMPUTATIONS OF UP- 
 PER EXTREMITIES. 
 
 General Remarks. 
 In all the amputations 
 
 of the hand and fingers, it is important to remember that usefulness 
 and symmetry are the ends to be attained. If strength and usefulness 
 be desiderata, all those points should be preserved into which the 
 muscles and ligaments are inserted, which endow the part with impor- 
 tant functions.
 
 AMPUTATIONS. 
 
 It therefore be- 
 comes imperative for 
 the surgeon to careful- 
 ly study the functions 
 of the muscles associ- 
 ated with the hand, 
 and to preserve as care- 
 fully as possible their 
 points of insertion. It 
 is a well - established 
 principle that every 
 portion of the hand of 
 a laboring man which 
 possesses motion and 
 can become of service 
 to him should be saved. 
 In the case of one 
 whose circumstances or 
 avocation will permit, 
 the sacrifice of useful- 
 ness to symmetry may be made with the concurrence of the patient. 
 
 Amputation at the Phalangeal Articulations. Surgical Anatomy. 
 The first row of surgical phalanges is flexed by the terminal inser- 
 tions of the flexor profundus digitorum; the 'second, by the flexor sub- 
 
 FIG. 331. Two-tailed retractor applied. 
 
 FIR. 332. Attachments of tendons to phalanges. 1. Extensor communis digitorum. 2. 
 First surgical phalanx. 3. Fibrous bands between common flexor tendons and distal 
 extremity of the third surgical phalanx. 4. Tendons of flexor sublimus digitorum. 
 5. Tendon of flexor profundus digatorum. 6. Vincula accessoria tendinum. 7. Head 
 of metacarpal bone. 8. Joint between second and third surgical phalanges. 9. Joint 
 between first and second surgical phalanges.
 
 238 
 
 OPERATIVE SURGERY. 
 
 limis digitorum ; the third, by the flexor sublimis, through the vincula 
 accessories tendinum ; by dense fibrous bands connecting the tendons 
 of the flexor sublimis with the distal extremity of that phalanx as it 
 passes across it ; also by the secondary action of the lumbrical mus- 
 cles (Fig. 332). 
 
 The Terminal Phalanx is amputated by seizing and flexing it to 
 a right angle with the second (Fig. 333) ; a transverse incision is then 
 
 FIG. 333. Flexed phalanx. FIG. 334. Making flap. FIG. 335. Flap completed. 
 
 made on its dorsal surface, on a line corresponding to the center of 
 the long axis of the second phalanx, which will open the joint ; divide 
 the lateral ligaments with the point of the knife, separate the articular 
 surfaces, and pass the blade between them, then cut along the under 
 surface of the phalanx to be removed, close to the bone (Fig. 334), far 
 enough to make a palmar flap of sufficient length to easily cover the end 
 of the bone (Fig. 335). The rule previously given regarding the length 
 of flaps will enable the operator to meet this requirement. If the at- 
 tached extremity of the flap be commenced by dividing the tissues at 
 each side of the phalanx, for three or four lines, down to the bone, 
 the knife can follow its under surface without the danger of making 
 the attached end of the flap too narrow, owing to the extremities of 
 
 the phalanges being 
 thicker than their bodies. 
 If any of the tissue of 
 the flexor tendon be in 
 the flap, it should be re- 
 moved. Tie the vessels, 
 place and retain the flap 
 in position by two or 
 three fine sutures and 
 adhesive strips ; or dress 
 antiseptically. 
 
 Amputation of the Second Row can be done in precisely the same 
 manner as at the first, or, with the finger extended, by making a 
 palmar flap first by transfixion through the palmar surface opposite the 
 joint, and cutting downward until a well-rounded flap is formed (Fig. 
 
 FIG. 336 Flap by trans- 
 fixion. 
 
 FIG. 337. Opening joint.
 
 AMPUTATIONS. 
 
 239 
 
 336). Then carry the knife upward between the articular surfaces 
 and through the soft parts on the dorsum (Fig. 337). 
 
 Either of the 
 phalanges may be 
 amputated at the 
 center by a short 
 posterior and a long 
 inferior or palmar 
 flap. If the third 
 surgical (first ana- 
 tomical) phalanges 
 be amputated at the 
 center, the power of 
 flexion is limited to 
 the lumbrical mus- 
 cle, and the vincular 
 tendons connecting 
 them with the flex- 
 or sublimis digi- 
 torum (Fig. 332). 
 When symmetry is a 
 secondary consider- 
 ation, this amputa- 
 tion may be made. 
 In the case of the 
 thumb, the index 
 and little fingers, 
 everything possible 
 adding to the length 
 of the digit should 
 be saved, as the range of motion of the thumb and little finger is more 
 extensive than the others, and the presence of the index-finger or its 
 stump greatly aids the crippled thumb in the performance of its 
 functions. 
 
 Amputation at the Metacarpo-phalangeal Articulation. It is recom- 
 mended by some that this operation be practiced in lieu of amputation 
 at the middle of the third phalanges (surgical) of the second and third 
 fingers, or even disarticulation between their second and third pha- 
 langes. I am satisfied, however, that the hand will be far stronger if 
 the stumps be allowed to remain, since they soon become easily flexed 
 and extended, and the continuance of these motions serves to stimu- 
 late and nourish the common muscles engaged in them, and thereby 
 strengthens the power of the remaining fingers. 
 
 Amputation of the Second or Third Finger. This is done by the 
 oval flap, which should be marked out before the operation is com- 
 
 FIG. 338. Amputating middle finger, oval flap.
 
 240 
 
 OPERATIVE SURGERY. 
 
 menced (Fig. 338). The flaps must be taken from the finger to be 
 removed, and should be of generous dimensions. The limit of the in- 
 cision above corresponds to the head of the metacarpal bone, the lower 
 limit to the transverse line of the palm joining the fingers to the 
 web. Separating widely the contiguous fingers, the surgeon seizes 
 the condemned finger, extends it well, and carries the incision trans- 
 versely along the line beneath, then in a curved direction upward, 
 along the side of the finger to the head of the metacarpal bone. This 
 incision is repeated on the opposite side ; the tissue carefully divided, 
 and the finger removed (Figs. 338, 339). Better drainage will be se- 
 cured if this flap be reversed by forming its retiring angle on the 
 palmar instead of the dorsal surface of the hand (Fig. 340). 
 
 Lateral-Flap Operation. This is best adapted to the thumb, in- 
 dex, and little fingers (Fig. 340) ; it can, however, be employed at 
 the ring and middle fingers. The limit of the dorsal incision is the 
 same as in the preceding. The lower limit, after crossing the trans- 
 
 FIG. 339. Finder removed. 
 
 FIG. 340. Lateral-flap method. 
 
 FIG. 341. Oval 
 method. 
 
 verse line of the web, extends toward the palm about a third of an 
 inch. The flaps are taken from the sides of the finger to be removed. 
 
 In the case of the middle and ring fingers the flaps should be equi- 
 lateral. For the thumb, index, and little finger, that portion of each 
 against which pressure is most liable to be brought should be covered 
 by a longer flap, which is taken from the outer surface of the index- 
 finger, from the inner surface of the little finger, and from the palmar 
 aspect of the thumb, the base of the flap being on a level with the 
 joint. The longer one is dissected off, after which the smaller one is 
 made. Divide the ligaments and tendons, and remove the member. 
 
 Amputation of the Thumb at the Carpo-metacarpal Articulation. 
 Oval Method. This can be employed equally well upon the thumb,
 
 AMPUTATIONS. 
 
 241 
 
 index, and little fingers. The limit of the dorsal incision in either in- 
 stance is the proximal extremity of the metacarpal bone to be removed. 
 Its palmar limit is the transverse line at the junction of the finger 
 with the palm. Begin the first incision at the base of the metacarpal 
 bone of the thumb (Fig. 341), carrying it along in a slightly curved 
 direction to the outer side of the metacarpo-phalangeal articulation ; 
 then inward through the line of the 
 web. The second one joins the first 
 near the base of the metacarpal bone, 
 and takes a corresponding course 
 along the inner side, meeting the 
 former at the inner extremity of the 
 transverse line of the web. The 
 flaps are dissected off, and the artic- 
 ulation between the metacarpal bone 
 and the trapezium is opened from 
 the ulnar side, to avoid injuring con- 
 tiguous joints (Fig. 342). The union 
 of the flaps leaves a linear cicatrix 
 (Fig. 343). 
 
 The Lateral-Flap Method (Fig. 
 344). This method can be more 
 quickly and easily performed than 
 the former, but leaves the cicatrix 
 in a less advantageous situation. Abduct the thumb and enter the 
 knife between the first and second metacarpal bones ; carry it up be- 
 tween them with a sawing motion, till the head of the first is reached. 
 
 Cautiously disarticulate it from within 
 outward ; increase the abduction, and 
 carry the blade through the joint and 
 along the outer side of the metacarpal 
 
 FIG. 342. Opening 
 joint. 
 
 FIG. 343. Flaps 
 united. 
 
 FIG. 344. Lateral-flap method. 
 16 
 
 FIG. 345. Making outer flap.
 
 242 
 
 OPERATIVE SURGERY. 
 
 bone, making the outer flap, which should terminate opposite the web 
 of the thumb (Fig. 345). 
 
 Tlie bases of the metacarpal bones of the index, middle, and little 
 fingers should be preserved in all possible instances, as they afford 
 attachment to the important extensor and flexor muscles of the carpus. 
 
 Amputation through the Metacarpal Bones. In amputation 
 through two or more of these bones, the principal flap should be 
 taken from the palmar surface, although it may be taken from the 
 border and palm of the hand (Fig. 346). If through but one bone, the 
 
 FIG. 346. Amputation through fourth FIG. 347. Amputation through one metacarpal 
 and fifth metacarpal bones. bone. 
 
 incisions are the same as those for amputation at the metacarpo-pha- 
 langeal articulation by the oval method, the only difference being that 
 their upper limit will correspond to the point of proposed section of 
 the bone (Fig. 347). The bone is exposed by reflection of the soft 
 parts upon the point of proposed section, after which it is sawn 
 through with either a chain- or metacarpal bone-saw, separated from 
 its palmar connections and removed with the finger attched. If a saw 
 be not convenient, the cutting bone-forceps (Liston) can be used, al- 
 though with some risk of splintering the bone. This operation is 
 often performed in preference to disarticulation at its head, in order 
 to give symmetry to the hand (Fig. 348). 
 
 The division of the transverse ligament, which extends between 
 the heads of the metacarpal bones, lessens the strength of the grip.
 
 AMPUTATIONS. 
 
 243 
 
 This operation is, therefore, not to be recommended except in those of 
 sedentary habits. 
 
 Amputation of the Last Four Metacarpal Bones (Disarticulatiori). 
 (Fig. 349). Make a semilunar flap from the palm by a curved incis- 
 ion, beginning at the web of the thumb and terminating at the ulnar 
 border of the fifth metacarpal bone. This flap can be made by trans- 
 fixion, if desired' (Fig. 350). The dorsal incision (Fig. 351) begins 
 
 at the same point of the 
 web of the thumb, and is 
 carried to the upper third 
 of the metacarpal bone of 
 the index - finger, and 
 
 FIG. 348. Appearance of hand FIG. 349. Line of palmar FIG. 350. By transfixion, 
 after amputation through flap, 
 
 third metacarpal bone. 
 
 from there transversely across until it meets the ulnar extremity of 
 the first incision. The flaps are now reflected up to the carpo-meta- 
 carpal joint, the hand 
 strongly abducted, and i i 
 
 the carpo - metacarpal 
 joint opened from the 
 ulnar side, using great 
 caution not to injure the 
 trapezium and the meta- 
 carpal bone of the thumb. 
 Without the thumb this 
 operation would be of lit- 
 tle avail in securing a use- 
 ful stump. Unite the 
 flaps with interrupted su- 
 tures, introduce a drain- 
 age-tube (Fig. 352), and 
 treat antiseptically. 
 
 The results of ampu- 
 tations of the thumb and 
 
 FIG. 351. Line of dorsal 
 flap. 
 
 FIG. 352. Appear- 
 ance of stump.
 
 244 
 
 OPERATIVE SURGERY. 
 
 fingers are favorable ; only three to six per cent, and even less, with 
 antiseptic precautions, die. 
 
 Amputation at the Wrist (Disarticulatiori). The bones enter- 
 ing directly into this articulation are the radius, scaphoid, and semi- 
 lunar. The location of the joint can be determined, 1, by forcibly 
 bending the carpus backward, when. the summit of the angle on the 
 dorsal surface formed by the hand and forearm indicates the radio- 
 carpal joint ; 2, by drawing a line transversely from one styloid pro- 
 cess to the other the joint is about one fourth of an inch above it. 
 This operation can be done by either the circular, single palmar or 
 radial flap, or by the double-flap method. 
 
 The Circular Method. Ascertain one fourth of the circumference 
 
 FIG. 353. Circular method. 
 
 FIG. 354. Flaps united. 
 
 at the articulation. Measure this distance downward from the articu- 
 lation, and divide the soft tissues at that point by a circular incision ; 
 dissect up the sleeve of integument until opposite the joint ; pronate 
 and forcibly flex the carpus, and open the wrist-joint on the dorsal 
 surface by an incision extending between the styloid processes ; divide 
 the lateral ligaments, pass the blade through the articulation, and 
 sever the remaining structures (Fig. 353). Unite the flaps in the long 
 axis of the joint, introduce drainage-tubes and sutures, and dress anti- 
 septically (Fig. 354). 
 
 Double-Flap Method (Ruysch). Mark out the distal limits of the 
 flaps as in the circular method ; flex and pronate the hand ; carry a 
 semilunar incision over its dorsum, beginning at the styloid process of 
 the ulna and extending to the circular line indicating the dorsal ex- 
 tent of the flap, terminating at the radial styloid process (Fig. 355).
 
 AMPUTATIONS. 
 
 24:0 
 
 FIG. 355. Making dorsal flap. 
 
 FIG. 356. Making anterior flap. 
 
 Dissect up the flap, allowing the tendons to remain ; flex the carpus 
 firmly, and open the articulation, as in the circular method; carry 
 the blade of the knife through the articulation (Fig. 356) and make 
 the anterior flap by cutting outward. 
 
 Single Palmar Flap. This method is easily performed, and makes 
 as serviceable a stump as any. Mark out a 
 flap on the palmar surface, semilunar in 
 shape, and about three inches and a half 
 in length, its base being located just below 
 the apices of the styloid processes (Fig. 
 357); reflect it upward ; divide the remain- 
 ing tissues in front of the articulation ; 
 open it, passing the knife through, and 
 making a short dorsal flap. The dorsal flap 
 can be made first, the joint opened from 
 behind, and the long anterior flap cut from 
 the joint outward. 
 
 Radial Flap (Dubrueil). Mark out a flap, semilunar in shape, 
 the base of which shall embrace the radial third of the carpus, corre- 
 sponding to the base of the second phalanx of the thumb (Fig. 358). 
 Separate the thumb-flap, then connect the extremities by an incision 
 carried transversely around the ulnar side, draw the skin upward, 
 open the joint as before, remove the carpus, and properly adjust the 
 flaps and drainage-tube (Fig. 359). 
 
 Results. The rate of mortality in amputation at the wrist-joint is 
 from fifteen to thirty per cent for gun-shot wounds, being about eight 
 per cent greater than for amputation through the forearm. 
 
 FIG. 357. Single palmar flap.
 
 246 
 
 OPERATIVE SURGERY. 
 
 It therefore follows that amputation at 
 the wrist-joint can not be recommended, on 
 the ground of safety to the patient. There 
 are other objections of less importance, 
 which, with the one just stated, should place 
 the operation in disfavor with 
 the surgeon. It makes a 
 stump which, owing to the 
 feebleness of the circulation 
 in the flaps, becomes cold and 
 even chilblained ; in addi- 
 tion, its extremity is bulbous, 
 thereby interfering with the 
 application of the properly 
 
 FIG. 358. Radial flap. 
 
 fitting sockets connected with 
 
 FIG. 359. Ap- 
 pearance of 
 stump, 
 artificial appliances. 
 
 Amputation of the Forearm. The forearm is best amputated by 
 the circular- flap method ; although the equilateral skin, and musculo- 
 cutaneous flaps are often employed. 
 
 Circular Amputation. Carefully lay out the length of the pro- 
 posed flap, based on a fourth of the circumference. Divide the 
 tissues by a circular incision down to the fascia surrounding the 
 muscles ; the integumentary cuff is then dissected upward by 
 repeated incisions directed toward the fascia surrounding the mus- 
 cles. 
 
 If the cuff be too small to be turned up readily, its most dependent 
 part when dressed can be slit up. After the flap is reflected suffi- 
 ciently, the muscles are divided half an inch or so below the line of 
 its reflection by a circular sweep of the knife down to the bone, the 
 bone sawn off, and the wound dressed in the usual manner. The in- 
 terosseous membrane and its vessels should be divided a short distance 
 below the point of proposed bone section and its borders separated 
 from those of the contiguous bones up to the point of section. This 
 avoids the risk of cutting the vessels too short, as when they are 
 divided at a level with the bones, which permits them to retract above 
 the point of easy access. These remarks apply with equal force to 
 amputation of the leg. 
 
 The Equilateral Skin-Flaps are raised from the anterior and pos- 
 terior, or internal and external surfaces of the forearm ; the latter be- 
 ing by far the most frequently adopted. Their length is determined 
 in the same manner as in the circular ; in fact, if the circular be first 
 done, and the angles of the cuff trimmed off down to near the site of 
 the muscular section, the lateral flaps will be formed. It is better, 
 however, to mark out their outlines before beginning them ; since, to 
 make each with the same curve and same breadth of base is not an
 
 AMPUTATIONS. 
 
 247 
 
 easy task without this precaution. The remaining procedures are the 
 same as those of the circular method. 
 
 Tlie Musculo- Cutaneous Flaps are made by transfixion and cutting 
 outward ; in other respects the steps do not differ from the preceding 
 operation. 
 
 Results. The rate of mortality in amputation of the forearm is 
 about fifteen per cent for all causes. 
 
 Amputation at the Elbow-Joint (Disartlculation). The methods 
 commonly employed are the circular and the single flap. Before op- 
 erating, carefully define the most prominent portions of the condyles. 
 Just below the outer, is felt the movable head of the radius ; about an 
 inch below the inner, the ulna joins the inner condyle ; the articula- 
 tion is therefore oblique, the inner portion being about half an inch 
 the lower, owing to the inner condyle being that much longer than 
 the outer. 
 
 Circular Method. Lay out the flaps in the usual manner, measur- 
 ing around the coudyles. Divide the superficial tissues down to the 
 
 fascia surrounding 
 the muscles, as be- 
 fore ; dissect the 
 flap upward to a 
 level with the joint, 
 
 FIG. 360. Amputation at elbow-joint. 
 
 FIG. 361. Circular ampu- 
 tation at elbow. 
 
 the bony indications to which should be carefully determined. For- 
 cibly extend the arm and make an incision on the line of the articula- 
 tion (oblique) down to and into it ; sever the internal and external 
 lateral ligaments, and press the arm still farther backward ; draw the
 
 248 
 
 OPERATIVE SURGERY. 
 
 olecranon process forward into the wound, and sever its connection 
 to the triceps (Fig. 360). Unite the borders of the flap as indicated in 
 the figure (Fig. 361). The flaps can also be united from before back- 
 ward, which causes the cicatrix to fall between the condyles, and like- 
 wise increases the drainage facilities two very important indica- 
 tions. 
 
 The Single-Flap Method. This flap can be made either of integu- 
 ment and subcutaneous tissue alone, or be musculo-cutaneous, and 
 formed by transfixion. In either instance it should be taken from the 
 anterior surface of the forearm. If made by transfixion (Fig. 362), 
 supinate and flex the forearm slightly, raise the soft parts in front of 
 the joint, and enter the knife an inch below the inner condyle, pass it 
 
 in front of the bones obliquely outward, 
 causing it to escape about one inch and 
 a half below the outer condyle. Cut 
 the anterior flap downward and outward, 
 making it about three inches and a half 
 in length ; dissect and draw the flap up 
 to a level with the joint in front. Make 
 the posterior flap by connecting the ex- 
 tremities of the first incision by a trans- 
 verse one (Fig. 363), and dissect this up, 
 after which the joint is opened in front ; 
 the lateral ligaments divided, olecranon 
 process displaced forward, and the tri- 
 ceps cut off. It is advisable, when pos- 
 sible, to saw off the olecranon, allowing 
 it to remain with the triceps attached. 
 The stump will be stronger if it be pos- 
 sible to sever the ulna below the inser- 
 tion of the brachialis anticus, allowing 
 the fragment to remain along with its 
 muscular attachments. In amputations 
 near the elbow, the tubercle of the ra- 
 dius, together with the biceps tendon 
 inserted into it, should be carefully pre- 
 served. 
 
 Results. The deaths from this amputation vary from thirteen to 
 twenty per cent without antiseptic treatment. 
 
 Amputation of the Arm. Either the circular, double flap, or the 
 single circular incision method of Celsus can be employed. The former 
 is usually preferred. In the second, the flaps may be antero-posterior, 
 or lateral; integumentary alone, or combined with muscular tissue. 
 The single circular operation is seldom employed at the arm. 
 
 Circular-Flap Method. Plan the length of the flap upon the cir- 
 
 FIG. 362. Flap by transfixion. 
 
 FIG. 363. Making posterior flap.
 
 AMPUTATIONS. 
 
 249 
 
 cumference of the limb at the point of proposed section. Divide the 
 superficial tissues down to the muscular fascia, and turn the flap up as 
 elsewhere ; then divide the muscles down to the bone, about an inch 
 below the reflection of the flaps. Apply the two-tailed retractor, saw 
 through the bone opposite the point of reflection of the flap, and unite 
 the flaps in the direction best calculated to provide dependent drainage. 
 Unequal Double- Flap Method. If skin alone be used, the flaps 
 should be carefully mapped out upon the integument of the arm, in 
 the general manner before described. Dissect them np, and make a 
 circular section of the muscles down to the bone ; unite the flaps, and 
 dress the stump as before. 
 
 If Musculo- Cutaneous Flaps (Langenbeck) be desired, they can be 
 made by transfixion from within outward, or with a scalpel from with- 
 out inward. The latter plan secures the more uniformity of outline 
 
 in the flap. If they are to be 
 ) made from without inward, 
 
 first mark them out carefully, 
 then with a sharp scalpel form 
 them as planned (Fig. 364) ; 
 when dissected up the desired 
 
 FIG. 364. Langenbeck's method. 
 
 FIG. 365. Unequal skin-flaps.
 
 250 
 
 OPERATIVE SURGERY. 
 
 distance, complete the operation by dividing the muscles as be- 
 fore. 
 
 Large Anterior and Small Posterior Skin-Flaps are sometimes 
 
 made (Fig. 365), also a 
 large anterior one, with 
 a posterior circular in- 
 cision (Fig. 366). They 
 possess the advantage of 
 good drainage, and of 
 placing the cicatrix where 
 it is well removed from 
 irritation. The outline 
 of these flaps can be easi- 
 ly estimated on the same 
 - basis as if they were to be 
 equal in length viz., if 
 one be proportionately 
 increased in length, the 
 other is to be shortened. 
 Results. The death- 
 rate from amputation of 
 the arm varies somewhat 
 according to the seat of 
 the operation. It is about 
 eighteen per cent when 
 FIG. 366. Long anterior flap. done in the upper third, 
 
 sixteen per cent at the 
 
 middle third, and about twenty-six per cent at the lower third the 
 greater per cent in this situation being due, no doubt, to the greater 
 degree of injury calling for it at this point. If done for disease, the 
 percentage would no doubt be reversed. 
 
 Amputation at the Shoulder-Joint (Disarticulation). There are 
 various methods recommended for amputation at this joint. It is 
 hardly necessary to enter into the details of more than two or three of 
 those commonly recognized and employed. The remainder, while 
 ingenious in many instances, do not present differences of enough 
 practical worth to be introduced into a hand-book of operative surgery. 
 Amputation ly Internal and External Flaps (Dupuytren). Place 
 the patient on the edge of the table, partially upon the healthy side, 
 with the body raised. An external oval flap is made by an incision 
 extending from the coracoid process downward and outward to the 
 insertion of the deltoid ; then upward and backward, terminating at 
 the junction of the acromion process with the spine of the scapula 
 (Fig. 367). The flap, including the deltoid muscle, is now raised as 
 far as the acromion, turned back, and the capsule of the joint exposed,
 
 AMPUTATIONS. 
 
 251 
 
 the head of the humerus pushed upward, capsule divided above ; then 
 the arm is rotated outward and the subscapularis severed ; then in- 
 ward, followed 
 by the rapid di- 
 vision of the ex- 
 ternal rotators 
 attached to the 
 greater tuberos- 
 ity. While the 
 arm is rotated 
 internally, the 
 capsule is still 
 further divided, 
 together with 
 the tendon of 
 the long head of 
 the biceps, the 
 head of the hu- 
 merus tilted out- 
 ward, and the 
 blade of the 
 knife passed be- 
 neath it (Fig. 
 368) ; the head 
 of the bone is 
 then seized and 
 drawn outward, 
 and the knife 
 carried along its 
 inner surface 
 until within 
 about four inch- 
 es below the ax- 
 illary fold, when 
 its edge is turned 
 inward and the 
 flap completed. 
 The last sweep 
 of the knife sev- 
 ers the principal 
 vessels, and this FIG. 367. Disarticulatlon of shoulder-joint, 
 
 flap should be 
 
 seized by an assistant and tightly grasped before it is completed. The 
 vessels in this operation are controlled by either pressure upon the 
 third portion of the subclavian, or by the elastic band arranged as
 
 252 
 
 OPERATIVE SURGERY. 
 
 shown in the illustration. The appearance of the wound after the 
 operation is apparent from Fig. 369. 
 
 Amputation by Circular Incision. Control the circulation as be- 
 fore. Abduct the arm and 
 make a circular incision entirely 
 around it through all the tis- 
 sues, down to the bone, at a 
 point corresponding to the in- 
 sertion of the deltoid. Saw off 
 
 FIG. 368. Making inner flap. 
 
 FIG. 369. Flaps united. 
 
 the bone and ligature the vessels. Make a second incision longitudi- 
 nally, from the anterior border of the acromion, the whole length of the 
 stump, down to the bone. The bone is then held firmly and the soft 
 parts separated from it (Fig. 370), after which it is rotated outward, 
 then inward, to admit of the division of the muscular and fibrous at- 
 tachments to its head, when it can be removed. This is a good oper- 
 ation and well calculated to provide favorable drainage (Fig. 371), and 
 is done with a minimum amount of injury to the soft parts. If the 
 periosteum be separated from the bone without disturbing the sur- 
 rounding soft parts, there will be less danger of the extension of in- 
 flammatory action beyond the line of the longitudinal incision ; more- 
 over, a greater degree of firmness will be given the stump, even though 
 new bone be not produced. 
 
 Oval Method (Larrey). This method is well thought of, and is 
 performed by making a vertical incision from the extremity of the 
 acromion process, with the arm extended, about three inches in
 
 AMPUTATIONS. 
 
 253 
 
 FIG. 370. Removing the bone. 
 
 length down to the bone ; this incision should terminate about one 
 inch below the head of the humerus. Two oblique incisions are then 
 made, each beginning near the middle of the vertical cut, one on the 
 anterior and the other on the posterior aspect of the limb ; these, when 
 carried through the structures composing the anterior and posterior 
 walls of the axilla, to the lower border of each, divide their attachments 
 to the humerus (Fig. 372). The soft parts at the inner side of the 
 humerus still remain undivided. The borders of the wound are now 
 drawn apart, the joint exposed and opened above ; the bone drawn 
 downward to separate the joint surfaces, and the blade of the knife 
 passed between them, behind the luxated bone, and the operation 
 completed by cutting the remaining tissues at the inner side of the 
 humerus intervening between the lower extremities of the incisions 
 previously made (Fig. 373). 
 
 Spence's Method has attracted considerable attention, and is cer- 
 tainly entitled to additional consideration. 
 
 It does not possess any practical advantages over the method by 
 circular incision. It is done in the following manner : Abduct the
 
 254 
 
 OPERATIVE SURGERY. 
 
 outer side. 
 
 arm slightly ; rotate the 
 humerus outward ; cut 
 down upon the head of 
 the bone, beginning im- 
 mediately external to the 
 coracoid process, thence 
 directly downward 
 through the fibers of the 
 deltoid and pectoralis ma- 
 jor to the lower border of 
 the latter, which is di- 
 vided ; carry the incision 
 with a gentle curve out- 
 ward across and through 
 the lower fibers of the del- 
 toid, to, but not through, 
 the posterior border of 
 the axilla (Fig. 374). Be- 
 gin the inner incision at 
 the lower extremity of 
 the vertical one, carry it 
 around the inner side of 
 the arm, through the 
 skin and fat only, to 
 meet the one made at the 
 If the fibers of the deltoid have been thoroughly divided, 
 
 FIG. 371. Flaps united. 
 
 FIG. 372. Larrey's method. FIG. 373. Forming inner flap. FIG. 374. Spence's 
 
 method. 
 
 the flap, together with the posterior circumflex artery, can be easily 
 separated by the finger from the bone and joint, and drawn upward
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 255 
 
 and backward until the head of the bone is exposed ; then the liga- 
 ments and muscular attachments are divided, disarticulation accom- 
 plished, and the limb removed by dividing the remaining soft parts at 
 the axillary aspect. 
 
 In very muscular subjects, a redundancy of that tissue in the flap 
 can be avoided by dissecting the integument and subcutaneous tis- 
 sues a short distance upward over the deltoid, and dividing its fibers 
 high up. 
 
 Results. The rate of mortality varies from twenty-five to thirty- 
 eight per cent for gun-shot injuries. 
 
 Amputation above the Shoulder-Joint. It may become necessary, 
 on account of malignant growths and severe injuries, to amputate the 
 scapula together with a portion or the whole of the clavicle. 
 
 The operation is often tedious and attended with great loss of 
 blood. Inasmuch as the situation of the disease or injury calling for 
 it will modify the location and direction of the incisions, no definite 
 plan can be prescribed. However, the aim should be always to save 
 enough healthy integument to cover the wound and to avoid hemor- 
 rhage. 
 
 Results. Fifty-one cases are reported, with a mortality of twenty- 
 five and a half per cent. 
 
 CHAPTEE X. 
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 No better or more comprehensive statement can be made bearing 
 on the duty of the surgeon in amputations of the lower extremity, 
 than that " under all circumstances, except where poverty, advanced 
 age, and confirmed dissolute habits so combine in the individual as to 
 render it certain that mechanical appliances would be of little service, 
 give the patient the stump best adapted to the most useful artificial 
 limbs. In all amputations of the lower extremity, the surgeon should 
 be governed in the selection of the point of operation and the method 
 to be adopted by the mortality of the operation in question ; by the 
 adaptability of the stump to the most serviceable artificial limb for 
 locomotion."* 
 
 Amputation of the Phalanges in their Continuity, or through the 
 articulations, is done by the same rules as those applied to amputation 
 of the fingers. In the case of the toes, however, it is often difficult 
 
 * From report of Drs. Valentine Mott, Gurdon Buck, John Watson, A. C. Post, Wil- 
 lard Parker, Ernst Krackowizer, W. H. Van Buren, and Stephen Smith.
 
 256 
 
 OPERATIVE SURGERY. 
 
 to open the joints on account of the changes induced in them, and in 
 the contour of the bones, by the pernicious influence of illy fitting 
 boots and shoes. The flaps are made from the plantar surface. In 
 amputation at the metatarso-phalangeal articulations, remember the 
 relation of the web to the joints in question, the former being a con- 
 siderable distance below the latter (Fig. 375). 
 
 Amputation of Single Toes (Disarticulation). T}\QJ can be re- 
 moved by the oval or by the lateral-flap method. 
 The former is the better, and is done by first 
 grasping the condemned toe, while the assistant 
 pulls aside its fellows. Commence the incision on 
 the dorsum over the joint, carry it downward along 
 the side of the phalanx to be removed, beneath 
 
 7 
 
 FIG. 375. Incision for 
 amputation at meta- 
 tarso-phalangeal ar- 
 tictilation. 
 
 FIG. 376. Removal of 
 single toe. 
 
 FIG. 377. Lateral-flap 
 method. 
 
 the toe through the line of the web to the sole of the foot. A second 
 incision is then made of a similar extent and outline on the opposite 
 side of the toe, down to the bone (Fig. 376). The ligaments are di- 
 vided, the tendons are cut off, and the bone removed by cutting from 
 below. If the extremities of the divided tendons remain exposed, 
 they are pulled down and severed on a level with the divided border 
 of the soft parts. 
 
 The removal of either the second, third, or fourth toes can be 
 effected by making a transverse incision on the dorsum over the joint, 
 and passing the knife through it and along the under surface of the 
 bone a sufficient distance to make the necessary plantar flap, which is 
 turned upward and united. If it be required to remove the whole or 
 part of the metatarsal bone of either of these toes, the dorsal incisions 
 of the oval flap for disarticulation have only to be extended upward 
 on the dorsal surface of the bone to be removed, to the point of in- 
 tended section (Fig. 376). 
 
 The lateral flap is better for the disarticulation of the great and
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 257 
 
 FIG. 378. Completion of operation. 
 
 FIG. 379. Square-flap 
 method. 
 
 little toes (Fig. 377), and is made by abducting the toe and entering 
 the knife vertically between it and the contiguous toe, and cutting 
 through the web 
 till the line of 
 articulation is 
 reached, when 
 the knife is 
 turned outward 
 from the median 
 line of the foot, 
 joint opened, 
 blade pa ssed 
 through it, and 
 the lateral flap 
 made of sufficient 
 length by cutting 
 
 along the opposite side of the toe (Fig. 378) to 
 be removed. The importance of the great toe as 
 a lever in propelling the body, requires that am- 
 putation through its phalanges be practiced when 
 possible. With the remaining toes, however, it 
 is not a matter of so much importance. 
 
 The prominent head of the metatarsal bone of the great toe, which 
 remains after disarticulation, has so frequently become the seat of 
 painful bunions, that many surgeons of prominence advise that the 
 bone be amputated behind its head by either a transverse or oblique 
 section of its shaft. Of one fact there can be no doubt : if that por- 
 tion of the boot or shoe in contact with this stump be not fitted to it 
 and kept elevated by some means, the leather will in a short time press 
 upon it, cause great annoyance, and cripple the patient unnecessarily. 
 
 The great toe can be amputated by a large square internal flap (Fig. 
 379) and by the oval method (Fig. 375). Begin the longitudinal in- 
 cision at the outer side of the extensor tendon a little below the joint ; 
 carry it through the tissues down to the first phalanx (surgical) ; make 
 a transverse incision from the termination of this one around the inner 
 side of the toe to a point opposite, on the plantar surface ; extend the 
 toe and make another incision from the termination of the last toward 
 the foot along the outer side of the tendon of the flexor longus pollicis 
 to the web ; connect this with the center of the dorsal one by a trans- 
 verse cut carried around the outer side of the base of the toe ; dissect 
 off the flaps and divide the ligaments and the remaining soft parts 
 from within outward. The oval method is performed in a similar 
 manner to the same method when applied to the fingers. 
 
 Amputation of Two Adjoining Toes. Begin the dorsal incision 
 between the metatarsal bones of the toes to be removed, just below 
 17
 
 258 
 
 OPERATIVE SURGERY. 
 
 the joint, where the bones are to be divided ; carry it to the outer side 
 of one of the toes to be removed, taking a good-sized flap from it, 
 thence through the digito-plantar fold to the outer side of the remain- 
 ing toe, back to the point of starting. Eemove each toe separately in 
 the usual manner, and close the wound. 
 
 Amputation of all the Toes at the Metatarso-phalangeal Joint 
 
 (Disarticulatiori). Forcibly ex- 
 tend the toes with the left hand, 
 and make a curved incision on the 
 plantar surface from the inner 
 side of the articulation of the great 
 toe, to the outer side of the corre- 
 sponding joint of the little toe, 
 carrying it through the groove be- 
 tween the sole of the foot and the 
 base of the toes (Fig. 380). Flex 
 the toes and join the first incision 
 by a similar one across the dorsum 
 (Fig. 381). Dissect up the flaps, 
 expose the joints, and remove each 
 Fm. 380. Plantar incision. toe separately, allowing the sesa- 
 
 moid bones of the great toe to re- 
 main. If the flaps be too short, the heads of the metatarsal bones 
 should be cut off sufficiently to permit proper adjustment, and the 
 
 FIG. 381. Dorsal incision. 
 
 divided surfaces united. When recovery takes place, the foot presents 
 the following appearance (Fig. 382). 
 
 Amputation through all the Metatarsal Bones. This is best done 
 by a short dorsal and a long plantar flap. Make the plantar flap first, 
 dissecting the tissues backward down to the bones, from the junction 
 of the toes with the sole, to the point of amputation. A short dorsal 
 flap is then made with the convexity downward, its extremities being 
 united to those of the preceding. Divide the interosseous tissues with
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 259 
 
 a sharp, narrow-bladed knife ; introduce a carbolized six-tailed re- 
 tractor (Fig. 383), draw the soft parts upward, and divide the bones 
 
 FIG. 382. Appearance of stump. 
 
 FIG. 383. Sawing the bones. 
 
 FIG. 384. Amputation at proximal end of 
 metatarsal bone. 
 
 with a fine saw, and turn the plantar flap upward and unite it in the 
 
 usual manner. 
 
 Amputation of the Great Toe with its Metatarsal Bone. This is 
 
 best done by the oval method 
 
 (Fig. 384), which is similar to 
 
 that for removal of the thumb. 
 
 It is recommended, on account 
 
 of the width of the base of the 
 
 metatarsal bone, to make a short 
 
 transverse incision across it at 
 
 the joint ; remove the flap, 
 
 thereby exposing the whole 
 
 length of the bone ; open the 
 
 joint on the dorsal aspect, sep- 
 arate its remaining connections, and remove it. 
 
 Amputation of the Fifth 
 Toe, with the Metatarsal 
 Bone. This can be done 
 by either the oval or later- 
 al-flap method ; the steps 
 of the former being in all 
 respects substantially simi- 
 lar to those for the removal 
 of the great toe. 
 
 FIG. 385. Amputation of little toe and metatarsal The lateral-flap method 
 
 bone - is done by separating the
 
 260 
 
 OPERATIVE SURGERY. 
 
 F;G. 386. a, a. Line of Lisfranc's amputation. 6. 
 Line of Hey's modification of Lisfranc's amputa- 
 tion, c. Line of Skey's modification of Lisfranc's 
 amputation, d. Line of Baudens' modification 
 of Lisfranc's amputation, e, e. Line of Forbes' 
 amputation. /, /; /,/. Lines of Miculicz's am- 
 putation, g, ff. Lines of Chopart's amputation. 
 
 fifth from the fourth toe, 
 at the same time carrying 
 a narrow-bladed knife up- 
 ward between the meta- 
 tarsal bones from the web, 
 until it is obstructed, 
 when the knife is with- 
 drawn and the incision 
 prolonged upward on the 
 dorsal and plantar sur- 
 faces in a straight line 
 about one inch. Strongly 
 abduct the metatarsal 
 bone to be removed, sepa- 
 rating it from its fellow 
 and from the cuboid ; 
 carry the knife around 
 the base to the outer side, 
 and so on downward to 
 the metatarso-phalangeal 
 articulation (Fig. 385) ; 
 remove the bone, and the 
 tongue - shaped flap just 
 made will fit the iuter- 
 metatarsal incision. 
 
 Amputation at the 
 Tarso - metatarsal Joints 
 (Lisfranc's). It will very 
 much expedite matters, 
 save considerable annoy- 
 ance to the operator, and 
 preserve the edge of his 
 knife, if the relations of 
 the bones entering into 
 the joints be fully noted 
 before attempting to open 
 them (Fig. 386). The ar- 
 ticulation between the cu- 
 boid and the fifth meta- 
 tarsal is seen to be to the 
 inner side of its tuberosity. 
 
 The joint of the inter- 
 nal cuneiform and the 
 metatarsal bone of the 
 great toe is about an inch
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 261 
 
 and a half in front of the tuberosity of the scaphoid, and the head of 
 
 the second metatarsal bone is lodged between the three cuneiform 
 
 bones. In every instance these joints must be carefully located. 
 
 Operation. Raise the foot and mark out a large semilunar flap on 
 
 the plantar surface, the base of which shall correspond to the distance 
 
 between the joints just 
 
 indicated, and its distal 
 
 extremity to the heads of 
 
 the metatarsal bones. Ex- 
 tend the foot, and make 
 
 a short dorsal flap with 
 
 the convexity forward, 
 
 and its base corresponding 
 
 to that of the plantar flap 
 
 (Fig. 387). Draw the 
 
 small dorsal flap upward, 
 
 and commence the disar- 
 
 ticulation at the outer 
 
 side of the tarsus ; strong- 
 ly extend and adduct the 
 
 bones, which will better 
 
 mark the outlines of the 
 
 articulation ; separate the 
 
 fifth, fourth, and third 
 
 articulations ; skip the second and open the first. The articulation 
 
 of the second with the cuneiform bones is peculiar, in that it is about 
 
 two fifths of an inch 
 higher (Fig. 388); 
 however, with the 
 bones depressed, a 
 short transverse in- 
 cision liberates its 
 dorsal connections 
 with the middle cu- 
 neiform, after which 
 it is disconnected 
 from the internal 
 and external cunei- 
 form bones, as well 
 as its contiguous 
 
 metatarsal, by cutting upward (Fig. 389). Open the joint well, divide 
 
 the ligaments on the side and plantar surface, carry the knife along 
 
 the sole, and make the plantar flap as previously laid out (Fig. 390). 
 
 If all the muscular tissues of the sole be removed, it will be too bulky ; 
 
 a part should therefore be omitted from it. 
 
 FIG. 387. Dorsal flap. FIG. 388. Articulation of 
 second metatarsal. 
 
 FIG. 389. Separating second metatarsal.
 
 262 
 
 OPERATIVE SURGERY. 
 
 The plantar flap may be made by transfixion, before the articula- 
 tions are opened ; this method can not be recommended, however, as 
 
 the flaps thus formed must await the 
 completion of the operation without 
 facilitating it. Moreover, if the plan- 
 tar flap be made by transfixion, before 
 disarticulation, the transverse arch of 
 the foot will be intact, causing the 
 center of the flap to be made thin, 
 since the knife can not come suffi- 
 ciently close to other than the first 
 and fifth metatarsal bones. After the 
 removal of the part, the flap appears 
 as seen in Fig. 391. This method 
 has been variously modified, the mod- 
 ifications, in some instances, becom- 
 ing confused with the original meth- 
 od. Hey sawed off the projecting 
 portion of the internal cuneiform ; this, however, is not expedient, #s 
 it lessens the attachment of the tibialis anticus and shortens the lever- 
 age of the foot. 
 
 Skey sawed off the base of the second metatarsal, leaving it in the 
 mortise. This adds nothing to the usefulness of the stump, and ex- 
 poses the remaining fragment to the danger of necrosis. 
 
 Baudens proposed that the first metatarsal bone only should be 
 disarticulated, and the remaining ones sawn off transversely on a level 
 with the internal cuneiform. 
 
 Reported as Results. The rate of mortality in amputation of the 
 toes is about six per cent. 
 
 Amputation through the Medio-tarsal Joint (Chopart's). The me- 
 
 FIG. 390. Making plantar flap. 
 
 FIG. 391. Appearance of flap 
 (after Lisfranc's amputation). 
 
 FIG. 392. Inner flap. 
 
 dio-tarsal joint is formed by the astragalus and os calcis behind, and 
 the scaphoid and cuboid bones in front. 
 
 This articulation can be located by drawing a transverse line across
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 263 
 
 FIG. 393. Inferior aspect. 
 
 the dorsum of the foot, beginning just behind the tuberosity of the 
 scaphoid ; the outer extremity will be about one inch behind the tu- 
 berosity of the fifth metatarsal bone. The foot is raised and a curved 
 incision is carried over the sole, extending from the articulation of the 
 scaphoid with the astragalus (Fig. 392), forward to within a thumb's 
 breadth of the heads of 
 the metatarsal bones 
 (Fig. 393), then across 
 the sole and backward to 
 the outer extremity of 
 the articulation of the 
 cuboid and os calcis (Fig. 
 394). Forcibly extend 
 the foot and make a 
 slightly curved incision, 
 
 through the skin only, the convexity downward, across the dorsum, 
 connecting the upper extremities of the plantar incision (Fig. 395). 
 
 Turn the dorsal flap up- 
 ward, open the joint on the 
 dorsal surface ; beginning 
 from within, bend the met- 
 atareal bones toward the 
 heel, and sever the ligamen- 
 tous connections thus made 
 tense. Finally, pass the 
 knife through the articula- 
 tion to the plantar surface, 
 turn the edge toward the 
 toes, and complete the plan- 
 tar flap (Fig. 396). Fig. 
 397 represents the stump after the flaps are united. 
 
 This operation is objected to on account of the liability of the 
 stump to become extended, causing the patient to walk on the cicatrix 
 at its anterior extrem- 
 ity. The division of 
 the tendo Achillis at, 
 or subsequent to, the 
 operation is made to 
 counteract this tenden- 
 cy ; but frequently, 
 however, without suc- 
 cess. If the foot-stump 
 be confined in a flexed 
 
 FIG. 394. Outer aspect. 
 
 :>, [ j i ' r * : - '-V-"_Vrr;rrr.~'^' -*^ 
 
 FIG. 395. Dorsal aspect. 
 
 position during the healing, and for a time afterward, there is less 
 danger of its becoming extended. This operation can not be recom-
 
 264 
 
 OPERATIVE SURGERY. 
 
 mended as a substitute for those that are to follow, in point of com- 
 fort and usefulness. Better execution is done with an artificial limb- 
 appliance after the Syme's 
 amputation than after this 
 operation. 
 
 Results. The mortali- 
 ty is about eight per cent. 
 
 Forbes 9 Modification. . 
 This is made through the 
 same incisions as Chopart's. 
 After the cuneiform bones 
 have been separated from 
 the scaphoid, the cuboid is 
 sawn through on a line with 
 them. Inasmuch as this 
 
 FIG. 396. Removing the foot. 
 
 FIG. 397. Appearance of stump. 
 
 operation offers no additional power of flexion by reason of its muscu- 
 lar attachments, its stump may become subjected to the same annoy- 
 ance as the former. 
 
 In this, as in the medio-tarsal amputation, the after-treatment ex- 
 ercises a most important 
 influence upon the results. 
 Sub-astragaloid Disar- 
 ticulation (De Lignerolles). 
 Make two lateral flaps by 
 an incision beginning im- 
 mediately above the tuber- 
 osity of the os calcis on the 
 outer side, which divides 
 the tendo Achillis, and is 
 FIG. 398. External incision. carried along the outer side
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 265 
 
 of the os calcis in a curved manner, convexity downward, below the 
 external malleolus, thence extending obliquely upward across the mid- 
 dle of the cuboid to the dorsum of the foot (Fig. 398) ; then vertically 
 downward across the inner border of the scaphoid (Fig. 399) till it 
 reaches the center of the sole of the foot ; it is then turned directly 
 backward at a right an- 
 gle with the preceding 
 cut, and joins the begin- 
 ning of the incision at 
 the inner border of the 
 tendo Achillis (Fig. 400). 
 Dissect up both flaps 
 till the lateral surface of 
 the os calcis and the talo- 
 scaphoid joints are 
 
 ex- 
 
 FIG. 399. Internal incision. 
 
 posed, being careful not 
 
 to injure the tibio-tarsal 
 
 joint ; remove the bones 
 
 in front of the medio-tarsal junction ; seize the anterior extremity of 
 
 the os calcis with bone-forceps, depress and turn it inward, and divide 
 
 the external lateral ligaments with a narrow knife about a third of 
 
 an inch below the tip of the malleolus ; then divide the interosseous 
 
 FIG. 400. Plantar incision. 
 
 FIG. 401. Internal ligaments. 
 
 ligament between the os calcis and astragalus ; finally, the talo-calcane- 
 an ligament is divided an inch below the internal malleolus (Fig. 401). 
 The os calcis is then removed (Fig. 402), and the flap united in its 
 proper position. Fig. 403 shows the appearance of the stump after 
 union of the flaps.
 
 266 
 
 OPERATIVE SURGERY. 
 
 FIG. 402. The bones separated. 
 
 Results. Over twelve per cent are reported to have died from the 
 operation alone. 
 
 Hancock's Amputation. This 
 may be considered a combination 
 of the sub-astragaloid and Piro- 
 goff's method. The operation can 
 be done through incisions similar 
 to the latter ; the flaps, however, 
 should be made somewhat longer. 
 Saw the os calcis as in Pirogoff's 
 method. Make a transverse sec- 
 tion of the astragalus (Fig. 402) ; 
 remove it, together with the asso- 
 ciated fragment of the os calcis, 
 and bring the sawn surfaces of the 
 remaining portions of the os calcis in contact with the under surface 
 of the articulated portion of the astragalus. 
 
 Tripier's Method. By this method it is thought 
 possible to prevent the retraction of the flap and 
 extension of the stump by the powerful muscles 
 attached to the heel, the os calcis is divided on 
 a level with the sustentaculum tali and at a right 
 angle with the long axis of the tibia, which makes 
 the cut surface of the bone parallel with the 
 ground. 
 
 Operation. Begin the incision of the soft 
 parts at the outer border of the tendo Achillis, on 
 a level with the outer malleolus, carry it along the 
 outer border of the foot to the base of the meta- 
 tarsal bone of the little toe, thence directly across 
 the dorsum of the foot to the base of the metatar- 
 sal bone of the great toe ; from this, it passes 
 across the sole of the foot, forming a convex flap 
 at least one inch longer than the dorsal one, join- 
 ing the outer incision at an oblique angle. The flaps are dissected up 
 sufficiently to admit of the disarticulation of the astragalo-scaphoid 
 joint and the horizontal section of the os calcis just below the susten- 
 taculum tali. If the bone be divided from without inward, the pos- 
 terior tibial artery is less likely to be injured. The wound is drained, 
 and the flaps united and surrounded by antiseptic dressing. 
 
 The results from some sources, in all forms of amputation through 
 the foot, show a death-rate of about twenty-three per cent. How- 
 ever, in this respect, the records of American surgery in these opera- 
 tions are but little in excess of ten per cent. 
 
 Irregular Tarsal Amputations (Molliere). In view of the great ad- 
 
 FIG. 403. Appear- 
 ance of stump.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 267 
 
 vantages to be gained by a strict use of antiseptic measures, in pro- 
 moting union by first intention, limiting suppuration, and lessening 
 the danger of necrosis, it is suggested that amputations across the 
 foot be made irrespective of the articulations of the tarsal bones ; in 
 other words, that the foot be treated as if it contained but one bone. 
 Heretofore, such measures have been followed frequently by necrosis 
 of the fractional portions of the tarsal bones remaining in the stump. 
 Amputation at the Ankle Removal of the Entire Foot (Syme). 
 This may be considered one of the most practical of the operations on 
 the foot and ankle. It is followed not only by a low rate of mortality, 
 but also by a most servicea- 
 ble stump, either with or 
 without an artificial appli- 
 ance. The patient is placed 
 upon a table, with the leg 
 overhanging it ; the thigh 
 raised by an assistant, who 
 at the same time flexes the 
 condemned foot upon the 
 leg, by seizing and pulling 
 upward on its anterior por- 
 tion. The outlines of the 
 respective flaps should now 
 be carefully drawn before 
 
 the incisions are commenced. The line indicating the proper course 
 of the plantar incision begins at the apex of the external malleolus 
 for left side and, with a slight backward inclination, passes around 
 
 the foot (Fig. 404) to a 
 point opposite to its begin- 
 ning, which is about a fin- 
 ger's breadth below the 
 apex of the internal malle- 
 olus (Fig. 405). 
 
 The second or dorsal 
 line is drawn directly 
 across the instep, and con- 
 nects the extremities of the 
 plantar incision. 
 FIG. 405. Inner incision. Operation. The SUr- 
 
 geon selects a scalpel of 
 
 large size and with a strong shank, and inserts the point at the com- 
 mencement of the incision down to the bone at a right angle to its 
 outer surface, with the edge undermost ; carries it along the guiding 
 line in contact with the bone to its inner extremity ; places the fin- 
 gers on the heel and the thumb within the cut, and draws firmly 
 
 FIG. 404. Outer incision.
 
 268 
 
 OPERATIVE SURGERY. 
 
 backward on the posterior flap, at the same time liberating it from 
 the outer surface and sides of the os calcis, back to near the insertion 
 of the tendo Achillis. An incision is now made down to the bone on 
 the anterior line, and the joint opened in front ; the foot well ex- 
 tended, lateral ligaments divided, and foot removed by liberating the 
 remaining tissues attached to the posterior surface of the os calcis, in- 
 cluding the tendo Achillis ; always remembering to closely hug the 
 bone, else the flap may be perforated and its integrity impaired. After 
 
 the removal of the foot, 
 dissect up the soft parts 
 around the malleoli a suf- 
 ficient distance to permit 
 the articular ends of the 
 bones to be sawn off (Figs. 
 FIG. 406. Bones of leg sawn through. 406 and 407) ; cut off the 
 
 extremities of the tendons 
 
 even with the cut surface of the soft parts, bring the flap into position, 
 unite it in front (Fig. 408), and dress with antiseptic precautions. 
 
 FIQ. 407. Heel flap. 
 
 FIG. 408. Flaps united. FIG. 409. Side view. 
 
 Modifications. Sawing the malleoli obliquely (Fig. 410) instead of 
 removing them together with a thin transverse section, that includes 
 the articular surface of the tibia, as recommended by Mr. Syme is a 
 modification which has been long and somewhat extensively practiced. 
 It is believed to give a better-shaped stump, and to be attended with
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 269 
 
 less danger to life, than if the bony canals of the tibia be extensively 
 opened, as in the case of transverse section. 
 
 Many surgeons, after making the 
 plantar incision, open the joint in front, 
 as before described, disarticulate, and 
 dissect the heel-flap from behind for- 
 ward. 
 
 This affords more room and leverage 
 to aid in the removal of this flap, but 
 increases the danger of cutting it. The 
 removal of the periosteum from the 
 sides and the posterior surface of the 
 os calcis, including the insertion of the 
 tendo Achillis, has been practiced. If 
 it can be done without too much lacer- 
 ation of its structure, it is a commend- 
 able modification. 
 
 By some, the articular cartilage re- 
 maining on the extremity of the tibia is 
 scraped off ; this procedure is thought 
 to hasten the healing process. Many 
 methods, adapted to various forms of 
 injury to the soft parts, have been de- 
 vised to modify the construction of the 
 flaps to cover the end of the stump. 
 When the heel-flap is impossible, tissues 
 can be taken from all or either of the 
 three remaining aspects of the foot to 
 
 supply it ; being ever cautious to avoid injuring the posterior tibial 
 artery, as it lies below the inner malleolus. 
 
 Fallacies. The incision across the instep lies below the line of 
 articulation between the astragalus and the tibia ; therefore, unless 
 care be taken to locate the joint, the operator will cut down upon the 
 neck of the astragalus, and, not finding the joint, will become much 
 confused ; or he may even open the articulation between the scaphoid 
 and astragalus. If the plantar flap be made too long, it will be im- 
 possible to carry it over the point of the heel ; therefore, if it be neces- 
 sary to make a long heel-flap, the joint should be opened at once 
 from before backward, and the heel-flap dissected off from above 
 downward. 
 
 Results. The rate of mortality from Syme's operation is from 
 five to nine per cent. 
 
 Roux's Operation. Begin the incision at the outer side of the 
 tendo Achillis, a little above the insertion ; carry it straight forward 
 beneath the outer malleolus (Fig. 411), then in a curved line across 
 
 FIG. 410. Oblique division of 
 malleoli.
 
 270 
 
 OPERATIVE SURGERY. 
 
 the instep half an inch in front of the articular edge of the tibia back- 
 ward and downward, in front of the inner malleolus, to the sole 
 (Fig. 412) ; then obliquely backward to near its outer border ; then 
 
 FIG. 411. Outer incision. 
 
 FIG. 412. Inner incision. 
 
 backward and upward over the heel to the point of beginning. Dis- 
 sect up the edges of the flaps, open the joint at the outer side, and 
 complete the internal flap after disarticulation of the foot. The bones 
 should then be divided, as in Syme's method ; flaps united and dressed 
 antiseptically. 
 
 Pirogoff's Amputation. This is osteo-plastic in character, and con- 
 sists in the application of the sawn surfaces of the posterior portion 
 of the os calcis (Fig. 416) to the sawn surfaces of the bones of the leg. 
 The length of the limb is well preserved, and, without the use of an 
 
 artificial appliance, the 
 stump is often superior to 
 that of Syme's operation. 
 Operation. Flex the 
 foot at a right angle with 
 the leg ; make an incision 
 down upon the bone, from 
 the tip of the internal 
 malleolus directly across 
 the sole, its lowermost 
 portion being a little in 
 front of the long axis of 
 the tibia (Fig. 413), 
 around the foot to a point 
 in front of the apex of 
 the external malleolus 
 (Fig. 414). 
 
 The extremities of 
 this are connected by 
 another carried down to 
 the bone", half an inch in 
 FIG. 414. Outer incision. front of the lower extrem- 
 
 ity of the tibia. Open 
 the joint in front, divide the lateral ligaments, disarticulate the
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 271 
 
 head of the astragalus (Fig. 415), and with a narrow saw divide the 
 
 os calcis obliquely downward and 
 forward in the line of the plantar 
 incision. Raise the anterior flap, 
 dissect up the tissues around the 
 lower ends of the bones, and saw 
 
 V" 
 
 FIG. 415. Separating articular surfaces. 
 
 FIG. 416. Lines of section of os calcis. 
 
 through the lower extremities of the tibia and fibula, just above their 
 articular surfaces. If any of the divided tendons be below the edge 
 of the wound, cut them off on a level with it. 
 
 The cut surface of the os calcis is then brought forward and placed 
 in contact with that of the tibia ; the wound united and dressed anti- 
 septically. 
 
 Fallacies. If the posterior border of the os calcis be cut too long, 
 the divided bone surfaces can not be properly 
 apposed without force which will cause the 
 fragment to tilt backward. This can be reme- 
 died by removing more bone from this border, 
 or by dividing the tendo Achillis. Whenever 
 this tendon inclines to tilt the bone, it should 
 be divided. The fragment can be united to 
 the tibia by silver wire to retain the sawn sur- 
 faces in apposition. The os calcis has been 
 sawn at different angles to that bone (Fig. 416), 
 but the one just considered has given the most 
 satisfactory results. Fig. 417 shows the ap- 
 pearance of the stump after Pirogoff's operation. 
 
 Results. The death-rate from this opera- 
 tion is about ten per cent. 
 
 Modifications of Pirogoff's Operation. 
 Fergusson's modification consists in not remov- 
 ing the malleoli, unless they are diseased, but Fm 417 ._ Appearance of 
 in dividing the tendo Achillis, and placing the stump.
 
 272 
 
 OPERATIVE SURGERY. 
 
 sawn end of the os calcis between them. Dr. Turnipseed and others 
 have practiced this modification and recommend it. 
 
 Le Fort's Modification. The incisions for the flaps are similar to 
 those in Eoux's modification of Syme's amputation. The ankle-joint 
 is exposed by raising the dorsal flap, keeping close to the bone so as 
 not to injure the posterior tibial artery. Divide the external lateral 
 ligament, and the ligaments between the astragalus and os calcis. 
 Turn the foot inward, and remove the anterior portion of the foot at 
 the medio-tarsal joint. Seize the astragalus with strong forceps, make 
 tense the ligaments connecting it with the bones above, which should 
 then be cut and the bone removed. Push down the os calcis, and 
 with a narrow saw remove its upper third 
 from behind forward, beginning just 
 above the insertion of the tendo Achillis. 
 Saw off the malleoli and the articular 
 surface of the tibia, as in Pirogoff's opera- 
 
 FIG. 418. Sawn bones in Le Fort's method. 
 
 FIG. 419. Appearance of stump in 
 Le Fort. 
 
 tion (Fig. 418) ; place the sawn surfaces in apposition, and dress in 
 the usual manner. This modification permits the reserved fragment 
 
 of the os calcis, when placed in 
 position, to maintain the same rel- 
 ative axis to the end of the stump 
 that it held to the foot ; conse- 
 quently the direct pressure is re- 
 ceived upon the integumentary 
 covering already adapted to the 
 purpose (Fig. 419). 
 
 Bruns recommended that the 
 sawn surfaces of the os calcis be 
 made concave, and the tibia con- 
 Fm 420. Bruns' modification. VCX (Fig. 420).
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 2T3 
 
 FIG. 421. Outer incision. 
 
 Esmarctts Modification of Le Fort's operation consists of two in- 
 cisions : one across the sole, the other across the dorsum of the foot. 
 The former commences about four fifths of an inch below the tip of 
 the external malleolus, 
 and with the convexity 
 forward (Fig. 421), runs 
 under the cuboid and 
 scaphoid bones (Fig. 
 422), ending at the inner 
 side, one inch below and 
 in front of the internal 
 malleolus (Fig. 423). 
 The curved dorsal incis- 
 ion (Fig. 424), with its 
 concavity forward to the 
 tuberosity of the scaph- 
 oid, connects the ex- 
 tremes of the plantar one. 
 Dissect up the dorsal flap 
 to the tibio-tarsal joint, 
 which should be opened, 
 the foot bent downward, 
 and the upper surface of 
 the os calcis exposed suf- 
 ficiently to apply a small saw behind the upper margin of the tuber- 
 osity of the os calcis and the bone sawn, as before described (Fig. 418). 
 
 The flaps are then 
 united, drained, and 
 dressed antiseptically. 
 Osteoplastic Am- 
 putation of Heel and 
 Ankle (Mikulicz). 
 This operation is spe- 
 cially indicated in 
 cases in which the tis- 
 sues composing the 
 posterior part of the 
 foot have been de- 
 stroyed. 
 
 Operation. Select 
 a strong scalpel and 
 make an incision from 
 just in front of the 
 tubercle of the scaph- 
 oid directly across the 
 
 FIG. 422. Plantar incision. 
 
 FIG. 424. Dorsal incision. 
 
 18
 
 274 OPERATIVE SURGERY. 
 
 sole of the foot, down to the bone, terminating just behind the base of 
 the fifth metatarsal bone. From each extremity of the plantar incis- 
 ion, one is carried upward and backward to the bone of the corre- 
 sponding malleolus, and the upper extremities of these incisions are 
 connected by a fourth, passing directly transversely behind the limb 
 and carried through the tendo Achillis. The lateral ligaments of the 
 joint are divided, the joint opened from behind, and the calcaneum 
 and the astragalus are carefully dissected out and removed by disar- 
 ticulation at the medio-tarsal joint. The malleoli, including the 
 articular surface of the tibia, are sawn off transversely, and also the 
 cuboid and scaphoid bones are sawn transversely through on a line 
 corresponding to the middle of the latter bone. The sawn surfaces of 
 bone are then placed in contact with each other, and wired or pegged 
 in position. 
 
 AMPUTATIONS OF THE LEG. 
 
 Supra-malleolar Amputation. This operation resembles more near- 
 ly a Syme, in location, than any other that can be performed upon the 
 leg ; but, owing to the comparatively high rate of mortality resulting, 
 it is not to be recommended in preference to a higher amputation. 
 The flaps must always be made from the firmest and best-nourished 
 tissues accessible. 
 
 Operation. Two semilunar incisions, one external and one inter- 
 nal, are made, each beginning posteriorly at the posterior border of 
 the malleoli, and passing forward beneath them, then around upon the 
 dorsum of the foot, an inch in front of the ankle-joint, where they 
 join each other. Their posterior extremities are then united by a 
 curved transverse incision, with the convexity downward. The flaps 
 are dissected upward, and the bones of the leg divided transversely 
 about an inch above the articular surfaces. 
 
 Amputation of the Leg at the Lower Third. When possible, the 
 leg must always be amputated at this situation. It gives a long ful- 
 crumage for an artificial limb, and admits of the formation of a sym- 
 metrically tapering stump, which can be closely adjusted to the socket 
 of the artificial appliance. 
 
 Three methods can be employed : the circular, the bilateral, and 
 the hood flaps, embracing only the integument and subcutaneous tis- 
 sues, or combined with the periosteum covering the subcutaneous sur- 
 face of the tibia. 
 
 Circular Method ivith Periostea! Reflection. If the situation can 
 be selected for the site of the operation, it should be three or three 
 inches and a half from the lower extremity of the tibia; or, more 
 definitely, at the point where the tapering of the limb from above 
 downward ceases. The length of the flap should be equal to a fourth 
 of the circumference of the limb at the proposed point of section. 
 
 Operation. Prepare the patient in the usual manner; make a cir-
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 275 
 
 cular incision through the integument and subcutaneous tissue down 
 to the muscular fascia and the subcutaneous surface of the tibia. 
 Dissect the sleeve for about an inch all around, then divide the perios- 
 teum on the subcutaneous surface of the tibia, by a transverse incis- 
 ion at the point of reflection of the flap ; divide it also longitudi- 
 nally at the outer and inner borders of the surface of the tibia a suffi- 
 cient distance one fourth of an inch to allow the periosteum to be 
 reflected upward while attached to the inner surface of the flap. 
 These longitudinal incisions are repeated as often as it becomes neces- 
 sary to detach the periosteum and keep pace with the turning up of 
 the flap at the remaining portions of its circumference. That is, in- 
 stead of dissecting the flap from the tibia, its periosteum is detached 
 from its subcutaneous surface, and pushed up to the point of proposed 
 section while still adherent to, and forming a limited lining to the 
 flap. Fig. 425 shows the extent of the reflection of the periosteum, 
 
 which, however, in the operation, remains 
 attached to the inner surface of the corre- 
 sponding portion of the flap. The tibia 
 is sawn carefully through at the highest 
 point of the periosteal reflection, the fibula 
 
 Line indicating antero-postenor 
 
 8ab " 
 
 ne indicating oblique coapta- 
 tion of flaps. 
 
 FIG. 425. Reflection of the peri- 
 osteum. 
 
 FIG. 426. Oblique coaptation. 
 
 exposed one fourth of an inch higher and divided separately by sawing 
 toward the tibia. The flaps are then united obliquely, so that not 
 only will the line of union fall between the two bones, but that which 
 is more important the periosteal lining of the inner portion of the 
 flap will fall and lie smoothly across the divided extremity of the 
 tibia, since the subcutaneous surface of the tibia lies parallel with the 
 line of oblique coaptation (Fig. 426). It will be necessary, in order
 
 276 
 
 OPERATIVE SURGERY. 
 
 to reflect the sleeve-flap, that it be divided longitudinally ; this 
 is done at such a point as will become lowermost when the flaps are 
 obliquely joined. The limb should be dressed antiseptically, using cau- 
 tion to maintain the oblique direction of the 
 flaps till the healing process is complete. 
 The periostea! flap grows to the end of the 
 bone, preventing it from becoming atro- 
 phied, and likewise preventing the adhesion 
 
 Periosteum on 
 subcutaneous 
 surface of tibia 
 
 Tibia. 
 
 Cicatrix. 
 
 FIG. 427. Dissected specimen showing the relation 
 of parts. 
 
 FIG. 428. Bilateral flaps. 
 
 of the cicatrix to the end of the tibia. Fig. 427 shows a longitudinal 
 section through the flap three months after this operation had been 
 done. 
 
 Results. Of the eight cases done by myself all have resulted in ex- 
 ceptionally serviceable stumps. In no instance have bony spiculae ap- 
 peared, and in each the stump has given entire satisfaction to the 
 patient. 
 
 The Bilateral Flap Method (Fig. 428, a) consists of equilateral 
 flaps constructed from the integument and subcutaneous tissue at the 
 outer and inner surface of the limb. The operation may be performed 
 by this method either with or without the periosteal lining. The cir- 
 cular, with oblique coaptation, is by far the better method if the peri- 
 osteum be raised ; since in antero-posterior coaptation, the periosteal 
 flap will be tilted, and become more liable to eversion and the produc- 
 tion of bony spicular growths.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 277 
 
 The bilateral flaps are made by first ascertaining the circumfer- 
 ence of the limb at the point of the proposed amputation. The base 
 of each flap is then made equal to half, and the length to one fourth 
 of this circumference. Each one is nearly semicircular, and their 
 points of junction should be at the center of the limb, anteriorly and 
 posteriorly, which will bring the anterior point of union to the inner 
 side of the crest of the tibia ; it should also be a little below the point 
 of the proposed section of the tibia. The posterior point of junction 
 is made above that of the anterior, to provide for suitable drainage 
 (Fig. 428, a). When properly outlined, each flap is dissected upward 
 to near the point where the bone is to be divided ; the muscles are 
 divided by a circular incision, then pushed upward above the anterior 
 point of union of the flaps, and the bones sawn off the fibula a fourth 
 of an inch the shorter on a line corresponding to the junction of the 
 flaps posteriorly. If there be an undue amount of muscular tissue be- 
 hind, it can be trimmed off until it admits of the ready union of the 
 divided borders of the flaps. Suitable drainage, antero-posterior co- 
 aptation, and an antiseptic dressing, comprise the immediate atten- 
 tion to the case. 
 
 The Hood, or Oval Flap Method is a modification of the circular, 
 the skin-cuff being slit up posteriorly to the point at which the bone 
 is to be divided, and the corners trimmed off to resemble the outlines 
 of the lower portions of the bilateral flap. This flap is then reflected 
 upward, and the muscles and bones divided as before. The line of 
 union is made antero-posteriorly. 
 
 The advantages claimed for this method are : its perfect drainage ; 
 the location of the cicatrix on the posterior surface ; and the carrying 
 of the integument over the end of the bone, thus preventing the adhe- 
 sion of the cicatrix to it. Like the bilateral, it can be employed in con- 
 nection with the periosteal flap ; still, as it is joined to form an antero- 
 posterior line of union, it is open to the same objections as the former 
 with reference to the periosteum. 
 
 Results. The rate of mortality from amputation in the lower third 
 is variously estimated at from thirteen to twenty-two per cent ; this 
 being, however, less than at any other part of the limb. 
 
 Amputation through the Middle Third. The limb can be ampu- 
 tated at this point by the same methods employed at the lower third 
 of the leg. The principles applicable to the lower third have an equal 
 force at this situation. The presence of the calf offers an additional 
 difficulty in obtaining the oblique coaptation, but does not interpose 
 an insurmountable obstacle to it. Care in dressing the stump will 
 maintain the obliquity of the line of coaptation in the periosteal flap 
 method. The bilateral and hood flap methods, either with or without 
 the periosteal lining, present to the surgeon the means of making a 
 most serviceable stump. If other than the preceding be desired, the
 
 278 
 
 OPERATIVE SURGERY. 
 
 FIG. 429. Long external flap. 
 
 long external and short internal flaps are to be preferred, instead of 
 either the long anterior or the long posterior, since either of these im- 
 pede drainage, and both by their weight exert undue traction across 
 the crest of the tibia. 
 
 The Unilateral Flap Method, combined with a semicircular in- 
 cision on the opposite side, offers good 
 drainage, and carries the cicatrix be- 
 yond the point of pressure. 
 
 These flaps may be muscular or in- 
 tegumentary ; the former are made by 
 transfixion, the latter by external in- 
 cision with the ordinary scalpel, and 
 circular section of the muscles with 
 the long knife. The principles con- 
 trolling the length of the flaps are the 
 same as previously stated. The long 
 flap should be made from the outer 
 side of the leg, having a base some- 
 what less than one half the circumfer- 
 ence of the limb. The inner, or short 
 flap, is semicircular in shape (Fig. 429). 
 The bones are sawn off just above the anterior point of junction of the 
 flaps, which are then to be united, and the wound dressed as before. 
 
 Results. The rate of mortality of amputations in this portion 
 of the limb is about twenty-seven per cent. 
 
 Amputation at the Upper Third. Either of the methods em- 
 ployed in the middle third is applicable at this situation. The fibula 
 should not be removed, as the superior tibio-fibular articulation some- 
 times communicates with the knee-joint. The tibia is sawn below the 
 insertion of the ligamentum patellae. 
 
 Results. The mortality is about forty-three per cent. 
 Amputation at the Knee- Joint (Disarticulation}. The bilateral, 
 the circular, the' long anterior, and the hood flaps are the ones best 
 constituted to meet the indications. The stump resulting from either 
 has an early sustaining power with a broad point of support, which, 
 however, later in life becomes somewhat lessened in size. The joint 
 surface is not to be molested in any other way than by scraping off 
 the articular cartilage. 
 
 The patella, unless diseased, should be allowed to remain. It will 
 be found to rest just above the condyles, where it affords a good point 
 of attachment for the quadriceps extensor. The ligaments should be 
 divided close to the femur, the semilunar cartilages remaining attached 
 to the tibia. The popliteal artery is tied, only after sufficient isolation 
 to admit of the application of the ligature above the articular branch- 
 es. The popliteal vein also should be isolated and tied.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 279 
 
 Bilateral Method. This, "without doubt, is the best method. It 
 provides two well-nourished flaps, which, when united, locate the 
 cicatrix between the condyles posteriorly, thereby affording admirable 
 drainage. 
 
 Operation. With the thigh elevated and the leg extended, begin 
 the anterior incision of either flap, one inch below the tuberosity of 
 the tibia, cutting through the skin and subcutaneous tissues and mus- 
 cles. Carry it downward and forward below the curve of the leg, 
 thence inward and backward to the middle of the under surface of the 
 leg, then directly upward to the middle of the popliteal space (Fig. 428, 
 #). The opposite flap is made in a similar manner ; remembering, how- 
 ever, that the flap at the inner side must be made the longer, on ac- 
 count of the greater length and size of the inner condyle. Eaise the 
 flaps until the articulation and the apex of the patella are reached ; 
 divide the ligamentum patellae ; open the joint in front ; divide the 
 crucial ligaments ; draw the head of the tibia forward, and pass a long 
 knife behind it ; extend the leg somewhat and cut the remaining tis- 
 sues directly downward. Before severing these tissues be careful to 
 ascertain if perfect control be had of the femoral artery. After re- 
 moval of the leg the flaps present the appearance shown in Fig. 
 430. The flaps are united and suitable drainage provided. A not in- 
 
 FIG. 430. Appearance of the flaps. 
 
 FIG. 431. Appearance of the stump. 
 
 frequent sequel to this operation is the formation of an abscess beneath 
 the quadriceps extensor, due to the collection of pus at the upper end 
 of the synovial pouch of the joint ; the elevation of the stump causing 
 it to gravitate to that point. This can be avoided by the division of 
 the lateral synovial bands commanding the entrance to it, and the in- 
 troduction of a drainage-tube to the uppermost portion ; or by carrying 
 the tube through the uppermost extremity to the anterior surface of the 
 thigh. Sometimes compression firmly and continuously applied over 
 the pouch will answer the purpose. When healed the stump presents 
 the appearance shown in Fig. 431. If care be not taken in the applica- 
 tion of the dressings, undue pressure will be made on the tissues cover- 
 ing the condyles of the femur, causing ulceration and even sloughing.
 
 280 
 
 OPERATIVE SURGERY. 
 
 Fallacy. It has, however, one fallacy, which has been the cause 
 of much chagrin to surgeons on rare occasions the danger of mak- 
 ing the flaps too short, followed by the necessity of removing the 
 patella, or sawing off the condyles before the flaps can be properly 
 united. If the semilunar fibre-cartilages be permitted to remain con- 
 nected with the femur, they will lessen the degree of retraction of the 
 soft parts; however, when thus allowed to remain, they not infre- 
 quently slough away. 
 
 Circular Method. Extend the leg and make a circular incision 
 around it, about four inches below the patella, through the integu- 
 ment and subcutaneous tissues. Dissect it up to the edge of the pa- 
 tella ; flex the leg and divide the ligamentum patellae at its apex ; then 
 open the joint in front, and divide the lateral ligaments close to the 
 
 FIG. 432. Circular flap method. 
 
 femur, so that the semilunar cartilage will remain connected with the 
 tibia. Flex the leg and cut the crucial ligaments. Pass a long knife 
 between the bones, extend the leg, and sever the posterior connections 
 as before (Fig. 432). The flaps can be united from before backward 
 
 FIG. 433. Anterior-posterior coaptation. 
 
 FIG. 434. Transverse coaptation. 
 
 (Fig. 433), or transversely (Fig. 434), the former being the better 
 method, for obvious reasons.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 281 
 
 Long Anterior, with a Short Posterior Flap. Flex the leg and 
 make a longitudinal semicircular-shaped flap, beginning a little below 
 the center of the in- 
 ner surface of the inter- 
 nal condyle, extending 
 around in front five 
 inches below the pa- 
 tella to a similar point 
 on the external con- 
 dyle (Fig. 435). Dis- 
 sect the flap upward 
 to the patella, open the 
 joint as before ; draw 
 the head of the tibia 
 forward and pass a long 
 knife behind it, mak- 
 ing the short posterior 
 flap from above down- 
 ward, beginning the 
 incision at the upper 
 borders of the anterior Fio. 435. Line of incisions. 
 
 flap. When united the 
 cicatrix is well protected and good drainage afforded (Fig. 436). 
 
 Hood Flap. This varies but little from the bilateral ; having a 
 
 somewhat oval outline in 
 front, instead of a retiring 
 angle. 
 
 Results. The rate of 
 mortality from amputation 
 through the knee-joint varies 
 but little from amputations 
 of the lower limb, as a whole, 
 averaging in the latter about 
 thirty-four pei; cent ; in the 
 former, thirty-two per cent. 
 Amputation through the 
 
 knee-joint offers, as a rule, a better chance for life than through the 
 upper third of the leg. 
 
 Amputation through the Condyles. This measure possesses no 
 advantage over the one made through the articulation. The rate 
 of mortality is somewhat increased, being reported at about forty- 
 eighb per cent, although this would be, without doubt, much less- 
 ened by the employment of antiseptic measures ; and the useful- 
 ness of the stump is decidedly in favor of the latter. However, 
 as conditions sometimes arise rendering the disarticulation imprac- 
 
 FIG. 436. Appearance of stump.
 
 282 
 
 OPERATIVE SURGERY. 
 
 ticable, amputation through the condyles becomes a valuable expe- 
 dient. 
 
 Cardenas Amputation, Extend the leg, seize the joint with the 
 left hand, the end of the thumb and index-finger resting as nearly as 
 possible over the center of each condyle. With a stout scalpel make 
 an anterior semilunar flap, commencing at the point indicated by the 
 end of the index-finger, passing around in front about two inches be- 
 
 FIG. 4?7. Garden's method. 
 
 FIG. 438. Gritti's and Stokes' method. 
 
 low the patella to the end of the thumb on the opposite side. If the 
 question of amputation or excision be undecided, reflect the anterior 
 flap first ; then, if the condition of the parts require amputation, con- 
 nect the extremities of the anterior flap by a short posterior one car- 
 ried directly down to the bone (Fig. 437). Eeflect both flaps upward 
 to the base of the condyles ; flex the leg to draw down the patella, and 
 divide the remaining tissues surrounding the condyles down to the
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 283 
 
 bone ; then saw off the condyles at their base, secure, the vessels as 
 before described, and unite the divided parts. 
 
 Results. The rate of mortality as reported by Garden was about 
 seventeen per cent. 
 
 Gritti's Amputation (Fig. 438, a). Extend the leg and make a 
 rectangular flap, extending from the center of the condyles to the tu- 
 berosity of the tibia. Divide the ligamentum patellae at its insertion 
 and dissect up the flap containing it. Divide the integument on the 
 posterior surface by a circular incision. Remove the synovial mem- 
 brane from its attachments to the femur in front, and saw the bone 
 just above the articular cartilages. Introduce a long knife and cut 
 the remaining tissues from within outward. Saw off the articular 
 surface of the patella. Allow the anterior flap to fall into position, 
 causing the sawn surface of the patella to come in contact with the 
 divided end of the femur. This operation is osteo-plastic in charac- 
 ter, being allied to Pirogoff's. 
 
 Stokes' Modification of Gritti's method consists in making an an- 
 terior oval instead of a rectangular flap the posterior flaps being 
 made one third its length ; and the femur is sawn off an inch above 
 the condyles (Fig. 438, Z>), instead of through their base. The car- 
 tilaginous surface of the patella is scraped off, and it is then united 
 to the extremity of the femur by strong catgut passed through the 
 soft tissues immediately behind the bone. 
 
 Results. The rate of mortality for Gritti's operation and Stokes' 
 modification is reported at about thirty per cent. 
 
 Amputation of the Thigh. The muscles surrounding the thigh are 
 of large size and many of them of great length. Those on the pos- 
 terior and many on the anterior surface extend from the pelvis to the 
 leg. On the inner side their length is but little less and their bulk is 
 increased. 
 
 The greater the length of a muscle from its origin to the point of 
 division, the more marked will be its retraction, other things being 
 equal. It therefore happens, in amputation of the thigh, unless care 
 be exercised to allow for the greater degree of contraction of the long 
 muscles, that the bone protrudes, or presses too strongly against the 
 flap, giving it an undue conicity, or otherwise distorting the stump. 
 The position in which the limb rests during the healing process has an 
 influence on the muscular retraction. For instance, if the limb be 
 extended during the division of the muscles, the posterior ones, on 
 account of their greater length and tension, retract the most, and if 
 to this be added the additional retraction due to placing the stump 
 in a semi-fixed position on a pillow, or by swinging during the heal- 
 ing process, the tendency to cause tender, painful, and otherwise 
 troublesome stumps is increased. To avoid this, the limb should be 
 held as nearly as possible at the same angle with the body, when the
 
 284 
 
 OPERATIVE SURGERY. 
 
 muscles are being divided, as that in which it will be placed when the 
 dressing is completed and during the process of recovery. 
 
 In all amputations of the thigh an ante- 
 rior rectangular, or oval periostea! flap should 
 be made, its outer surface remaining associ- 
 ated with the tissues connected with or spring- 
 ing from it (Fig. 439, a). If an amputation 
 be made close to the band of a tourniquet 
 or the elastic bandage of Esmarch, the mus- 
 cles will be held too firmly to admit of the 
 natural retraction until after the bone is sawn 
 and they are liberated ; this is a fault which 
 must be recognized and corrected by cutting 
 the muscles lower than would otherwise be 
 done. 
 
 Bilateral Flap Method. (Fig. 428, c). 
 This is admirably adapted to both the middle 
 and lower thirds of the thigh. 
 
 The outlines of the flaps are integument- 
 ary, and are dissected up from the muscles 
 two inches, or about half their length. The 
 muscles are divided by a circular sweep of the 
 knife, and the bone sawn off at the same situ- 
 ation. In the circular division of the mus- 
 cles, accompanied by the circular or equilat- 
 eral flaps, it is advisable that the first sweep of the knife should divide 
 only the superficial layer, which will then retract or can be drawn up- 
 ward and the second layer be severed at a 
 higher point, causing the open stump to pre- 
 sent a conical cavity, the sawn bone corre- 
 sponding to its apex (Fig. 440). The end 
 of the bone is then seized by strong forceps, 
 the soft parts on its posterior surface and 
 sides pushed up, and with a small, sharp- 
 pointed knife an oval or rectangular-shaped 
 flap of periosteum is marked out and pushed 
 upward from the anterior surface of the bone, 
 together with the soft parts resting upon it 
 (Fig. 439, a). The base of the periosteal flap 
 must correspond to the point of secondary 
 division of the bone, which will be about two 
 inches above the primary section. The bone 
 is sawn again and removed. The portion of the flap having the peri- 
 osteum is allowed to fall into its proper position across the end of 
 the divided femur ; the edges are united, and stump dressed as desired. 
 
 FIG. 439. Periosteal flap. 
 
 FIG. 440. Conical cavity.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 285 
 
 Vermale recommended that these flaps be musculo-integumentary. 
 Although these are favorable for drainage, their weight is liable to lead 
 to exposure of the bone at the upper angle of the wound. 
 
 Antero -posterior Musculo - integumentary 
 Flaps. These flaps include all of the tissues 
 down to the bone, and are made by transfixion 
 usually, although the anterior one may be made 
 by cutting from without and the posterior by 
 transfixion at the upper limit of the former. 
 The length of each flap should be about one 
 fourth the circumference of the limb. When 
 both flaps are to be made by transfixion, the tis- 
 sues should be raised somewhat by the left hand 
 of the operator, who then enters the point of 
 the knife at the side nearest himself, pushes it 
 through in close contact with the anterior sur- 
 face of the bone, and raises the handle a little 
 as it passes to cause the porat to emerge at the 
 opposite side of the limb, exactly opposite the 
 entrance. This flap is then formed by cutting 
 obliquely upward with a sawing motion, and 
 when completed is pulled backward by an as- 
 sistant assigned for that purpose. The knife is 
 reinserted at the original point of entrance, car- 
 ried behind the bone, point elevated so as to 
 emerge at the same situation as before, and the 
 posterior flap is made by cutting obliquely 
 downward. The remaining muscular fibers around the bone are cut by 
 a circular sweep of the knife, retractors applied and the bone divided. 
 In flaps of this structure the skin retracts more than the muscles, 
 causing the lower ends of the latter to be exposed. To avoid this, 
 Agnew recommends that the flaps be formed first from the integu- 
 ment, reflected up an inch and a half, and the muscles be divided 
 by transfixion ; the point of the knife being pushed through at the 
 junction of the reflected integumentary flaps. 
 
 The Circular Integumentary Flap method can be employed upon 
 the thigh, and with admirable results. The principles governing its 
 construction are similar to those applicable to this method in other 
 situations. The division of the muscles should be at a point not less 
 than two inches below the reflected flap, and their respective layers 
 should be divided independently, as seen in Figs. 440 and 441. 
 
 The Single Circular Incision Method (Celsus). Control the cir- 
 culation, and with a long knife divide all the soft parts by a circular 
 sweep down to the bone (Fig. 442), which is then sawn off. 
 
 The end of the divided bone is now seized by strong forceps, the 
 
 FIG. 441. Amputated 
 portion.
 
 286 
 
 OPERATIVE SURGERY. 
 
 surrounding soft parts drawn upward, the bone exposed, when, if de- 
 sirable, an oval periosteal flap can be made, its base corresponding to 
 
 the site of secondary 
 section of the bone 
 (Fig. 439). Saw the 
 bone a second time 
 close to the periosteal 
 flap, and allow the 
 parts to fall into po- 
 sition. They can be 
 united transversely 
 (Fig. 443) or the re- 
 verse ; the former holds 
 the periosteal flap in 
 position the better. 
 
 Long Anterior Flap 
 Method (Sedillot). 
 This can be employed 
 in any portion of the 
 thigh. Mark out on 
 the anterior surface of 
 the limb a flap, the 
 length of which is equal 
 to one third, and its 
 base to two thirds of 
 the circumference. Di- 
 vide the tissues, ob- 
 liquely, upward and backward, not making the flap too thick. The 
 tissues on the posterior por- 
 tion of the limb are divided 
 transversely down to the 
 bone, which is then exposed 
 about two inches higher and 
 sawn off. 
 
 Results. The rate of mor- 
 tality, in amputations of the 
 lower third of the thigh for 
 gun-shot injuries, is fifty- 
 five per cent ; at the middle 
 
 FIG. 442. Celsus' sinprle circular incision. 
 
 third, sixty-five per cent ; and 
 at the upper third, seventy- 
 eight per cent. About thir- 
 teen per cent more recover 
 with expectant treatment, in 
 gun-shot injuries, than after 
 
 FIG. 443. Appearance of stump.
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 287 
 
 amputation. The rate of mortality after primary amputations is 
 twenty-one per cent greater than after secondary. The results are 
 considerably more favorable when done in private practice, or with an- 
 tiseptic precautions, irrespective of the cause. 
 
 Amputations at the Hip. The causes of death from this amputa- 
 tion are, loss of blood, shock, 
 and septicaemia. Various plans 
 to limit the loss of blood have 
 been suggested compression 
 of the abdominal aorta by the 
 fingers of a hand introduced 
 into the rectum by an assist- 
 ant ; combined with digital 
 pressure upon the femoral as it 
 crosses the pubis. In all in- 
 stances, when abdominal pres- 
 sure is to be applied, the intes- 
 tines should be evacuated. Va- 
 rious forms of tourniquets have 
 been designed for the purpose, 
 as Pancoast's (Fig. 444), Es- 
 march's (Fig. 445), and Lister's 
 (Fig. 447). Fig. 446 shows Es- 
 march's elastic tourniquet in 
 position. 
 
 If a tourniquet be not at hand, a pad may be substituted, made by 
 winding a linen bandage about three inches wide and twenty-five feet 
 
 in length around 
 a stout rod or 
 stick, one inch or 
 so in diameter, 
 and twelve inches 
 long. This is 
 placed immediate- 
 ly below the um- 
 bilicus and held 
 in position by an 
 assistant. 
 
 FIG. 445. Esmarch's tourniquet. It Can be Con- 
 
 fined in position, 
 
 or the pressure still further increased by several turns of a rubber 
 bandage carried over it and around the body (Fig. 448). 
 
 If the elastic traction around the body be objectionable, a longer 
 stick can be substituted, and the compress secured in position by rubber 
 bands carried over the ends of the stick and under the table (Fig. 449). 
 
 FIG. 444. Pancoast's tourniquet.
 
 288 
 
 OPERATIVE SURGERY. 
 
 Davy's lever (Fig. 43) is a useful agent to control bleeding in this 
 situation. 
 
 It is open to the objection of being easily disturbed by the struggles 
 of the patient, as well as the danger of injuring the intestines, espe- 
 cially when carried to the right side of the body. 
 
 Trendelenbiirg's Rod (Fig. 44), which has also been previously men- 
 tioned, is of unquestionable utility. It is a steel rod, fifteen or six- 
 teen inches long, about one fourth of an inch broad, biconvex on 
 
 FIG. 446. Esmarch's tourniquet applied. 
 
 FIG. 447. Lister's tourniquet. 
 
 transverse section, and a twelfth of an inch thick at the center, with 
 blunt edges ; but provided with a movable lance-shaped point two 
 
 FIG. 448. Compression pad and elastic band. 
 
 inches in length. The rod is passed through the soft parts in front 
 of the joint ; entering an inch and a half below the anterior superior 
 spinous process of the ilium, passing across the femur behind the
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 289 
 
 femoral artery, emerging at the posterior seroto-femoral junction. 
 The point is removed and a strong elastic tube or band is wound firm- 
 ly, like the figure 8, around its ends, passing in front of the thigh. 
 
 FIG. 449. Brandis' method. 
 
 A long knife is then inserted in the course of the rod about half ar 
 inch below it, and the anterior flap made in the usual manner, and 
 the vessels ligated. The rod is then withdrawn, the hip-joint dis- 
 articulated, and the posterior flap made in a similar manner. Dr. 
 Varick, of Jersey City, N. J., who first employed the rod in this 
 country, did not disarticulate until he had transfixed a second time 
 behind the neck of the femur, including as much of the soft parts on 
 the posterior surface as possible ; compression was then applied as be- 
 fore, and the tissues were divided by a posterior semicircular incision 
 down to the bone. The amount of blood lost was trifling, and the 
 patient made a speedy recovery. The rod can be employed in the 
 various forms of flaps, and therefore has an element of universality. 
 It has not as yet been enough used to be esteemed more than a rational 
 expedient. 
 
 A seemingly admirable method of controlling hemorrhage in am- 
 putation at the hip-joint has recently been described (Lloyd) : 
 
 "A strip of black india-rubber bandage, two yards long, is to be 
 doubled and passed between the thighs, its center lying between the 
 tuber ischii of the side to be operated on and the anus. A common 
 calico thigh roller must next be laid lengthwise over the external 
 iliac artery. The ends of the rubber are now to be firmly and steadily 
 drawn in a direction upward and outward, one in front and one be- 
 hind, to a point above the center of the iliac crest of the same side. 
 They must be pulled tight enough to check pulsation in the femoral 
 artery. The front part of the band, passing across the compress, oo- 
 19
 
 290 
 
 OPERATIVE SURGERY. 
 
 eludes the external iliac artery, and runs parallel to and above Pou- 
 part's ligament. The back half of the band runs across the great 
 sacro-sciatic notch, and, by compressing the vessels passing through 
 it, prevents bleeding from the internal iliac artery. The ends of the 
 elastic band can be held by the hands of an assistant, or bandages may 
 be tied to its extremities, and passed across the opposite shoulder and 
 tied ; care should be taken to prevent the compression rollers from 
 slipping. This device has been employed on several occasions with 
 entire satisfaction." 
 
 Amputation at the hip-joint may be done by the single-flap method, 
 anterior or internal ; the double flap, either lateral or antero-poste- 
 rior ; the oval and the circular forms. 
 
 These general methods have been modified almost indescribably, 
 and certainly, in many instances, impracticably. 
 
 Amputation by a Long Anterior and Short Posterior Flap (Manec). 
 Place the patient on a table so that half the pelvis, on the side to 
 be operated upon, projects beyond the edge ; draw the scrotum to the 
 opposite side by a towel (Fig. 450). Exsanguinate the limb by the elas- 
 
 FIG. 450. Manec's method. 
 
 tic bandage ; after which control the hemorrhage from above by the 
 form of arterial compression selected. Then remove the elastic band- 
 age ; the limb to be amputated is held by one assistant, and another is 
 instructed to control the circulation in the femoral artery as it crosses
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 291 
 
 the pubes, and to catch the anterior flap and compress it before it 
 shall have been severed from below. 
 
 The operator then introduces the point of a long knife, midway 
 between the anterior superior 
 spinous process of the ilium 
 and the trochanter major, 
 pushing it down to the bone 
 parallel with Poupart's liga- 
 ment ; draws it back and low- 
 ers the handle ; at the same 
 time the assistant holding the 
 leg flexes the thigh slightly, 
 and the point is passed through 
 the anterior surface of the 
 capsular ligament ; the point 
 is then turned downward and 
 made to pass out at the inner 
 side of the thigh, an inch or 
 so from the perineum, and as 
 far posteriorly as it can be car- 
 ried easily (Fig. 451). It is 
 
 then carried downward, in con- 
 
 FIG. 451. Transfixing. 
 
 FIG. 452. Making posterior flap.
 
 292 
 
 OPERATIVE SURGERY. 
 
 tact with the bone, with long, sawing strokes, forming an anterior flap 
 six to eight inches in length. This is caught by an assistant, who at the 
 same time compresses the main vessel within it, and raises it upward. 
 The knife is then brought under the thigh to the opposite side (Fig. 
 452), connecting the sides of the base of the anterior flap by a posterior 
 
 FIG. 453. Flaps united. 
 
 incision extending a little below the gluteal fold, and carried down to 
 the bone ; after which the bone is disarticulated, by dividing the cap- 
 sular ligament and the muscular attachments to the greater and lesser 
 trochanters. 
 
 Bring the flaps into position, unite with sutures, and insert a long, 
 large drainage-tube into the acetabulum, allowing it to protrude at the 
 center of the flaps (Fig. 453). 
 
 Circular Method (Dieffenbach's). Control the hemorrhage as be- 
 
 FIG. 454. Elastic licrature. 
 
 fore, or by means of the elastic ligature (Fig. 454), and with a long 
 knife make a circular incision down to the bone, which is then sawn 
 through. Tie all vessels, veins included. If it be impossible to ern-
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 293 
 
 ploy the bloodless method, the femoral vessels should be secured by 
 forceps, or ligatures at the base of Scarpa's triangle, in two situations, 
 and the vessels be divided between them, the proximal end allowed to 
 remain until the operation is completed (Fig. 455). Eemove the elastic 
 ligature, secure all bleeding points, and insert a knife two inches above 
 the great trochanter, at its outer side ; carry it down to the bone, over 
 the middle of the trochanter, along the outer surface of the femur to 
 the circular in- 
 cision. Then ^^^^ 
 seize the bone 
 with a strong 
 pair of forceps, 
 separate the 
 edges of the ver- - 
 tical incision, 
 and remove the 
 periosteum with 
 a suitable in- 
 strument down 
 to the points 
 of muscular in- 
 sertion. These 
 must be sepa- 
 rated by a knife 
 with the edge 
 directed toward 
 the bone. Re- 
 move the peri- 
 osteum in this 
 
 manner up to the capsule (fig. 456), which is opened and the head 
 dislocated. The last step of the operation is attended with but slight 
 loss of blood. Fig. 457 shows the appearance of the parts after their 
 coaptation. An additional drainage-tube is inserted at the lower ex- 
 tremity of the wound. If the muscles are large, the flaps can be va- 
 riously modified by employing either the ordinary circular or the long 
 anterior flap, with a posterior circular incision below the gluteal fold. 
 
 If there be a deficiency of tissue on the anterior surface of the 
 thigh, the long posterior flap can be supplemented by a transverse in- 
 cision below Poupart's ligament, remembering to pass a large drainage- 
 tube in the course of the retreating extremities of the divided psoas 
 and iliacus tendons. 
 
 Single-Flap Method (Malgaigne). This admits of rapid execution, 
 and, were it not for the available anaesthetic, would be the proper 
 operation to select, in view of the additional shock caused by the 
 more methodical procedures advocated elsewhere. 
 
 FIG. 455. Dieffenbach's circular method.
 
 294 
 
 OPERATIVE SURGERY. 
 
 Having controlled the circulation, place the patient on the table, 
 with the hip overhanging the edge. The surgeon, standing at the outer 
 
 FIG. 456. Removing the bone. 
 
 side of the limb, which is slightly flexed and separated from its fellow, 
 introduces the point of a long knife midway between the anterior su- 
 perior spinous process 
 of the ilium and the top 
 of the trochanter ma- 
 jor, directing it in the 
 course of Poupart's liga- 
 ment down to the bone, 
 from which it is care- 
 fully withdrawn, and 
 the handle depressed 
 sufficiently to permit 
 the easy passage of the 
 point of the knife across 
 the neck of the femur, 
 FIG. 457.-Wound closed. and through the anteri- 
 
 or portion of the capsule. 
 
 If the handle be depressed before the point is raised, the point 
 may be broken. The handle is then raised and pushed onward until 
 the point emerges an inch below and in front of the tuberosity of the 
 ischium (Fig. 458).
 
 AMPUTATIONS OF THE LOWER EXTREMITY. 
 
 295 
 
 The flap is then made by carrying the blade downward six or eight 
 inches along the anterior surface of the bone, parallel with its line 
 of entrance, when it is brought directly 
 to the surface (Fig. 430). Before the 
 vessels are divided an assistant seizes the 
 flap, by inserting the hands into the in- 
 cision, above the knife, compresses the 
 vessels, and, when severed, carries it up- 
 ward on the abdomen (Fig. 459) at the 
 same time the surgeon divides the re- 
 maining anterior portion of the capsule 
 with the point of the knife ; another 
 assistant rotates the thigh inward, that 
 he may sever the attachments to the 
 great trochanter, then quickly rotates it 
 outward and abducts it, causing the 
 head of the bone to escape sufficiently 
 to expose the ligamentum teres, which 
 the surgeon divides with the point of 
 the knife, and as the head slips from its 
 cavity he passes the blade behind it (Fig. 459, 460), seizes the head 
 
 FIG. 458. Malgaigne's method. 
 
 A. Point of entrance of knife. 
 
 B. Point of exit of knife. C. 
 Poupart's ligament. D. Knife 
 passing through capsule. E. Tro- 
 chanter major. 
 
 FIG. 459. Compressing femoral vessels. 
 
 of the bone with the left hand, and quickly severs the posterior tis 
 sues by an incision directed downward and a little forward.
 
 296 
 
 OPERATIVE SURGERY. 
 
 The lateral-flap method offers no advantages over- the antero-pos- 
 terior, excepting, perhaps, easier drainage. This point, however im- 
 portant it may have 
 been before, like the 
 drainage - tube of the 
 present time, can not 
 now be said to be of 
 such marked signifi- 
 cance. 
 
 Anterior Oval Meth- 
 od (Verneuil). Apply 
 the elastic bandage as 
 far up as consistent with 
 the proposed incision. 
 Control the aorta and 
 make an incision through 
 the integument and fas- 
 cia, commencing an inch 
 below Poupart's liga- 
 ment, in the course of 
 
 FIG. 460. Passing blade behind head of bone. the femoral vessels, two 
 
 inches in length ; con- 
 tinue it outward, transversely across the base of the great trochanter, 
 to the gluteal fold, and along this to the inner side of the thigh ; 
 then obliquely upward two inches below the genito-crural fold, to the 
 lower end of the vertical incision. Isolate the femoral artery and 
 ligate it above and below the bifurcation of the profunda, and likewise 
 ligate the latter a little distance from its origin. If no intervening 
 branches exist, divide the femoral between the ligatures, isolate the 
 femoral vein, ligature it and divide in the same manner. Carry the 
 incision through the muscles, from whichever aspect of the limb is 
 most convenient, seeking for and ligating all bleeding points as soon as 
 apparent. Open the capsule in front, divide its posterior portion as 
 closely as possible to the neck of the femur, together with the remain- 
 ing tendons inserted into the head of the great trochanter. Depress 
 the thigh, causing the wound to gape widely, and divide the muscles 
 on its inner and posterior surface, in the same manner as those preced- 
 ing. Finally, draw down the sciatic nerve, and cut it short enough 
 to be above the border of the flap. 
 
 The tissues left are not sufficient to close the wound, which is 
 dressed with a thin layer of tarletan in contact with the cut surface, 
 upon which charpie saturated with some antiseptic solution is placed, 
 and the whole covered with cotton batting surrounded by oiled silk, 
 which is held in position by a simple bandage. The wound is kept 
 moist with the antiseptic solution.
 
 DEFORMITIES. 297 
 
 Results. The rate of mortality is governed by the cause calling 
 for the operation. 
 
 In immediate amputation in military practice, ninety-three per 
 cent die. 
 
 In civil practice, the mortality after the primary amputations 
 reaches eighty per cent. Secondary amputations offer better results ; 
 sixty per cent recover in the civil and military combined. 
 
 The results are more favorable in non-traumatic cases, being less 
 than forty-one per cent. Taken together, the rate is a little over 
 sixty-four per cent, being a trifle more than for amputation in the 
 continuity of the thigh, which is about sixty-three and a half per 
 cent. 
 
 CHAPTEE XL 
 
 DEFORMIIIES. 
 
 DEFOKMITIES may be either congenital or acquired, and in either 
 case they can be referred to the soft or hard parts, either individually 
 or conjointly. 
 
 The acquired deformities calling for operation in a special sense 
 depend on anchylosis of joints, distorted shafts and extremities of 
 bones, irregular or unequal muscular contraction, and the congenital 
 fusion of parts. To overcome the deformities dependent upon anchy- 
 losis, we resort to forcible movement, if it be fibrous ; and the division 
 of the bone, or joint structure, if it be bony. 
 
 The forcible breaking of an anchylosed joint, while not an opera- 
 tion in the accepted sense of the term, is nevertheless often associated 
 with consequent complications,' which entitle it to a greater degree of 
 prominence than many accepted operative procedures. 
 
 Brisement Forc6, as it is sometimes called, should be preceded by 
 subcutaneous section of all the tendons, muscles, and fascia upon 
 which "point pressure" causes reflex action. 
 
 The incisions having united, place the patient upon a hard table, 
 administer an anaesthetic, and while the portion of the limb between 
 the joint and the body of the patient is held firmly by assistants, the 
 surgeon seizes the distal portion and forcibly flexes it, employing steady 
 and persistent force. As soon as moderate movement follows flexion, 
 it is then forcibly extended, and by repeated flexion and extension the 
 range of motion of the joint is re-established. 
 
 If the knee be the one in question, the patella must be loosened 
 before it is attempted. After the operation strap the toes and band-
 
 298 
 
 OPERATIVE SURGERY. 
 
 age the limb from the toes to the knee firmly, having first applied ad- 
 hesive plaster for the purpose of extension. Pad the popliteal space 
 with cotton, and compress the knee-joint with strips of adhesive plas- 
 ter. Continue the roller over the knee and up the thigh, applying 
 pressure to the femoral artery by means of a small piece of wet sponge, 
 applied over its course and held in position by the ascending bandage. 
 Place the patient in bed, apply extension, with the foot of the bed 
 elevated, also ice-bags to the knee, the limb being immovably con- 
 fined. At the end of five or six days the dressings are opened and 
 
 again replaced, after slight motion is made. 
 The sponge over the femoral artery is 
 omitted. 
 
 If the anchylosis le bony, the deformity 
 can be relieved by osteotomy above the 
 condyles, and, if necessary, below the head 
 of the tibia at the same time, or by excision 
 of the joint, or by the removal of a trian- 
 gular piece above the joint, having the 
 sa-me angle as that formed by the junction of 
 the tibia and femur in the popliteal space. 
 The same principle can be applied above 
 the knee as practiced by Barton (Fig. 461). 
 Boring the joint and other expedients 
 The most 
 
 FIG. 461 Barton's operation. 
 
 have been resorted to. 
 satisfactory of all, however, is os- 
 teotomy above the condyles, which 
 is described under that heading. 
 
 In all joints, anchylosis is 
 amenable to the same procedures 
 as previously stated. 
 
 Deformities caused by distor- 
 tion of the long bones can be best 
 corrected by osteotomy, associated 
 with the antiseptic dressing. 
 
 Curvature of the Spine. A 
 popular method of treatment at 
 the present time is the application 
 of the plaster - of - Paris dressing. 
 The body of the patient is first 
 surrounded by a closely-fitting 
 knit jacket, between which and 
 the region of the stomach is in- 
 troduced a wedge-shaped "din- 
 ner-pad," with the point down- 
 ward ; composed of several thick- 
 
 FIG. 462. Apparatus applied.
 
 DEFORMITIES. 
 
 299 
 
 nesses of cloth, or cotton wadding surrounded by it. All sensitive 
 parts and projecting points should be relieved from direct pressure by 
 spongio-piline, cotton, or other similar ma- 
 terial. The same can be placed over the 
 iliac spines and the adjoining portions of 
 the crest. 
 
 "The mammary glands in the female 
 should be protected, and suitable space be 
 provided by the introduction of properly 
 shaped pads. 
 
 " Tie the shirt over the shoulders and 
 fasten it between the legs. Then the pa- 
 tient is drawn up by the extending appara- 
 tus (Figs. 462, 463, and 464) gently and 
 slowly until he feels perfectly comfortable, 
 and never beyond that point. A prepared, F IG . 463. Extension apparatus, 
 saturated plaster-of- Paris roller having been 
 
 gently squeezed, so that all sur- 
 plus water is removed, is now 
 applied around the smallest part 
 of the body, and is carried round 
 and round the trunk downward 
 to the crest of the ilium and a 
 little beyond it ; afterward in a 
 spiral direction from below up- 
 ward, until the entire trunk 
 from the pelvis to the axillae has 
 been incased. 
 
 "The bandage should be 
 placed smoothly round the body, 
 and must not be drawn tight ; it 
 should be simply unrolled with 
 one hand while the other follows 
 and brings it into smooth close 
 contact with all irregularities of 
 the trunk. 
 
 "After one or two thick- 
 nesses of bandage have been 
 placed around the body in the 
 manner described, narrow strips 
 of roughened tin can be placed 
 parallel with each other on either 
 side of the spine, if the case re- 
 quires it, with intervals of two 
 FIG. 464. Body extended. or three inches, and in number
 
 OPERATIVE SURGERY. 
 
 sufficient to surround the body* Over these another plaster bandage 
 is applied. In a very short time the plaster sets with sufficient firm- 
 ness, so that the patient can be removed from the suspending appa- 
 ratus and laid upon his face or back on a hair mattress, or, what is 
 preferable, especially when there is much projection of the spinous 
 processes or sternum, an air-bed. Before the plaster has completely 
 set, the "dinner-pad" is removed, and the plaster gently pressed in 
 with the hand, in front of each anterior iliac spinous process, for the 
 purpose of molding the case over the bony projections. 
 
 " \Yhile the jacket is drying it is necessary, sometimes, to wet it 
 with a little water and dust it with more plaster. The surgeon often 
 leaves some weak spots that need strengthening in this manner." The 
 preceding is a description as recorded by Dr. Sayre, to whom the pro- 
 fession is indebted for the prominence which has been given this 
 method. 
 
 The Deformities dependent upon Perverse Muscular Action are, in 
 an operative sense, relieved by subcutaneous division, called myotomy 
 and tenotomy, which has been before considered. 
 
 Deformities due to Fusion of the parts and supernumerary attach- 
 ments, like webbed fingers and toes, and supernumerary digits, al- 
 though not common, are, nevertheless, entitled to some consideration. 
 Webbed Fingers. The operative treatment will depend very much 
 upon the extent as well as the thickness of the attachments ; whether 
 the connections be limited to the soft parts alone, or the bones be 
 fused. Digits that are united by their extremities only can easily be 
 separated by the division of the tissues which connect them. If they 
 
 be united their entire length, even then 
 an incision in the median line of their 
 attachments, down to the line of the 
 normal web, may be sufficient to effect 
 a cure, if the tissues connecting them 
 be not too thick ; if such be the case, 
 great difficulty is often experienced in 
 healing the divided surfaces, owing to 
 the tendency to reunion at their point 
 of junction. To obviate this, various 
 expedients have been recommended, 
 one of which is to introduce a rubber 
 seton at the base of the malformation, 
 on a line with the normal web of the 
 hand, and allow it to remain until the 
 opening becomes permanent (Fig. 465), 
 when the remaining portion is divided 
 and the borders united by sutures. Another plan is to make a trian- 
 gular flap from the posterior portion of the web, the base to remain 
 
 FIG. 465. Webbed fingers.
 
 DEFORMITIES. 
 
 301 
 
 attached, and to correspond in shape and size to the space between the 
 knuckles. 
 
 Its apex is of course directed to the free edge of the abnormal at- 
 tachment. The flap having been raised, the remaining portion of the 
 attachment between the fingers is divided, and the triangular flap 
 adjusted to the base of the cleft, and kept in position until union 
 takes place. The remaining borders of the wound are united by su- 
 tures the same as before. 
 
 It has been suggested to make two such flaps, one on the palmar 
 and one on the dorsal aspect, in the same situation ; to cut off their ex- 
 tremities and unite them at the cleft, when the 
 remaining portion can be divided longitudinally. 
 
 Another, a very effectual and ingenious 
 method, is best described by M. Nelaton, its de- 
 signer : " A longitudinal incision is made in the 
 center of the phalanx of one finger on the dorsal 
 aspect, for the posterior flap ; on the palmar as- 
 pect of the other for the dorsal flap, the length 
 of the incision will correspond with the depth 
 of the web. From either extremity of the longi- 
 tudinal incision, a small transverse one is to be 
 made toward the phalanx of the connected finger 
 (Fig. 466, B). The lower transverse incision 
 will correspond to the free edges of the web ; 
 the upper one will cross the cleft between the 
 
 fingers. Each flap is now to be dissected back toward the contiguous 
 fingers. In doing this the two folds of the web will be separated from 
 each other, one entering into the formation of the posterior flap, the 
 other into the formation of the anterior. Each flap will now be found 
 to be attached by one edge only, and is to be wrapped around the de- 
 nuded surface of the finger to which it is attached. The flaps are to 
 be adjusted by strips of adhesive plaster, and by sutures." 
 
 Annandale says : " The principal objection to this ingenious opera- 
 tion appears to me to be that it necessitates cutting into the palmar 
 and dorsal aspects of the fingers in order to get a flap to cover their 
 sides." If the web or fold of the skin be loose, he deems it pref- 
 erable " to make the longitudinal incision along the sides of each 
 finger instead of along the center of the dorsal and palmar aspects." 
 Triangular flaps may be made at the base of the web, and the remain- 
 der cut directly through (Fig. 466, A). If Nelaton's operation be 
 performed, care must be taken in uniting the flap, or sloughing will 
 follow. When the joints of the digits are fused, it is not wise, as a 
 rule, to attempt their separation, since, -though it be accomplished, 
 the remaining digit may have its function greatly impaired ; however, 
 tliis course is not so imperative now, since the advent of antisepsis. If 
 
 FIG. 466. Nekton's 
 method.
 
 302 
 
 OPERATIVE SURGERY. 
 
 a supernumerary digit possess an independent articulation, it can be 
 removed without any great danger to its associate. 
 
 Ingrowing Toe-nail. This is quite a common affliction, to the 
 relief of which various palliative measures have been directed. As 
 a rule, however, they have been found inadequate to effect a cure. 
 This condition is largely induced by improperly fitting boots and 
 shoes, although in some persons there exist additional predisposing 
 causes. Going barefooted would in a ma- 
 jority of cases bring about a speedy cure, but, 
 since this is impracticable, operative measures 
 are often necessary. 
 
 Operation. When the affection is fully 
 established, administer an anaesthetic, and 
 with a sharp-pointed scalpel divide the nail 
 its whole length on a line with its ingrowing 
 portion (Fig. 467), which portion can then be 
 quickly and easily removed by a thin-bladed 
 pair of forceps, or a narrow spatula passed 
 beneath it. If the other side be affected, it 
 too should be removed in the same manner. 
 Cauterize the exposed matrix and apply a hot 
 anodyne poultice at once. The patient must 
 keep quiet until the tenderness has in a meas- 
 ure subsided. In no instance ought the entire 
 nail to be removed, unless it be diseased. 
 
 Bunion. This affliction is accompanied in 
 
 a large proportion of cases by malposition of the great toe (Fig. 468), 
 and an increase in the normal size of the bursa, or the development 
 of an adventitious one. The operative means for relief consist either 
 in the excision of the bursa, or its subcuta- 
 neous division into numerous fragments by 
 means of a narrow tenotome. If these means 
 fail, a sufficient amount of the metatarsal 
 bone should be excised to admit of the toe 
 being returned to its normal position, or the 
 operation described on page 222 can be per- 
 formed, after which the toe is confined in 
 place until recovery is established. 
 
 Flat "FootOgston's Operation. With 
 the foot lying on its outer side, an incision an 
 inch and a quarter in length is made paral- 
 lel with the sole down to and at the inner 
 side of the bones forming the astragalo-scaphoid articulation. The 
 ligamentous structures are detached from the bones for half an inch 
 at either side of the wound, with a knife and periosteal elevator. As 
 
 FIG. 467. Ingrowing nail. 
 
 FIG. 468. Bunion with hal- 
 lux valgus.
 
 DEFORMITIES. 303 
 
 soon as the contiguous articular surfaces of the scaphoid and astragalus 
 are well exposed, they are denuded of their cartilage and of a sufficient 
 amount of bone to permit the correction of the deformity and the per- 
 fect coaptation of the cut surfaces. The surfaces are then fastened to- 
 gether by ivory pegs or by wiring. If the motion between the internal 
 cuneiform and scaphoid bones be unusually free, their contiguous 
 surfaces can be treated in a similar manner instead. 
 
 Results. If performed with strict antisepsis, the danger to life is 
 slight. The anchylosed arch gives the patient a useful foot. Stokes' 
 operation, it is claimed, corrects the deformity, which if true makes 
 it much the more preferable operation, as it does not involve the joint. 
 
 Astragaloid Osteotomy (Stokes). This operation is recommended 
 to relieve the deformity of flat foot, and should only be conducted 
 under strict antiseptic precautions. 
 
 Operation. Make an incision an inch and a half in length along 
 the inner side of the foot, the center of which should correspond to 
 the prominence caused by the head of the astragalus ; at the center of 
 this another is made about three fourths of an inch in length at right 
 angles to it, and situated a little behind the medio-tarsal joint. 
 The triangular flaps thus formed are dissected back half or three 
 fourths of an inch. A wedge-shaped piece of bone is then removed 
 from the head and neck of the astragalus with an osteotome ; the foot 
 adducted and supinated, in which position it is retained until recovery 
 takes place. 
 
 Results have thus far been satisfactory, but as yet there are not 
 sufficient data upon which to estimate a mortality record. 
 
 Tarsectomy. In old and obstinate cases of talipes varns and equi- 
 no-varus, this method of treatment has been performed with varying 
 success for a long time. 
 
 Operation. Place the foot on its inner side and make an incision 
 parallel to the sole down upon the outer border of the cuboid bone, 
 its entire length, and expose its upper and lower surfaces by means of 
 a knife and periosteotome, carefully protecting the surrounding soft 
 parts from injury. A triangular piece of bone, with the base outward, 
 is then removed from the cuboid of sufficient dimensions to admit of 
 the correction of the deformity. In extreme cases the entire cuboid 
 and even portions of the contiguous bones may be included in the base 
 of the wedge. As soon as the deformity can be reduced, the bony 
 surfaces are wired together, the limb dressed antiseptically, and the 
 foot confined in the corrected position until recovery takes place. 
 
 Results. When cautiously done, the dangers to life do not con- 
 traindicate the measure, and the usefulness of the limb is very much 
 enhanced.
 
 304: OPERATIVE SURGERY. 
 
 CHAPTER XII. 
 
 PLASTIC SURGERY. 
 
 THIS form of operative surgery relates to the various means 
 adopted to overcome or alleviate the deformities of aspect and func- 
 tion resulting from congenital defects, disease, and accidents. 
 
 Inasmuch as the successful issue of these operations depends far 
 more on the careful attention to the details and small matters con- 
 nected with them than anything else, it is well for the operator to 
 understand at once that there is no precaution too trifling to be 
 treated with indifference. 
 
 Preparation of the Patient. The patient ought to be in a vigorous 
 physical condition, his appetite and functions normal, and the sur- 
 roundings of such a character as to combine quietude of mind with 
 close and gentle attention. No association can be allowed with putre- 
 factive processes, or diseases known to engender changes derogatory 
 to union and repair. Prior to the operation, the part should be puri- 
 fied by a solution of carbolic acid or other suitable agent. 
 
 Size of the Flap. The shape and size of the flap must be ascer- 
 tained by careful measurement. A pattern of the deformity to be re- 
 paired is to be carefully cut out and used to outline the tissues to be 
 employed in filling the gap, since the contractile power of the normal 
 tissues, when loosened from their underlying attachments, causes 
 enough shrinkage to require undue force to maintain proper coapta- 
 tion of the borders. The reparative flaps must always be made large 
 enough to admit of at least three lines of shrinkage to each inch of 
 their surface. 
 
 In choosing the material to form the flap, it is necessary that it 
 consist of sound, healthy skin ; and under no consideration can cica- 
 tricial tissue possessed of a pale, glossy surface be employed ; for, 
 when its subcutaneous connections are severed, it is almost certain to 
 slough, especially when the result of a burn. The thickness of the 
 flap should be sufficient to include all the vessels that normally afford 
 it nourishment. The relation which cicatricial tissue bears to a flap is 
 all-important. If it exists at its base, sloughing is quite certain to occur. 
 Cicatricial tissue at the border of a flap is quite certain to die, and its 
 presence must not be estimated in computing the area of the new flap. 
 When the new flap is to be surrounded on three sides by cicatricial 
 formations, its base must be large, vascular, and but little twisted, as 
 the medium of supply at its sides will be very much lessened by its 
 new association. The long axis of the flap should correspond to the 
 course of the vessels from which it derives its nourishment, and its 
 base must be located as nearly as possible to the nutrient vessels. 
 All hemorrhage must be checked before the flaps are united, since it
 
 PLASTIC SURGERY. 305 
 
 not infrequently happens that a thin clot of blood prevents union. 
 The direction of the flap should be such that it can be placed with 
 the least twisting of the pedicle. The silver wire and carbolized silk, 
 or horse-hair, make efficient sutures, which should not be drawn 
 tightly. To avoid the danger of ulceration at the pressure points, 
 small squares of carbolized, bibulous, or unglazed paper, having a 
 diameter of half an inch or less (Fig. 469), with small 
 holes through the center, or punctured through the cen- 
 
 o 
 
 ter by the pin or needle carrier at the time of carrying 
 the ligature, can be used to tie them upon. The edges 
 of flaps may be beveled ; this increases the width of the 
 opposed surfaces, and, when combined with undercutting F IG- 469. Pa- 
 of the other borders, increases the chances of union. A P cr protective, 
 small slip of the aseptic bibulous paper can be placed be- 
 tween the sutures and the edges of the wound at the point of crossing. 
 The use of carbolized cotton yarn, which is to be frequently changed, 
 in connection with the plastic pins, offers a soft and otherwise ad- 
 mirable retaining agent. 
 
 If small pins be inserted to indicate the extent of flaps, the incis- 
 ions will be made more accurately than if they be formed by the aid 
 of the eye alone. 
 
 Methods of Transfer. The methods of transfer may be classified 
 into six general forms, with their subdivisions : 1. Sliding in a direct 
 line. 2. Sliding in a curved line. 3. Jumping. 4. Inversion, or 
 eversion. 5. The Taliacotian. 6. Grafting. 
 
 Sliding in a Direct Line. The first and simplest variety of this 
 method consists in uniting the lips of an ordinary incision, and is 
 sometimes called " simple approximation of divided surfaces." . 
 
 The second variety is called "undercutting," and consists in cut- 
 ting under the edges of the incision at each side, and drawing them 
 together. 
 
 The third variety consists in sliding in a direct line, by aid of par- 
 
 ^ ^^> allel incisions on 
 
 ~~ both sides of the 
 
 primary one, which 
 ^^_______^ is closed. The out- 
 
 __ _^^_ *" ^"""^-L side incisions are al- 
 
 FIG. 470. Parallel incisions. FIG. 471. Opening closed. lowed to heal by 
 
 granulation (Figs. 
 
 470 and 471). Undercutting in this method lessens the tendency to 
 separation of the parallel lines. 
 
 In the fourth method the liberating incisions are made transversely, 
 
 that is, at right angles to the extremities of the oval opening, and 
 
 undercutting is employed (Figs. 472 and 473) to enable this opening 
 
 to be closed. The uppermost curve is undercut, and the lowermost is 
 
 20
 
 306 
 
 OPERATIVE SURGERY. 
 
 FIG. 472. Transverse FIG. 473. Open- 
 incision, ins closed. 
 
 liberated by a combination of undercutting and sliding by the aid of 
 the transverse incisions. If this method be applied to those parts 
 
 which can not resist the traction of 
 the displaced tissue, a second de- 
 formity is liable to follow. 
 
 Sliding in a Curved Line. This 
 operation can be done with flaps 
 having either curved or angular bor- 
 ders. In the former instance, the 
 space from which the flap is taken is 
 filled by undercutting its borders 
 and drawing them together. In the 
 latter, the space is usually allowed 
 to granulate. 
 
 Jumping. Jumping, as the name implies, consists in " jumping 
 a flap connected by a pedicle over intervening undetached tissues." 
 It can be done with or without the pedicle being twisted. 
 
 If the flap be not moved more than a quarter of a circle, twisting 
 of the pedicle is not necessary. Undercutting is employed in this 
 operation when necessary to adjust the parts properly. 
 
 The plan of operation without twisting the pedicle is shown in 
 Fig. 474. When the flap is moved more than a quarter of a circle, 
 the pedicle will be twisted, and the degree of twisting will depend on 
 the distance the flap is moved. 
 
 If the pedicle be too much twisted, the circulation of the flap will 
 be impeded, and sloughing may ensue. 
 
 FIG. 474. Jumping method. 
 
 Inversion or Aversion. These methods relate simply to the em- 
 ployment of integument in the repair of mucous membrane, or vice 
 versa. Tubular formations may be constructed by either of these 
 methods, as in the formation of new canals, like the urethra, vagina, 
 and the closure of an extroverted bladder. 
 
 The Taliacotian Operation. This operation is familiarly known 
 as the dissection of a flap from another and distant portion of the
 
 PLASTIC SURGERY. 307 
 
 body, allowing it to granulate, and applying it to the part to be re- 
 paired, as is done in the ordinary operation for the construction of a 
 new nose. 
 
 Grafting. This method is but little employed, and the operation 
 is performed by entirely removing a flap from one place to the local- 
 ity to be repaired. 
 
 Skin-grafting, in the common acceptation of the term, is employed 
 to cause the healing of extensive granulating surfaces, when of a 
 healthy character. It is performed by first making small punctures 
 in the granulating surface with the sharp end of the common pocket- 
 probe, half an inch or so apart ; and, second, by placing over the 
 open mouths of these shallow punctures small pieces of integument, 
 a line or two square, with the fresh surface downward. They are 
 then pushed into the openings of the punctures, by the same probe, in 
 such a manner as to cause a close contact between the raw surfaces of 
 the small "grafts" and those of the punctures in the granulating 
 surface. Small pieces of lint are placed over each "graft," and the 
 whole is confined in position by narrow strips of adhesive plaster. The 
 part should be carefully redressed at the end of three or four days. 
 
 Rhinoplasty. This operation consists in the reproduction of a part 
 or the whole of the nasal organ. The present ability of the surgeon 
 to arrest the diseases causing deformities of the nose has lessened the 
 frequency of this operation. Ingenious contrivances of ivory, rubber, 
 etc., have been made to fit the nose, and to thus supply a substitute 
 for the lost parts. These contrivances, when tinted to conform to the 
 complexion of the wearer, often prove quite deceptive to the observer ; 
 but, being unaffected by the various contingencies of the weather and 
 the emotions, they are apt at times to cause the wearer to present a 
 ludicrous appearance. In operating on the nose, save all that is possi- 
 ble of its cartilaginous and bony tissues, for they wilt each afford im- 
 portant supports for the new structure. The cartilages of the alae 
 should, when possible, constitute the free border of the new structure. 
 
 The deformities of this organ may be due : 1, to a loss of the sn- 
 perficial soft parts, which may vary in extent and degree ; 2, to a loss 
 of the bony or cartilaginous septum, with' or without loss of the nasal 
 bones; 3, to a loss of both combined. The soft parts may be restored 
 by either of the five methods before named. The extent of the deform- 
 ity and its situation will determine the choice of a method. When the 
 loss of the integument is small and does not involve the alae and the 
 deeper structures, the deformity may be remedied by the direct ap- 
 proximation of its borders, aided, of course, by a free undercutting 
 with or without parallel incisions. The French method, by transverse 
 incisions combined with undercutting, can be employed (Fig. 475) 
 when the former is deemed inadequate. If the extremity of the nose 
 or the alae be involved, the second method, or " sliding in a curved
 
 308 
 
 OPERATIVE SURGERY. 
 
 line," the flap having either curved or angular borders, is recom- 
 mended. Fig. 476 represents the restoration of the alae by a flap taken 
 
 FIG. 475. Closure by transverse incisions. 
 
 FIG. 476. Repair by sliding. 
 
 from the cheek (a). It must be of sufficient size to allow at least one 
 fourth for its contraction, otherwise, when united in position, it will 
 displace the axis of the nose, thereby substituting one deformity for 
 
 another. Langen- 
 beck repaired a 
 similar deformity 
 by taking a flap 
 from the opposite 
 side of the nose (b). 
 As in the preceding 
 method, the dissec- 
 tion must be care- 
 fully made down to 
 the cartilaginous 
 frame- work. The 
 border of the new 
 ala, although fresh- 
 ly cut, heals in a 
 satisfactory man- 
 ner. Fig. 477 shows 
 
 FIG. 477.-Repair by sliding. the line of incision 
 
 employed to repair 
 
 the deformity with a flap possessing an already cicatrized border.
 
 PLASTIC SUPxGERY. 
 
 309 
 
 The vascular supply of this flap is not active, and every precaution 
 should, therefore, be taken to provide against the danger of slough- 
 ing. If either ala be absent, 
 and the resulting gap be a 
 large one, the material for its 
 repair can be taken from the 
 forehead, as shown in Figs. 
 478 and 479. It will be seen 
 that the pedicles are admira- 
 bly located to receive ample 
 nourishment. The loss of an 
 ala or of the end of the nose 
 may be repaired from the tis- 
 sue of the upper lip (Fig. 480) 
 or the cheek. 
 
 If the columna be absent, 
 it may be replaced by struc- 
 tures taken from the upper 
 lip. In this operation it is 
 better to include the whole 
 thickness of the lip, tipping 
 the flap directly upward into FIG. 478. Repair by jumping, 
 
 place, than to make an integ- 
 umentary flap, the adjustment of which will require a smart twisting 
 of the pedicle. In the former instance the cuticle is dissected off 
 
 and the raw surface carried 
 directly into its position. The 
 mucous surface of the flap 
 soon assumes integumentary 
 characteristics. If the lip be 
 deficient at the point of se- 
 lection, a flap can be taken 
 from beneath either ala and 
 carried into place. 
 
 Loss of the Bony or Car- 
 tilaginous Septum, with or 
 without Loss of the Nasal 
 Bones. The loss of the carti- 
 laginous portion of the sep- 
 tum, the other tissues remain- 
 ing intact, causes a flattening 
 of the end of the nose, or a 
 depression at the lower end of 
 the nasal bones. The opera- 
 FIG. 479. Repair by jumping. tion of sliding the tissues may
 
 310 
 
 OPERATIVE SURGERY. 
 
 FIG. 480. Repair 
 by jumping. 
 
 temporarily relieve the deformity ; but traction of the flap and various 
 interferences from without soon reproduce it. 
 
 Mechanical ingenuity bids fair to afford more 
 relief for this deformity than surgical, especially if 
 the defect be associated with an opening through 
 the hard palate. If the nasal bones be intact, the 
 loss of the bony septum is not manifested by any 
 external deviation of the organ. If both the septum 
 and nasal bones be gone, it then becomes necessary, 
 in order to relieve the deformity, to elevate and 
 maintain in position the tissues composing the soft 
 parts of the nose. To accomplish this requires an 
 internal support of some sort, although much may 
 be gained by dissecting up the soft parts on each 
 side of the nose, and raising them in the line of the 
 bridge by approximating their bases in position by means of pins 
 passed through them, and confining them until union of the flaps 
 takes place. In 1829 Dieffenbach published a method of performing 
 an operation by which he overcame the deformity resulting from the 
 loss of the nasal bones and the septum. An incision was made with a 
 narrow-bladed knife along the outer side of the sunken border of each 
 nostril, the intervening strip being three times broader at its connec- 
 tions with the upper lip than above where it joined the forehead. At 
 the outer side of each of these incisions, another was made down to the 
 bone, which began a few 
 lines below, and to the outer 
 side of the first, and was 
 carried obliquely down- 
 ward, parallel with the pri- 
 mary one, and external to 
 the side of the nose, around 
 into the nostril, thereby 
 separating the ala. The 
 columna was elongated by 
 short parallel incisions in 
 the upper lip, and the 
 cheeks were dissected up 
 from their bony attach- 
 ments, through- the lateral 
 cuts, sufficiently to render 
 them freely movable. The 
 flaps were then raised, their 
 borders were pared oblique- 
 ly, reunited and fastened 
 with pins and sutures, and retained in position by drawing the de- 
 
 Fio. 481. Dieffenbach's method.
 
 PLASTIC SURGERY. 
 
 311 
 
 tached portions of the cheeks toward the median line of the nose, 
 where they were fixed by two long pins passed through their borders, 
 under the nose. In this instance the pins were passed through two 
 narrow strips of leather, which equalized the force and prevented 
 the producion by the pins of premature ulceration. A quill sur- 
 rounded by oiled lint was then introducd into each nostril. The 
 accompanying figure illustrates the proceeding, with its result (Fig. 
 481). 
 
 Superimposed superficial flaps were successfully employed by Ver- 
 neuil. In this case the alae and tip of the nose were uninjured, but 
 
 FIG. 482. VerneuiPs method. 
 
 were flattened by loss of the support of the septum. He made a longi- 
 tudinal incision along the median line of the nose at the center of the 
 depression, and a transverse one extending from each end of the first 
 to just beyond the contour of the nose (Fig. 482), and dissected the 
 flaps freely from their attachments. An oblong flap of suitable size 
 was then raised from the forehead, its pedicle being located directly 
 between the eyes ; this flap was turned downward, bringing its raw 
 surface uppermost. The lateral flaps were then drawn inward and 
 placed upon it and united in the median line. 
 
 The Indian Method (483). This was at one time the prevailing 
 method of operation when the septum and a large proportion of the 
 soft parts of the nose were absent, and was employed even when the 
 lower extremities of the nasal bones had sustained a loss. The tend- 
 ency to atrophy and sliding down of the flap after union had taken 
 place, accompanied by closure of the nostrils and danger to the life of 
 the patient from the operation, caused the substitution for it of more
 
 312 
 
 OPERATIVE SURGERY. 
 
 satisfactory measures. A flap was made from the integument of the 
 
 forehead of the same shape, but of one fourth larger size than the 
 
 gap to be filled ; its base was 
 half an inch broad, and located 
 between the eyebrows. The flap 
 was therefore substantially the 
 shape of the ace of spades, and 
 included all the tissues down to 
 the periosteum (Fig. 483, a), the 
 stem above being intended to 
 form the columna. The edges of 
 the gap were freshened, and the 
 flap, with the raw surface un- 
 dermost, was twisted on its ped- 
 icle and attached to the mar- 
 gins of the gap. The flap was 
 then made prominent, b, by the 
 aid of greased plugs introduced 
 into the nostrils, and also by 
 drawing the cheeks toward the 
 median line, where they were 
 fastened by means of pins passed 
 The tendency of the flap to slide 
 
 downward has been combated in various ways such as connecting 
 
 the pedicle with a longitudinal incision 
 
 at the side of the nose, the attachment 
 
 of its whole length to a newly formed 
 
 raw surface at its base, and grafting the 
 
 sharpened pedicle into the integument 
 
 at its base. 
 
 Italian Method. This old method 
 
 has many virtues, and, were it not for 
 
 the great difficulty of keeping the parts 
 
 in position, would be much more em- 
 ployed. The flap is taken from over 
 
 the biceps, with its apex toward the 
 
 shoulder. It is first dissected up, and 
 
 its extremities allowed to remain at- 
 tached, until suppuration is established, 
 
 when the proximal end is separated and 
 
 the dressing continued until the flap 
 
 is well shrunken and the under surface 
 
 cicatrized. It is then applied to the 
 
 gap after the borders of both have 
 
 been freshened (Fig. 484). "When FIG. 484. Italian method. 
 
 FIG. 483. Indian method. 
 
 through them beneath the nose.
 
 PLASTIC SURGERY. 
 
 313 
 
 union is completed, the pedicle is cut, and the flap is fashioned so as 
 to relieve the deformity in the best possible manner. 
 
 Osteoplastic Rhinoplasty. The periosteum has been removed fre- 
 quently from a part of the frontal bone, in connection with the flap, 
 and consigned to the gap, with the hope that the formation of new 
 bone might occur, so as to give solidity as well as prominence to 
 the ew nose. The removal of the periosteum from the frontal bone is 
 not by any means devoid of danger. Osteo-myelitis has arisen there- 
 from, followed by pyaemia and death. The periosteum may be used 
 to form a portion of the flap first applied, in the double-flap method, 
 illustrated in Fig. 485. It is true that the relation of its surfaces will 
 be reversed, but this can not change its bone-producing value ; more- 
 over, if bone be formed, it can be easily shaped by manipulation to 
 suit the proposed 
 outline of the or- 
 gan. 
 
 Oilier 's Meth- 
 od. An opera- 
 tion was per- 
 formed some time 
 since by Oilier, 
 for a deformity 
 caused by the loss 
 of the alae, co- 
 lumna, cartilages, 
 lobe, and a por- 
 tion of the sep- 
 tum, due to lu- 
 pus. The nose 
 was not more 
 than an inch 
 long, due to ar- 
 rest of develop- 
 ment of the ossa nasi, to which was attached a strip of cartilage. The 
 integument of the lip and cheeks had been involved, and could not 
 therefore be depended upon for flaps. 
 
 Oilier commenced two diverging incisions in the median line of 
 the forehead, two inches above the eyebrows, and carried them down- 
 ward to a fourth of an inch from the outer side of the nasal orifice 
 (Fig. 485). The upper portion of the triangular flap included the 
 corresponding portion of periosteum down to the upper end of the 
 nasal bones. The dissection was continued along the right nasal bone, 
 omitting the periosteum, down to its lower end, from which the car- 
 tilage was separated ; but it remained attached to the flap. The left 
 nasal bone was separated from its bony connections with a chisel, 
 
 FIG. 485. Ollier's method.
 
 314: OPERATIVE SURGERY. 
 
 leaving it attached to the flap by its anterior surface ; the cartilagi- 
 nous septum was then divided from before backward and downward 
 with scissors, and left attached by its base to the cutaneous cartilage, 
 that a central support might be provided for the new structure. The 
 whole flap was then drawn downward, until the upper border of the 
 loosened nasal bone (left) came opposite to the lower border of the 
 right one, when they were fastened together with a metallic suture. 
 The sides of the flap were then united to the cheek and the frontal 
 incision closed above its apex. 
 
 In this case, the space left by the removal of the left nasal bone 
 was filled by bone developed from the periosteum that had been slid 
 down from the forehead. 
 
 This variety of deformity has also been relieved by attaching a finger 
 to the sides of the nasal chasm. The nail was first removed and the 
 palmar surface of the finger was denuded, by the formation of lateral 
 flaps, down to the distal third of the first phalanx. The finger was 
 then fastened into position upon the freshened borders of the deform- 
 ity, by means of sutures passed through the lateral flaps, and, when 
 union was sufficient to sustain the nutrition of the part, the finger was 
 amputated at the juncture of the middle and distal thirds of the third 
 surgical phalanx, and the distal end turned downward to form the end 
 of the nose and its columna. 
 
 The detail essential to the proper description of this operation, 
 which was lately done with success by Prof. T. T. Sabine, is too ex- 
 tensive to be considered here. A full account of this very interesting 
 case can be found in the April number of the " Illustrated Quarterly 
 of Medicine and Surgery," 1882. 
 
 Subcutaneous Method, This method consists in the subcutaneous 
 division of the depressed tissues, so that they are separated from their 
 bony connections, as was done by Prof. Pancoast in 1842, and can be 
 best described in his own language : 
 
 "A long, narrow-bladed tenotomy-knife was introduced on either 
 side by a puncture through the skin over the edge of the nasal pro- 
 cess of the upper maxillary bone. The knife was pushed up under 
 the skin to the top of the nasal cavity, and then brought down, 
 shaving the inner side of the bony wall, so as to detach the ad- 
 herent and inverted nose upon either side. The point of the nose 
 could now be brought out. The nose still remained adherent to 
 the top of the nasal chasm. The knife was a third time introduced 
 under the skin, in a direction corresponding nearly to the long 
 diameter of the orbit of the eyes, and the adhesions separated from 
 the nasal spine and the internal angular processes of the os frontis. 
 The soft parts and the cheeks were loosened, by sweeping the knife 
 outward along the surface of the bone, so far as to divide the infra- 
 orbital nerve and artery on each side, down toward the median line,
 
 PLASTIC SURGERY. 
 
 315 
 
 FIG. 486. Kingsley's nasal lever. 
 
 and held together with sutures passed through the cavity of the 
 nose." 
 
 As before mentioned, mechanical appliances can be employed to 
 support the soft parts of the nose, provided an opening exist through 
 the roof of the mouth. Fig. 
 486 shows a lever sometimes 
 employed to raise and sup- 
 port the parts in proper posi- 
 tion. 
 
 In this instance, however, 
 the lever is attached to an 
 apparatus intended to relieve 
 an additional deformity. 
 " The processes E E pass into 
 the nose, and support the 
 sunken portion. The nasal 
 elevator must be so arranged 
 as to fall back of the line B B, 
 to be introduced, and then 
 
 must extend into its position. This is accomplished by attaching the 
 elevator to the denture by a joint, as seen in the engraving, and also 
 by extending an arm of the elevator within the shell, and terminating 
 it with a hook." The dotted lines show the lower end of the lever 
 and the elastic attachment which retains it in position. The irritation 
 consequent upon the pressure of the lever is not severe, and can be 
 lessened by covering the ends with lint, cerate, etc. 
 
 The degree of elastic tension can be regulated at the will of the 
 patient, and even be entirely removed during the night. 
 
 Hare-lip. This deformity constitutes a large proportion of the 
 congenital defects calling for operations upon the face. 
 
 Operations for its relief can be performed at any age, but the best 
 time is as soon after birth as the infant becomes well educated to take 
 its food and enabled to bear the loss of blood. If the infant be plump 
 and robust, it can be performed earlier than if weak and puny. The 
 exceptions are rare when it is not admissible at three months of age. 
 It is important to have complete control of the patient during the 
 operation. For this purpose, an anaesthetic should always be given, 
 chloroform being usually selected. The arms of the patient are placed 
 at the sides, and are held in position by a napkin surrounding the 
 body and pinned sufficiently tight to prevent their withdrawal. 
 
 One assistant takes the child in his lap, while another stands be- 
 hind the former and holds the infant's body. The head is firmly 
 held between the hands of the first assistant, so that he is able not 
 only to control the movements of the head, but likewise the circu- 
 lation in the facial and coronary arteries, and to bend the head for-
 
 310 
 
 OPERATIVE SURGERY. 
 
 ward, that blood may escape from the mouth. He can also administer 
 the anaesthetic with a small sponge held between the index-fingers. 
 The success of the operation will depend in a very large degree upon 
 the entire absence of tension when the parts are placed in position. 
 To prevent tension, it is often necessary to separate the lip and cheeks 
 to a considerable extent from their bony connections. In some in- 
 stances, owing to the difficulties of the case, the loss of blood will be 
 considerable, unless every precaution to prevent it be taken. The 
 coronary vessels usually supply the bleeding points, but they can be 
 easily controlled by grasping the lip at both sides of the incision, be- 
 tween the thumbs and fingers. 
 By this procedure, the same force 
 that puts the part upon the 
 stretch also checks the flow of 
 blood. The fingers of the as- 
 sistant often hinder the operator, 
 especially if the cleft be a large 
 one, but their action can readi- 
 ly be supplemented by passing 
 through the lip, at each side of 
 the proposed cut, a strong silk 
 ligature, which, when looped, 
 makes it possible to keep the 
 parts on the stretch without in- 
 convenience. The ligature can 
 be so placed that when the parts 
 are put upon the stretch the cor- 
 onary vessels will be compressed. 
 Either Milne's artery compres- 
 sion forceps or Langenbeck's ser- 
 refines (Figs. 55 and 58) will con- 
 trol the hemorrhage admirably if 
 one of them be fixed at the angle 
 of the mouth on each side. If the 
 blades of the ordinary dressing 
 forceps be surrounded by adhe- 
 sive plaster and closed upon the 
 lip by rubber bands passed around 
 the handles, a useful substitute 
 will be had for the instruments 
 just mentioned. The additional 
 FIG. 487. Butcher's bone piiers. instruments needed are a strong 
 
 pair of scissors, two scalpels 
 
 one sharp pointed and Butcher's bone pliers (Fig. 487), if the case 
 be complicated with a projecting intermaxillary bone. The projecting
 
 PLASTIC SURGERY. 
 
 317 
 
 portion may be pressed into position often by direct manual force. 
 A liberal supply of hare-lip pins, Buck's needle-carrier (Fig. 48), silver 
 sutures, and needles and needle-holder are required. The variety of 
 suture to be employed and the degree of tension allowable have been 
 already considered under the heading devoted to that purpose. The 
 borders may be pared with a sharp-pointed scalpel, strong scissors, or 
 the triangular cataract-knife ; the latter is a very useful instrument 
 for this purpose. It is not permissible to sacrifice the parings taken 
 from the free borders of the cleft, except in cases with but little de- 
 formity ; they should remain attached and be utilized in filling in the 
 gap, this being the only satisfactory manner .of avoiding the occur- 
 rence of the objectionable notch often seen after operations for hare- 
 lip. The points of the pins should perforate the flaps at least a third 
 or fourth of an inch from the borders of the wound, and even far- 
 ther, if there be any degree of tension. One or two pins will be suf- 
 ficient in the majority of cases. Neither pins nor sutures are passed 
 through the flaps, but are passed near to their under surface. The 
 sutures may be inserted nearer to the edge of the wound than the 
 pins, and in sufficient number to properly connect its lips. The latter 
 are removed within two or three days ; the former may remain longer. 
 If ulceration begin around the pins, they should be removed after 
 others have been inserted at new points to receive the strain. 
 
 Simple Hare-lip. This variety of deformity can be treated by paring 
 and uniting directly the borders of the cleft, or by uniting them after 
 incisions extending more deeply, which likewise sacrifice the borders of 
 the cleft (Fig. 488), and also by the single and double flap method. 
 
 FIG. 488. Incisions for direct union. 
 
 The simplest method consists in refreshing the borders of the cleft, 
 loosening the labial connections to the bones, and bringing the edges 
 directly into contact. Care should be taken to secure an accurate co- 
 aptation of their vermilion borders. Unless the operation is carefully 
 performed, this method is often followed by a notch at the border of 
 the lip where the flaps are joined. 
 
 Single Flap (Fig. 489). Draw down both borders of the cleft and 
 freely sever their connections with the bone ; pare the border of the
 
 318 
 
 OPERATIVE SURGERY. 
 
 longer portion, c, and mate the flap on the shorter, b ; approximate 
 and unite them, as before described. 
 
 Double Flaps. Pass a silk ligature through each angle of the 
 fissure (Fig. 490, c) ; divide the sublabial connections, make one side 
 
 FIG. 489. Single-flap method. 
 
 FIGS. 490, 491. Double-flap method. 
 
 tense, transfix it near the border of the lip, and cut upward to the 
 apex of the cleft ; repeat the operation on the opposite side of the 
 fissure ; draw both flaps downward, bringing their cut surfaces in 
 contact with each other (Fig. 490, d) ; close the cleft with a pin or 
 suture passed near to the vermilion border, and insert another above 
 if necessary ; unite the everted flaps by a fine silken thread or horse- 
 hair, e ; cut off their extremities obliquely, leaving enough tissue to 
 form a permanent projection at the margin of the lip, in order to ob- 
 viate the formation of a notch. If the cleft be shallow (Fig. 491, a), 
 the flaps should remain connected above and be turned downward and 
 united, as before (Nelaton) (Fig. 491, b). 
 
 Double Flaps, Giraldes' Method. This method is principally em- 
 ployed only when the deformity extends into the nasal cavity, and the 
 flaps are constructed so as to provide a floor to its entrance (Fig. 492). 
 
 FIGS. 492, 493. Giraldes' method. 
 
 When the flap c is carried upward to repair the floor of the nostril, the 
 angle of the cut b a is then brought in contact with the angle of the 
 border d, and their cut surfaces are made of a similar length. The 
 border b then comes in contact with d, and the point of the flap a, 
 rests upon the undermost cut, in which position they are united (Fig.
 
 PLASTIC SURGERY. 
 
 319 
 
 FIG. 494. Double hare-lip. 
 
 493). This operation is an admirable one, and should be employed on 
 all occasions where an extensive deformity exists. 
 
 Double Hare-lip, simple. Pare the central portion (Fig. 494, c) 
 on both sides ; make lateral 
 flaps with their attachments be- 
 low (Fig. 494, a b) ; liberate the 
 labial attachments, and approx- 
 imate the raw surfaces by the 
 aid of pins and sutures. 
 
 Complicated Hare-lip. Hare- 
 lip is often complicated by a 
 fissure through the alveolar process, which sometimes extends to the 
 hard palate, and even beyond, to the soft parts. For a time before 
 the operation, it is well for the parents or nurse to make gradual 
 pressure upon the more prominent bony portion, combined with out- 
 ward traction on the depressed side, endeavoring thereby to cause the 
 alveolar arch to assume as nearly as possible a normal outline. A 
 reasonable degree of patience in making these painless manipulations 
 will in time effect a more satisfactory result than .the application of 
 sudden force by means of forceps. The practice of forcing the alve- 
 olar extremities into position, paring and wiring them, is a pernicious 
 one, since to do it still further shortens the outline of the arch of 
 mastication of the superior maxilla, and does not result in a bony 
 union of the extremities. The gentle but constant traction exerted 
 by the united lip will in time as certainly reduce the bones as the 
 more vigorous measures, 
 
 It is better to allow the deformity of the hard parts to remain un- 
 molested until the teeth appear, when the outline of the biting surface 
 of the upper jaw may be compared with that of the lower jaw, and 
 made to meet it by rectifying the upper, and introducing, if neces- 
 sary, additional teeth upon a plate to fill the 
 gap in the biting surface. Giraldes' method 
 offers the best opportunity of closing the fis- 
 sures in the lip in these cases. 
 
 The fissure may be double, and involve 
 both the hard and soft parts, back to and 
 through the soft palate. The intermaxillary 
 bone in this connection may project freely, 
 and even be adherent to the soft parts cover- 
 ing the end of the nose (Fig. 495). If such 
 be the case, after the division of the vomer, 
 or the removal of a triangular piece from the 
 septum, the projecting portion is forcibly 
 pressed into position, its borders refreshed, 
 and the soft parts united, as in the simpler forms ; except, perhaps. 
 
 FIG. 495. Complicated hare- 
 lip.
 
 320 
 
 OPERATIVE SURGERY. 
 
 it may not be prudent to unite both sides simultaneously, for fear of 
 causing too great traction. 
 
 "When the protruding portion is connected to the nose, it should be 
 
 FIG. 496. Uainsley's compressor. FIG. 497. Operation by V-shaped incision. 
 
 separated from this with care, or the columna will be impaired. The 
 parings are utilized in correcting the upper lip, when practicable. 
 
 The cheek-compres- 
 sor, designed by 
 Hainsley, may be 
 
 \:l 
 
 . <= 
 
 employed to hold the 
 parts in position 
 when the conditions 
 require it (Fig. 496). 
 Cheiloplasty is an 
 operation directed to 
 the restoration of de- 
 formities of the lips 
 dependent on dis- 
 ease or congenital 
 defects. 
 
 Deformity of Low- 
 er Lip, V-Incision. 
 ^\ This incision is 
 employed for the re- 
 moval of epithelio- 
 mata, or other morbid growths, that do not require the removal of 
 
 FIG. 498. Celsus' method.
 
 PLASTIC SURGERY. 
 
 321 
 
 FIG. 499. Celsus' method. 
 
 more than one third of the lip. The whole thickness of the lip is di- 
 vided ; the length of the arms of the V being increased proportionate- 
 ly to the width of 
 its base. The usual 
 liberating incisions 
 may be required, 
 and the cut sur- 
 faces are united by 
 the same means, 
 and cared for in 
 the same manner, 
 as in operations for 
 hare-lip (Fig. 497). 
 Method of Cel- 
 sus. When the 
 morbid growth in- 
 volves the whole or 
 half of the lip, the 
 broad -based V in- 
 cision is supple- 
 mented by trans- 
 verse ones extending outward, from each angle of the mouth, a suf- 
 ficient distance to admit the easy joining of the V borders after the 
 
 tissues have been freely 
 liberated from their bony 
 attachments (Figs. 498 and 
 499). If difficulty be ex- 
 perienced in sliding the 
 flaps, it may be overcome 
 by making short vertical 
 incisions through the cheek 
 at the outer extremities of 
 the horizontal ones (Fig. 
 498, e, e). The most in- 
 genious feature of this 
 
 FIG. 500. Horizontal incision. method consists in divid- 
 
 ing the buccal mucous 
 
 membrane at least a fourth of an inch above the incision made 
 through the cheek and parallel with it, so that when the outward cuts 
 are completed, and the parts joined in the median line to form the lip, 
 its raw upper borders can .be covered by turning the processes of mu- 
 cous membrane over them, thereby forming an excellent vermilion 
 border. The angles of the mouth are also to be formed by stitching 
 the membrane and buccal cuts to each other. 
 
 Horizontal Incision (Fig*. 500). When the morbid process does 
 21
 
 322 
 
 OPERATIVE SURGERY. 
 
 FIG'. 501. Syme's method. 
 
 not involve the free border of the lip, it can be removed by an oval 
 incision, and the gap closed in the usual manner. If the space be too 
 
 large to admit of 
 closure, it can be 
 left to heal by 
 granulation, or be 
 remedied by the 
 sliding process, 
 either with or 
 without parallel or 
 transverse incis- 
 ions. 
 
 Syme's Method 
 (Fig. 501). In 
 this method the 
 operation is per- 
 formed by contin- 
 uing the sides of 
 the V downward 
 and outward in a 
 curvilinear direc- 
 tion for about two inches, dissecting up the flaps in the usual man- 
 ner, raising them up to form the lip, uniting them in the median line, 
 and allowing the remaining portion to heal by granulation. The 
 mucous membrane should then be stitched to the integument, to pro- 
 vide a suitable border. Buchanan's method differed from Syme's in 
 making the extremities of the flaps 
 straight, as shown by dotted lines 
 (Fig. 501). In other respects, no 
 radical difference exists between 
 these methods. 
 
 Buck's Method. He first re- 
 moved the morbid growth by the 
 V-shaped incision, and united the 
 parts in the usual manner. After 
 union had taken place, the short 
 lower lip was overhung by the up- 
 per, giving to the patient a sucker- 
 mouthed appearance (Fig. 502). 
 The steps taken to relieve this de- 
 formity can best be described in 
 Dr. Buck's own language : " In 
 
 FIG. 502. Operation for contracted lower 
 lip. 
 
 order to insure precision in mak- 
 ing the requisite incisions, their course should first be designated by 
 pins, temporarily inserted erect in the skin at certain points, as shown
 
 PLASTIC SURGERY. 
 
 323 
 
 by Fig. 503. Letters a a represent two pins inserted at one finger's 
 breadth below the under-lip border, one on either side of the chin, a lit- 
 tle to the outside of the angle of the mouth, and both equidistant from 
 the median line ; 1) b are also two pins inserted, one on either side, 
 into the upper lip at the margin of the vermilion border, both equi- 
 distant from the median line, and at such a distance apart as to in- 
 clude between them sufficient length of lip border with which to form 
 a new upper lip. The steps of the operation are then the following : 
 with the forefinger of the left hand placed on the inside of the mouth, 
 the cheek is held moderately on the stretch, while with a sharp-pointed 
 knife it is transfixed at the point a, as marked by the lower pin in the 
 side of the chin. An incision is then carried through the entire thick- 
 ness of the cheek upward and a little outward a distance of one inch 
 and a half to a point c, near 
 the middle of the cheek. The 
 upper lip should next be trans- 
 fixed at the point J, marked 
 by a pin on the vermilion bor- 
 der, and the incision carried 
 through the lip and cheek 
 outward and a little upward 
 to join the first incision at its 
 terminus c in the middle of 
 the cheek. A triangular 
 patch, T), c, a, will thus be 
 formed, which will include 
 the entire thickness of the 
 cheek, with its apex free and 
 disconnected, while its base 
 remains attached toward the 
 mouth. The next step is to 
 transfer the patch from the 
 cheek to the side of the chin. 
 
 For this purpose an incision should be made on the side of the chin 
 from the starting-point of the first incision #, vertically downward 
 to the edge of the jaw and to the depth of the periosteum (Fig. 
 503). The edges of this incision retracting wide apart, afford a 
 V-shaped space for the lodgment of the triangular patch, which 
 is now to be brought around edgewise and adjusted by sutures in 
 the new location. By this transfer the portion of the upper-lip 
 border that formed a part of the base of the patch, is brought into a 
 transverse line, continuous with the upper lip, and forms an extension 
 of it. The space upon the cheek from which the triangular patch 
 was taken is closed by bringing its edges together and securing them 
 by sutures. By this adjustment a new and naturally shaped angle is 
 
 FIG. 503. Buck's incision.
 
 324 
 
 OPERATIVE SURGERY. 
 
 formed for the mouth at the point Z>, where the lip was transfixed in 
 commencing the second incision of the cheek. The incisions must be 
 made with the utmost precision, and special care taken that the mu- 
 
 FIG. 504. Maljraijcne's method. 
 
 FIG. 505. Sedillot's method. 
 
 cous membrane is divided exactly to the same extent as the skin. 
 The same procedure may be applied to the other side of the mouth 
 and executed at the same operation." 
 
 Malgaigne's Method (Fig. 504). The growth is removed by means 
 of one horizontal and two vertical incisions. The vertical incisions 
 begin at the angles of the mouth, the horizontal one is located between 
 them and below the disease. Two additional horizontal incisions are 
 
 subsequently made on each side, to 
 permit the closure of the gap by 
 the sliding method. The flaps are 
 freely separated, brought forward, 
 united in the median line, and the 
 mucous membrane of their upper 
 borders stitched to the integument. 
 The mucous membrane can in this 
 instance be taken with the cheek- 
 flap to form the vermilion border, 
 as in Celsus' method. 
 
 Sedillot's Method (Fig. 505). 
 The diseased portion is removed as 
 in the preceding method, after which 
 FIG. 506. Buck's method. the vertical incisions are extended
 
 PLASTIC SURGERY. 
 
 FIG. 507. Semicircular-flap method. 
 
 to the lower border of the jaw, then backward far enough to make 
 
 flaps of sufficient width to fill the gap ; thence directly upward to a 
 
 point opposite the angle of 
 
 the mouth. These flaps are 
 
 dissected up, and united in 
 
 the median line by the usual 
 
 means. 
 
 Deformities of the Upper 
 Lip. If the deformity here 
 be slight, it can be remedied 
 by the simple means employed 
 upon the lower lip. 
 
 Inter o-lateral Flap (Buck). 
 This operation was done to 
 restore one half of the upper 
 lip and the adjacent portion J---- 
 of the cheek (Fig. 506). Di- 
 vide the under lip where it 
 joins the cheek by a vertical 
 incision, a, b, at right angles 
 to its border, and one inch in 
 length. Make a second in- 
 cision, b, c, one inch and a 
 
 half in length, beginning at the lower end of the first, a, b, and run- 
 ning forward parallel with the border of the lip. An oblique incision, 
 c, d, about half an inch in length, is then made upward and forward 
 from the end of the horizontal one, leaving the flap with a good at- 
 tachment at this point. Pare the edges of the deformity and the end 
 of the half-lip above ; separate the half-lip from its bony attachments 
 by free section of the underlying tissues directed upward- toward the 
 orbit ; the under-lip flap is then tipped endwise, and its upper extrem- 
 ity connected by sutures with the end of the upper half-lip. The re- 
 maining space between the flap and the cheek is closed by sutures. 
 Fig. 512 shows the result of this operation. 
 
 Entire Loss of the Upper Lip. This deformity may be repaired by 
 semicircular or vertical flaps. 
 
 Semicircular-Flap Method (Buck). Commence an incision at the 
 median line, on a level with the floor of the nasal cavity on each side ; 
 carry it outward and downward in a semicircular manner below the 
 lower lip, to a point corresponding to its middle third, a, b and a, c (Fig. 
 507). These incisions are to be carried through the entire thickness of 
 the cheeks and lips at a uniform distance of an inch and a quarter from 
 the border of the opening. Dissect up the remaining portions of the 
 cheeks freely from their attachments beneath, that they may be easily 
 brought forward. The upper extremities of the semicircular flaps are-
 
 326 
 
 OPERATIVE SURGERY. 
 
 trimmed off at a proper angle, e, d, after which they are united in the 
 median line by the usual means. The interval between the cheeks 
 and the newly constructed mouth is closed by sutures. 
 
 | 
 
 FIGS. 508, 509. Sedillot's vertical-flap method. 
 
 Vertical-Flap Method (Sedillot). The bases of the flaps in this 
 method may be made either upward or downward, the former being 
 
 the better plan, 
 should com- 
 the entire 
 
 They 
 prise 
 
 thickness of the 
 cheeks; their length 
 and width corre- 
 sponding to the di- 
 mensions of the 
 proposed new lip, 
 plus the one-fourth 
 allowance for its 
 shrinkage. They 
 are carried into po- 
 sition, and united 
 in the median line. 
 The gaps in the 
 cheek may be closed by sutures, or allowed to heal by granulation. 
 Dieffenbach's Method. Freshen the lower border of the remaining 
 
 FIGS. 510, 511. Dieffenbach's method.
 
 PLASTIC SURGERY. 
 
 327 
 
 portion of the original lip, then raise two S-shaped flaps, one at each 
 side of the nose, turn them across the space in front of the alveolus, 
 unite them to each other, and also to the freshened border beneath the 
 nose (Figs. 510 and 511). 
 
 Stomatoplasty. This operation is employed to increase the size 
 and regulate an abnormally shaped mouth, when resulting either 
 from disease or from previous operations. 
 
 The deformity can be corrected by an operation already described 
 (Fig. 502), when the lower lip is the 
 contracted portion. The angles of the 
 new mouth may be formed by means 
 of transverse incisions, made at the 
 proper situation. Whenever this is 
 done the mucous membrane must be 
 stitched over the raw surfaces, to pre- 
 vent them from becoming united to 
 each other. 
 
 The operation described by Buck 
 for restoring the angles of the mouth 
 is simple and effective (Fig. 512). An 
 incision is made with great exactness 
 along the line of the vermilion border, 
 circumscribing the circular half of the 
 mouth, and extending to an equal dis- 
 tance in the upper and lower lips, a to 
 
 b. This incision should only divide the skin, and not involve the 
 mucous membrane. A sharp-pointed double-edged knife is inserted 
 
 FIG. 512. Stomatoplasty. 
 
 FIG. 513. Whitehead's mouth-gag. 
 
 FIG. 514. Mason's mouth-gag.
 
 328 
 
 OPERATIVE SURGERY. 
 
 at the middle of this curved incision, and directed toward the cheeks, 
 flatwise, between the skin and mucous membrane, so as to separate 
 
 FIG. 515. Chcek-rctractora. 
 
 FIGS. 516, 517. Whitehead's 
 forceps. 
 
 them from each other as 
 far as the new angle of the 
 mouth requires to be ex- 
 tended. 
 
 The skin alone is next 
 
 divided outward toward the cheeks, on a line with the commissure of 
 the mouth, d to c. The underlying mucous membrane is then di- 
 
 D E F G H 
 
 FIG. 518. Lancrcnbeck's knives. 
 
 FIG. 519. Tcnaculum. 
 
 vided in the same line, but not so far outward. The angles at the 
 outer ends of the two incisions are accurately united by a single-thread 
 suture. The freshly cut edges of skin and mucous membrane, above 
 and below, that are to form the new lip-borders, are to be shaped by
 
 PLASTIC SURGERY. 
 
 329 
 
 paring first the skin, and then the mucous membrane, in such a 
 manner that the latter shall overlap the former after they have been 
 secured together by fine-thread sutures at short intervals. 
 
 Operations upon 
 the Palate. The op- 
 erations employed to 
 relieve the deformities 
 of the hard and soft 
 palate are denomi- 
 nated stapliyloplasty , 
 stapJiylorrhajjhy, and 
 ur anaplasty. The in- 
 struments required 
 are the gag, for the 
 purpose of holding the 
 mouth well opened 
 (Figs. 513 and 514) ; 
 cheek-retractors (Fig. 
 515) ; seizing forceps 
 (Figs. 516 and 517) ; 
 variously shaped 
 
 knives for refreshing 
 the borders of the de- 
 formity (Fig. 518) ; 
 tenaculum employed 
 
 FIG. 520. Curved 
 
 scissors. 
 
 FIG. 521. Sayre's 
 periosteotome. 
 
 FIG-. 522. Good- 
 willie's perios- 
 teotome. 
 
 in holding the flaps, 
 etc. (Fig. 519); curved 
 scissors (Fig. 520) ; periosteotomes (Figs. 521 and 522) ; spiral needle 
 
 FIG. 523. Whitchead's spiral needle. 
 
 FIG. 524. Sims' suture-adjuster. 
 
 FIG. 525. Sims' wire-twisting forceps. 
 
 FIG. 526. Goodwillie's oral saw.
 
 330 
 
 OPERATIVE SURGERY. 
 
 for sutures (Fig. 523) ; suture-adjuster (Fig. 524) ; forceps for twist- 
 ing wire sutures (Fig. 525) ; oral saw (Fig. 526) ; hoe for dividing the 
 muco-periosteal membrane (Fig. 527) ; sponges, sponge-holders, etc. 
 
 Staphylorrhaphy consists in 
 closing an abnormal opening 
 in the soft palate by bringing 
 FIG. 527. Whitehead's hoe. its freshened borders in con- 
 
 tact with each other. The 
 
 openings vary from a simple cleft of the uvula to a complete fissure 
 of all the soft parts (Figs. 528, 529, and 530). Some time prior to 
 
 FIGS. 528-530. Degrees of the deformity. 
 
 the operation, the patient should be instructed by manipulation to 
 control properly the fauces, so that the surgeon may handle the parts 
 without causing involuntary movements of them. If the fissure be a 
 small one, it can be closed by the aid of a solution of cocaine with- 
 out further preparation. 
 
 If the cleft extend through the whole of the soft palate, even en- 
 croaching somewhat upon the 
 hard portion, it will be neces- 
 sary, especially if the gap be a 
 wide one, and the muscles con- 
 trolling it be active, to destroy 
 their influence before attempt- 
 ing to unite the cleft. The ten- 
 sor- and levator-palati muscles, 
 together with palato-glossi and 
 palato-pharyngei, are the ones 
 that exercise contraction on the 
 part, and if they be properly 
 severed, the velum will remain 
 motionless and flaccid. The ac- 
 companying illustration shows 
 their relations to the surround- 
 ing parts (Fig. 532). 
 FIG. 531. Freshening the borders. The palato-pharyngei mUS-
 
 PLASTIC SURGERY. 
 
 331 
 
 cles should be cut, with a pair of blunt-pointed scissors, by dividing 
 the posterior pillars of the fauces, of which they form the principal 
 part. The palato-glossi muscles, comprising the anterior pillars, may 
 be cut in the same manner. The remaining muscles are divided after 
 first passing a silken thread through the velum at a point correspond- 
 ing to the origin of the uvula, on each side of the cleft ; the extremi- 
 ties of the thread are looped and a tenaculum is used to make the ve- 
 lum tense, while the following muscles are divided : 
 
 Tensor Palati. Eecognize the hamular process around which the 
 tendon tensor palati runs, a little behind and internal to the posterior 
 molar tooth. Make tense that segment of the velum by the suture 
 just introduced, and. enter the point of a narrow-bladed knife a little 
 
 FIG. 532. Muscles of the soft palate. 
 
 below and at the inner side of the process, with the edge upward ; 
 carry it upward, backward, and inward, until the point is seen through
 
 332 
 
 OPERATIVE SURGERY. 
 
 the gap ; this divides almost the entire width of the velum, with the 
 main, if not the entire portion of the tendon of the tensor palati. 
 
 Levator Palati. Many of the lowermost fibers of this muscle will 
 be cut by the preceding incision. If a greater section be required, 
 depress the handle of the knife and carry it outward, so as to make an 
 oblique incision on the posterior surface of the velum as it is with- 
 drawn. It is well to allow two or three days to elapse before attempt- 
 ing the union of the cleft, so as to permit hemorrhage and inflammatory 
 action to subside, and to determine more clearly whether further sec- 
 tion will be required. This muscle, if it be made tense by drawing 
 the velum toward the incisor teeth by means of the silken thread, may 
 be cut with blunt scissors under direct observation, especially if the 
 cleft be a deep one. 
 
 Operation of Staphylorrliaphy. There are three steps to the opera- 
 tion of staphylorrhaphy : 1. Freshening the edges of the cleft. 2. Pass- 
 ing the sutures. 3. Coaptating the divided borders, and tying the su- 
 tures. First apply a solution of cocaine to the palate, and then place 
 the patient in a chair which will permit the head to be thrown well 
 back so as to expose the parts to a strong light. The lower point of 
 the cleft is then seized with the forceps, made tense, 
 and the border freshened from below upward (Fig. 
 531), or the reverse if desired. Treat the opposite side 
 in a similar manner. 
 
 The patient is allowed to rest after the completion 
 of the first step, until the hemorrhage ceases and self- 
 control is regained. The sutures should be one yard 
 in length, and doubled before passing, and thoroughly 
 antiseptic. Either silk, horse-hair, silk-worm gut, or 
 metallic sutures can be employed. Three or four are 
 usually sufficient. The first should be introduced at 
 the middle, the second at the lower extremity of the 
 gap, while the remaining ones close the spaces between. 
 They can be passed from before backward on one side, 
 and from behind forward on the other, by means of the 
 needle-holder and the ordinary short-curved needle 
 (Fig. 533), or in the following manner by means of 
 Whitehead's spiral needle (Fig. 523). Seize the left 
 side of the cleft with a pair of forceps, and carry the 
 needle through it at the point selected from before 
 backward ; draw one end of the suture through between 
 the borders of the cleft ; withdraw the needle, arm it 
 with another suture, and pass it on the opposite side in 
 the same manner ; catch the thread and withdraw the 
 FIG 533 -Gross' nee dle, leaving the looped suture in the border of the 
 needle-forceps, cleft (Fig. 534) ; then pass the end of the ligature, first
 
 PLASTIC SURGERY. 333 
 
 inserted, through the loop, which is then drawn out, carrying the 
 single thread through the opposite side. 
 
 The remaining sutures are passed in a 
 similar manner. Each one is then tied some- 
 what loosely, to allow for the swelling, with 
 a reef-knot, or, what is better, the slip-knot 
 held in place by a second knot over it. Per- 
 forated shot may be passed over the sutures, 
 and held in position by compressing them, or 
 by the ordinary knot. If silver wire be used, 
 it must be very fine and flexible, and applied FIG- 534. Looped suture, 
 with an adjuster. The sutures are left suf- 
 ficiently long in either case to admit of their easy removal, which is 
 done at the end of a week. The diet should be plain, and all con- 
 versation interdicted. The sponging during the operation must not 
 be done with any form of antiseptic fluid that possesses a poisonous 
 nature, since the patient may swallow a certain portion of it, with an 
 unfavorable if not an unfortunate result. 
 
 Results. The prospect of union of the parts is very favorable, 
 scarcely more than five per cent of the operations being failures. The 
 time necessary to acquire a distinct voice is variable, and often this is 
 not attainable. 
 
 Uranoplasty. This operation is performed to close a fissure in the 
 hard palate. It should not be attempted on a patient under two 
 years of age, and not then unless the patient is in all respects in per- 
 fect health. It can be completed at one sitting, or may require sev- 
 eral, depending on the obstacles to be overcome. 
 
 If the deformity in the hard palate be complicated with a complete 
 cleft of the soft palate, each one should be treated separately. If, 
 however, the cleft of the soft palate be partial, it can then be operated 
 on at the same sitting. The soft portion should be united first, in the 
 manner before described, to prevent it from being obscured by the 
 blood associated with the operation on the hard palate. 
 
 This operation consists of four stages : 1. The paring of the edges 
 of the fissure. 2. The making of a longitudinal curvilinear incision 
 along the alveolar process close to the teeth (Fig. 535). 3. The rais- 
 ing of the muco-periosteal flaps from the roof of the mouth. 4. Their 
 union along the median line. The patient is anaesthetized, placed 
 in a chair facing a good light, the gag introduced, and the first step 
 is performed easily with an ordinary knife and forceps. The flaps are 
 made by beginning the incision at the posterior border of the last 
 molar tooth, or, more practically, in front of the hamular process, 
 and carrying it down through the periosteum and forward along the 
 inner margin of the alveolar process to the line of junction between 
 the lateral and middle incisors. If the curvilinear incision be made
 
 334: 
 
 OPERATIVE SURGERY. 
 
 at the base of the alveolar process, or be carried forward to the central 
 incisors, the posterior and anterior palatine vessels will be divided. 
 
 These flaps are now to be carefully 
 detached by a periosteotome from 
 without inward and from before 
 backward until the edges of the fis- 
 sure are reached ; they are then 
 carried toward the median line, and, 
 if no degree of traction be noticed, 
 united throughout to each other by 
 silver sutures. The displaced peri- 
 osteum fills in the gap and often de- 
 velops sufficient bone to produce an 
 admirable degree of firmness. The 
 sutures are allowed to remain in po- 
 sition ten days or two weeks, the 
 patient is fed on liquid food, any 
 cough is relieved by anodynes, and 
 the parts are kept clean. 
 
 Langenbeck closed the fissure by 
 two flaps, which were formed by an 
 antero-posterior division of the hard 
 palate on either side of it ; fresh- 
 FIG. 535. Uranopiasty. ened their contiguous borders and 
 
 pushed them against each other at 
 
 the median line, where the mucous membrane was united by sutures, 
 the anterior and posterior extremities of the osseous flaps being still 
 connected with the soft parts. 
 
 Ferguson divided the hard palate with a chisel. Mears uses Ad- 
 ams' saw after drilling an opening for its entrance, and claims less 
 injury is done to the bone than by any other means. The hemorrhage 
 is quite severe during the removal of the periosteal flaps, but it is 
 readily controlled by pressure and cold. When the osseous flaps are 
 made, the bleeding is usually still greater. If the fissure be not in the 
 center, the flap is generally taken from the side of the hard palate 
 which has the greatest width. 
 
 Lannelongue closed the opening by taking a properly shaped flap 
 of the mucous membrane from the septum, its base being lowermost, 
 and stitching its upper border to the opposite side of the chasm. 
 
 Mechanical means are employed to fill the opening in the hard 
 and soft parts, and to provide even an artificial uvula. This apparatus 
 is made of vulcanized rubber, and is held in position by being attached 
 to a plate fitted to the roof of the mouth. An expert dental surgeon 
 ought to be consulted, since he is, as yet, the only one fully compe- 
 tent to treat the cases by this method. The ability to speak and to
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 335 
 
 otherwise control the action of the throat and pharynx with this con- 
 trivance is very satisfactory ; in the majority of instances equaling, 
 if not exceeding, the best results from an operation. 
 
 Staphyloplasty consists in filling in the gap of the soft palate, and 
 as much as possible of the hard, by a flap taken from the posterior wall 
 of the pharynx. The degree of success attending this operation is suf- 
 ficient to warrant its adoption when the conditions demanding.it are 
 present. 
 
 Operation. Anaesthetize the patient, perform a preliminary tra- 
 cheotomy, and introduce the tampon-canula into the trachea. The 
 flap from the posterior wall of the pharynx is made with the hase down- 
 ward, and the apex is carried as far upward as possible to permit its 
 introduction into the cleft without the least tension. The width and 
 shape of the flap must be determined by the size and outline of the 
 deformity, plus its normal shrinkage. It should consist of the mucous 
 lining of the pharynx, along with the subjacent muscles. The fibro- 
 mucous coverings of the hard palate are dissected up until its tissues 
 and those of the velum are freely movable. The borders of the cleft 
 are freshened, and the flap brought in place and united by several 
 sutures. The tampon-canula can be removed as soon as hemorrhage 
 has ceased, or, at the farthest, on the day following the operation. 
 The parts should be cleansed frequently and carefully with a mild an- 
 tiseptic fluid, to wash away the abundant secretions. The sutures 
 should be removed on the sixth or seventh day following the opera- 
 tion. 
 
 Elongated Uvula. An elongated uvula is easily shortened by caus- 
 ing the patient to withdraw the tongue by aid of a dry towel ; seizing 
 the end of the uvula with forceps and removing the required amount 
 with scissors. The little pain that may be caused by the operation 
 can be relieved by the application to the part of a solution of cocaine. 
 
 CHAPTER XIII. 
 
 OPERATIONS ON THE MOUTH, PHARNYX, AND (ESOPHAGUS. 
 
 Salivary Fistula. With this morbid condition the saliva is dis- 
 charged on the external surface of the cheek instead of into the 
 mouth. The object of an operation is to establish an internal com- 
 munication so that the external opening can heal. 
 
 The cure may first be attempted by passing the ends of several 
 long silken threads through the external opening directly into the
 
 336 
 
 OPERATIVE SURGERY. 
 
 FIG. 536. Seton in position. 
 
 mouth, or through the internal opening of the duct, and bringing them 
 out at the angle of the mouth and tying their extremities (Fig. 536). 
 The internal communication is easily established in eight or ten days ; 
 
 then the seton can be removed and the 
 borders of the external opening freshened 
 and closed. The patient should be ad- 
 vised to chew upon the opposite side 
 during the healing of the external open- 
 ing, to limit as much as possible the flow 
 of saliva on the diseased side. Another 
 method consists in passing a good-sized 
 thread of silk into the mouth, through 
 the fistula, from without inward, and 
 leaving it there ; removing the needle 
 and attaching it to the end of the thread 
 remaining outside, and carrying it 
 through the tissues into the mouth in 
 the same direction as the former, but 
 not exactly in the same track. The needle is then removed, and the 
 extremities of the thread are firmly tied within the mouth. A fine 
 rubber ligature can be substituted for the silk. The loop cuts its way 
 through the tissues grasped, forming an internal opening, which per- 
 mits the healing of the external one. 
 
 The method recommended l)y Dr. Homer, which is employed in 
 obstinate cases, consists in the introduction of a wooden spatula into 
 the mouth, opposite the site of the fistula, upon which, by means of a 
 saddler's or other 
 suitable punch, the 
 diseased tissues, duct 
 and all, are removed 
 (Fig. 537). The ex- 
 ternal opening is 
 closed, a cold, dry 
 dressing is applied, 
 and quiet ordered. 
 The end of the duct 
 can be dissected up 
 and passed through 
 a small incision made 
 through the mucous 
 membrane into the 
 mouth, after which 
 
 the external opening is closed (Van Buren). A small probe should 
 be introduced into the duct from without to prevent it from being 
 cut during the dissection ; when turned inward, the borders of the 
 
 FIG. 537. Homer's method.
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 337 
 
 open extremity can be confined to the edge of the incision by a stitch 
 of catgut or horse-hair. 
 
 Excision of the Tonsils. This operation can be done with an or- 
 dinary tenaculum and bistoury, or with curved scissors. The various 
 forms of tonsillotomes, while they simplify the operation by giving 
 the operator a perfect control over the cutting edge, are not necessary 
 to its execution. 
 
 To remove the Tonsil with the Knife or Scissors. If the patient 
 be young or unable to retain self-control, give an anesthetic or apply a 
 strong solution of cocaine. Cause a bright light to shine into the open 
 mouth, depress the tongue, seize the tonsil with the tenaculum or for- 
 ceps, draw it inward from between the pillars of the fauces, and with 
 scissors curved on the flat or the probe-pointed bistoury, or an ordi- 
 nary bistoury with the point guarded by adhesive plaster, sever the 
 gland from below upward. It is not necessary at first to remove the 
 entire tonsil, since a curative influence is often established by its incom- 
 plete removal. Among the forms of tonsillotomes in common use are 
 Tiemann's (Fig. 538), Hamilton's (Fig. 539), Mackenzie's (Fig. 540), 
 
 FIG. 538. Tiemann's tonsillotome. 
 
 FIG. 539. Hamilton's tonsillotome. 
 
 and others, the majority of which combine the ability to seize, hold 
 up, and sever the growth. The patient is placed as before stated, and 
 22
 
 338 OPERATIVE SURGERY. 
 
 with the index-finger the ring of the instrument is adjusted around 
 the tonsil properly, and the tonsil elevated with a tenaculum, and 
 
 FIG. 540. Mackenzie's tonsillotome. 
 
 severed by pressing the knife against it. Any undue hemorrhage 
 can be controlled by ice, pressure, and astringents ; actual cautery is 
 rarely needed. In four instances the internal carotid artery has been 
 wounded by recklessness in cutting the tonsils. 
 
 OPERATIONS ON THE TONGUE AND OESOPHAGUS. 
 
 It is often necessary to remove the tongue in part or entirely on ac- 
 count of hypertrophy, and malignant and other growths of its structure. 
 The arteries supplying it are the dorsalis linguse, ranine, and branches 
 from the ascending pharyngeal. The ranine is the principal branch, 
 and runs along the under surface of the tongue, from its base to the 
 apex. The buccal, sublingual, and submaxillary glands are closely 
 associated with this organ in a surgical sense. The facial and sublin- 
 gual arteries will not be endangered, unless the floor of the mouth is 
 operated upon in conjunction with the tongue. It should be remem- 
 bered that the circulation in the opposite sides of the organ does not 
 communicate freely, and consequently ligaturing of the lingual artery 
 of one side will permit of free incision on that side with but trifling 
 hemorrhage. 
 
 Tongue-tie. This condition depends on an undue extension for- 
 ward of thefraenum linguae, either with or without an abnormal short- 
 ening of it. If the condition be severe enough to call for treat- 
 ment, the end of the tongue is pressed upward by passing the first 
 two fingers beneath it, palm downward, bringing the tense frsenum 
 between them on the palmar surface, when it can be divided with a 
 blunt-pointed scissors at a little distance from, but parallel with its 
 under surface, care being taken not to sever the ranine artery. 
 
 Ranula. The closure of the ducts of the sublingual and other 
 glands in this situation causes a cystic distention of the ducts, and
 
 OPERATIONS OX THE MOUTH, PHARYNX, AND (ESOPHAGUS. 339 
 
 even of the glands themselves. If it be not possible to find and probe 
 the duct-openings, it will be necessary to evacuate the contents at the 
 floor of the mouth below the tongue, or, if the tumor be of large size, 
 this must be done in the median line externally, close to the hyoid 
 bone. In either instance it may be necessary to pack the cavity with 
 lint and liquor ferri sulphatis, or cauterize the sack with nitrate of 
 silver, and even to dissect it partially or entirely away. 
 
 Excision of the Tongue. The tongue may be removed with the 
 knife, scissors, galvanic cautery, ecraseur, or ligature. The last 
 method should be excluded, as the time required and the pain caused 
 by it is greatly in excess of that by the other methods. If the diseased 
 portion be small, it may be taken away by the form of incision best 
 calculated to accomplish the object, since it is not a good plan to se- 
 cure symmetry at the expense of future safety. If the hypertrophy 
 involves the apex, or if a tumor be located at this situation, it can be 
 excised by removing a V-shaped piece in the following manner : 
 
 Operation. Anaesthetize the patient, place him in a chair in a strong 
 light with the mouth well opened by a special gag, or any suitable in- 
 strument, forced, with a string attached, between the posterior molars. 
 If the patient be in the recumbent posture, the head is turned to one 
 side, to collect the blood in the hollow of the cheek. Pass a stout 
 ligature through each side of the tongue, just outside of the intended 
 site of the apex of the V-incision ; loop them and give each to an assist- 
 ant with instructions to pull the tongue forward ; seize the tip with a 
 pair of forceps, or between the thumb and finger, and with a sharp- 
 pointed, narrow-bladed knife transfix the organ posteriorly from below 
 upward at the point of the V, cutting outward and forward through 
 its borders ; check the points of severe hemorrhage with forceps, and 
 make the incision on the opposite side in a reverse direction backward 
 
 FIG. 541. Removal of a V-shaped piece. FIG. 542. Flaps united. 
 
 to join the first incision (Fig. 541). Ligature the bleeding points and 
 unite the flaps by sutures in the usual manner (Fig. 542). A method
 
 340 
 
 OPERATIVE SURGERY. 
 
 has been recommended by Langenbuck to control the hemorrhage 
 when but half or two thirds of the anterior portion of the tongue is 
 to be removed by cutting. A long, well-curved needle, armed with a 
 strong ligature, is entered at the left of the median line of the tongue, 
 behind the portion to be removed, and passed through to the right 
 side and under surface of the organ, so as to carry the ligature beneath 
 the branches of the lingual artery. The ligature is then carried 
 through the right border of the tongue and firmly tied. A similar 
 procedure is repeated on the opposite side of the tongue. These liga- 
 tures can then be used to draw the tongue forward. Dr. Howe, of 
 this city, has devised a "safety-pin clamp," with which he proposes 
 to control the hemorrhage by passing the pin above the arteries and 
 screwing the clamp into position against the intervening tissues. 
 Heath highly commends the drawing of the stump of the tongue for- 
 ward by the finger passed into the pharynx. This traction not only 
 renders the bleeding point more accessible, but the hemorrhage is also 
 directly checked by means of the pressure necessary to draw the tongue 
 forward. 
 
 Hypertrophy of the Tongue (Fig. 543), involving its entire struct- 
 ure, can be treated by the re- 
 moval of a V-shaped piece in 
 the manner just described. 
 This will shorten its trans- 
 verse diameter and diminish 
 its length. The flaps are then 
 united, and, after union has 
 taken place, the thickness of 
 the tongue can be diminished 
 in the following manner : A 
 strong ligature is passed lat- 
 erally through the organ near 
 to the base, and by this it is 
 drawn forward and held while 
 a wedge-shaped piece is re- 
 moved by transfixing laterally 
 as far back as possible and 
 midway between its upper 
 and lower surfaces. The un- 
 der flap is first made by cutting downward and forward through the 
 under surface of the organ, then the upper flap is formed by applying 
 the knife to the tissue above the last incision. The bleeding points 
 should be ligatured, and the flaps united with sutures. 
 
 Half of the organ can be removed by first ligating the lingual 
 artery corresponding to that half, after which two long stout ligatures 
 are passed through it near the tip, one on each side of the median 
 
 FIG. 543. Hypertrophy of the tongue.
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 341 
 
 line, by these the tongue is drawn forward and upward ; the fraenum 
 and the mucous membrane beneath the tongue are cut with scissors 
 back to the base of the organ ; the tongue is then divided in halves, 
 from before backward, with a knife or scissors, its deeper tissues are 
 separated by tearing with the finger or handle of the knife, and the 
 portion to be removed is finally separated with scissors. The remain- 
 ing half can be removed in a similar manner. If the lingual arteries 
 have not been tied, the ecraseur can be employed, or if it be divided 
 by scissors the bleeding points should be secured as soon as possible. 
 
 Removal of the entire Tongue. This can be done either through the 
 mouth or beneath the inferior maxilla, or by division of the lower jaw 
 at the symphysis, or on either side of it. It can be removed through 
 the mouth by the knife, scissors, the galvano-cautery, or the ecraseur. 
 When the knife or scissors are to be employed, it is a wise precaution 
 to ligature both lingual arteries to prevent the profuse hemorrhage 
 which must otherwise occur. A stout thread is then passed through 
 the tongue at the juncture of the middle and anterior thirds, and by 
 this the organ is drawn forward and upward, and detached from its 
 connections with the jaw and pillars of the fauces. The muscles of 
 the tongue are then divided by scissors back to near the larynx, as 
 closely to its under surface as the disease will permit. The glosso- 
 epiglottidean folds are now brought under control by passing a long 
 ligature through each. These ligatures are allowed to remain in situ, 
 in order that the floor of the mouth may be drawn forward by them 
 in the event of secondary hemorrhage. The excision is then com- 
 pleted, and all bleeding points are checked. The surface is permitted 
 to heal by granulation. 
 
 Mr. Whitehead, of Manchester, has frequently operated in this 
 manner with great success, 
 without previously ligating 
 the lingual arteries, but by 
 tying the bleeding points as 
 they presented themselves. 
 The ecraseur offers an ad- 
 mirable means of removing 
 the whole organ, with less 
 danger from hemorrhage 
 than by the use of the knife 
 or scissors ; the results, too, 
 are quite satisfactory. This 
 instrument may be applied 
 
 through the mouth, or by + 
 
 J FIG. 544. Ecraseur m position. 
 
 way of a free puncture 
 
 made with a stout, sharp-pointed knife introduced from without 
 
 between the hyoid bone and the jaw, a little nearer the latter,
 
 342 OPERATIVE SURGERY. 
 
 and caused to enter the floor of the mouth, near the fraenum (Fig. 
 544). The wire or chain is passed through this opening, around the 
 base of the tongue, in which position, after the tongue is well drawn 
 forward, it is confined by means of three or four stout hare-lip pins 
 passed at short intervals through its base from side to side ; after 
 which the organ is slowly and carefully severed. If the tongue be 
 drawn forward in the usual manner and freely detached from its con- 
 nections with the jaw and floor of the mouth, the same instrument 
 can be quite as readily applied without the submental puncture. The 
 use of the ecraseur for complete ablation can be recommended with 
 confidence ; and it should, if accessible, be selected in preference to 
 galvano-cautery, which is much more likely to be followed by second- 
 ary hemorrhage. 
 
 The removal below or through the jaw does not offer the chances of 
 success enjoyed by the former methods. The operation devised by 
 Eegnoli affords easy access to all portions of the tongue, except its 
 base, and also furnishes good drainage, but creates a large and some- 
 what dangerous wound. 
 
 Operation. A crescentic-shaped incision is carried along the base 
 
 of the lower jaw (Fig. 545), extending 
 from in front of its angles. A vertical 
 incision is then made from the center 
 of this to the median line of the hyoid 
 bone. The flaps are reflected, and the 
 attachments of the lingual and hyoid 
 muscles divided from the surface of. 
 the lower jaw. The tongue is then 
 drawn through the opening and sev- 
 ered by the knife or ecraseur, the 
 bleeding points being secured as fast 
 as they appear. The flaps are united, 
 and the remaining raw surfaces allowed 
 
 . 545.-lieg, 1 oii', incision. to heal b J granulation. 
 
 Knox made a vertical incision 
 through the lower lip down to the hyoid bone, extracted a tooth and 
 sawed through the symphysis mentis. The mucous membrane and 
 the muscular attachments of the tongue were then divided, the lin- 
 gual arteries cut and tied, and the tongue removed close to the hyoid 
 bone. Mr. Heart employed the ecraseur instead of the knife. 86- 
 dillot made an <-shaped section of the bone to prevent the frag- 
 ments from sliding after approximation. Billroth divided the jaw 
 between the canine and last molar teeth, corresponding to the dis- 
 eased side of the tongue, and wired the fragments after the removal of 
 the diseased portion. 
 
 If the floor of the mouth be involved in addition to the tongue, Bill-
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 343 
 
 roth made an incision about one incli below the border of the lower lip 
 from one facial artery to the other ; at the ends of this incision he made 
 two vertical ones extending to a point about four fifths of an inch below 
 the border of the inferior maxilla ; at the juncture of these vertical incis- 
 ions with the jaw, he divided the bone and turned it downward along 
 with the soft parts, thereby affording ample room to reach the diseased 
 parts within. If the portion to be removed be extensive and the danger 
 from hemorrhage great, a preliminary tracheotomy is advisable. This 
 measure not alone prevents the blood from obstructing respiration, but 
 lessens the dyspnoea frequently caused by a wide separation of the jaws. 
 Kocher recommends the following plan if the floor of the mouth, 
 the pharynx, and contiguous glands be involved along with the tongue. 
 After a preliminary laryngo-tracheotomy and thorough cleansing of 
 the parts, a triangular flap is made, with the base upward, its lower 
 boundaries corresponding to the course of the digastric muscle, and 
 its apex being at the point of connection of this muscle with the hyoid 
 bone (Fig. 546, c, e, d, b). The posterior incision may also be made 
 from this point directly to 
 the anterior border of the 
 sterno - mastoid muscle, 
 thence upward along its 
 border to the angle of the 
 jaw, so as to afford a greater 
 space than is afforded by 
 the former line of incision. 
 These flaps cover the re- 
 gion of the jaw and neck 
 occupied by the facial ar- 
 tery and the submaxillary 
 gland posteriorly, and the 
 lingual artery and sublin- 
 gual gland anteriorly. The 
 flap is dissected up, the ar- 
 teries are tied, and the 
 glands, if involved, are re- 
 moved. This exposes the 
 side of the tongue and floor of the mouth for easy inspection and ma- 
 nipulation. The larynx and pharynx are then protected from the en- 
 trance of blood by a large sponge to which a string should be attached, 
 and the myo-hyoid muscle is divided close to the jaw, exposing the 
 tongue freely. The organ is now drawn through the opening, split, and 
 the half of it corresponding to the flap is removed, including, if neces- 
 sary, the floor of the mouth, pillars of the fauces, and pharynx down to 
 the hyoid bone. The remaining portion can be removed in a similar 
 manner, through a triangular opening on the side corresponding to it, or 
 
 FIG. 546. Kocher's operation.
 
 344 OPERATIVE SURGERY. 
 
 through the primary opening, if the extent of the disease will permit. 
 As before remarked, the operation, which involves the bone and soft 
 parts around it, results less favorably than when the tongue is re- 
 moved through the mouth by the methods described for that purpose. 
 The after-treatment consists in keeping the mouth cleansed, while to 
 the raw surfaces iodoform and iodoform gauze, or other suitable anti- 
 septic dressings, are applied. The tracheotomy-tube should not be re- 
 moved until all dangers from inflammation and the discharges are ended. 
 
 Results. The rate of mortality from removal of the tongue by all 
 of the methods described is considerable, fixty-six out of two hundred 
 and forty-four cases having died. 
 
 (Esophagotomy. It sometimes becomes necessary to open the oesoph- 
 agus on account of obstruction due to foreign bodies lodged in its cer- 
 vical portion. In this connection it is well to recall the relations of the 
 oasophagus. It begins opposite to the cricoid cartilage, and is located, 
 in this region, somewhat to the left of the median line. The situation 
 of the foreign body is usually marked by a greater or lesser prominence 
 on the left side, below the cricoid cartilage ; or, if this be not mani- 
 fest, the exact site of the canal can be determined by the introduc- 
 tion into it, through the pharynx, of a good-sized bulbous or other 
 form of probang. The following are the important surgical relations 
 of the oesophagus in the cervical region : In front, with the trachea, 
 above, and with the thoracic duct and the thyroid gland below ; be- 
 hind, with the vertebral column and longus-colli muscle ; at the sides, 
 especially the left, with the common carotid and inferior thyroid ar- 
 teries, and thyroid lobes. The recurrent laryngeal nerves lie between 
 it and the trachea. 
 
 Operation. Always employ an anassthetic ; place the patient on 
 the back, with the chest and shoulders elevated and the head turned 
 to the opposite side ; feel for the foreign body, and, when it is found, 
 make the incision directly at that point. 
 
 If the foreign body be not discernible, make an. incision about four 
 inches in length on the left side, between the sterno-mastoid muscle 
 and the trachea, beginning at the upper border of the thyroid carti- 
 lage. The platysma and fascia are divided on a director ; the borders 
 of the wound are separated, the omo-hyoid is drawn outward, and the 
 sterno- and thyro-hyoid muscles inward ; this exposes the sheath of the 
 carotid, which is drawn outward and retained ; the lobe of the thyroid 
 gland is raised and drawn inward ; the larynx carefully outlined and 
 drawn forward and held while the location of the foreign body is 
 sought for; if not present or distinguishable, the bulbous probang is 
 then introduced to mark the outline of the tube, the wall of which is 
 raised with a tenaculum and opened sufficiently to admit the finger, 
 care being taken to avoid the recurrent laryngeal nerve. The site of the 
 obstruction is located by passing the finger into the tube, and the cause
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 345 
 
 is removed by suitable forceps, aided by manipulations from without, 
 and by lengthening the incision if necessary. The opening in the 
 O3sophagus may be closed with fine catgut, the external incisions 
 united in the usual manner and dressed antiseptically, and liquid food 
 introduced through a tube for a few days. Or the entire wound may 
 be left open, a feeding-tube introduced through it into the stomach, 
 and allowed to remain three or four days at a time ; then it is re- 
 moved, to be cleaned. As soon as the cut surfaces become granulated, 
 the tube may be removed from the opening, and a smaller one em- 
 ployed, which is passed into the stomach through the nostril. The 
 patient is fed through this until the oesophageal opening has com- 
 pletely closed. 
 
 Fallacies. The foreign body may be mistaken for an enlarged 
 gland on external examination. The oesophagus may be confounded 
 with the longus-colli muscle at first ; however, a moment's examina- 
 tion will serve to dispel the doubt. If the probang be introduced 
 through the pharynx, its exact location will be established. The re- 
 spiratory movements of the oesophagus, distending and collapsing 
 alternately, are important aids in determining its identity. 
 
 Results. Eighty-two cases are reported, of which nineteen died ; 
 but from causes independent of the operation in many instances. The 
 rate can be placed at about twenty-two per cent, which will surely be 
 lessened in the future if the operation be done as early as it should be. 
 
 Stricture of the (Esophagus. This condition depends upon a cir- 
 cumscribed inflammatory action or other morbid process, involving one 
 or more coats of the tube, and causing a narrowing of its caliber, which 
 manifests itself proportionately to the degree of constriction. It may 
 be limited to one side, or involve the whole circumference of the tube. 
 The most frequent site is opposite the cricoid cartilage, where the 
 pharynx and oesophagus become continuous with each other. The 
 stricture can be treated by dilatation, for which purpose various forms 
 of dilators have been constructed (Fig. 547). These and all other 
 
 FIG. 54*7. (Esophageal dilators. 
 
 forms should be introduced as often as necessary by extending the 
 neck and passing the instrument carefully downward in contact with 
 the posterior portion of the pharynx, guided by the index-finger of 
 the disengaged hand. No force should be employed, for fear of causing 
 a false passage. The surgeon should always eliminate the possibility
 
 346 
 
 OPERATIVE SURGERY. 
 
 of aneurismal constriction of the tube before an attempt is made to 
 overcome the obstruction. The sponge extremity of the probang can 
 be used where unusual caution is desirable in explor- 
 ing this passage. 
 
 Retrograde Divulsion. In 1883 Loreta, of Bo- 
 logna, opened the stomach, passed a divulsor through 
 the opening into the lower third of the oesophagus, 
 and ruptured a stricture at this point sufficiently 
 to allow the passage of food. He has since repeated 
 the operation on two occasions, and in each case it was 
 followed by satisfactory results. 
 
 Internal CEsophagotomy. This operation is per- 
 formed by an appropriately constructed instrument 
 (Fig. 548), sometimes so arranged as to be passed 
 upon a guide, as in internal urethrotomy, and has 
 been successfully practiced on several occasions. How- 
 ever, the contiguity of important anatomical struct- 
 ures, and the inability to comprehend the exact re- 
 lations of the stricture to the outer wall of the tube, 
 make the operation an exceedingly hazardous one. 
 If it be attempted, the constriction should be incised 
 only sufficiently to admit a bougie, by the means of 
 which the treatment should be continued. 
 
 Strictures of the cervical portion of the oesopha- 
 gus may be divided from without. The stricture is 
 first located by a bougie introduced into the tube, 
 and is then cut down upon through an incision simi- 
 lar to that for cesophagotomy. 
 
 Results. Internal oesophagotomy has been per- 
 formed, in all, about nineteen times, of which one 
 third died in sixteen days from results associated 
 with the operation. Of the remainder, three are 
 said to have recovered, while the others survived 
 for a period from one month to several years. About 
 one third of the cases required one or more repeti- 
 tions of the operation. 
 
 CEsophagectomy. (Esophagectomy consists in ex- 
 cising a portion of the cervical oesophagus through 
 an incision made in the same manner as for oasophagotomy, for the 
 removal of a cancerous growth. The upper end of the lower portion 
 of the tube is then raised forward and united to the wound ; thereby 
 forming an opening through which food may be introduced by means 
 of a tube. 
 
 Results. Only five or six cases have as yet been reported. In 
 two of these, life was prolonged for months ; the remainder died soon 
 
 * 
 
 FIG. 548. Sands' 
 instrument for 
 internal cesoph- 
 agotomy.
 
 OPERATIONS ON THE MOUTH, PHARYNX, AND (ESOPHAGUS. 34-7 
 
 after the operation. There is reason to believe that life can be more 
 prolonged by feeding through a tube in the usual manner, than by this 
 procedure. 
 
 (Esophagostomy. This procedure is employed to establish a fistu- 
 
 FIG. 549. Bris- 
 tle probang. 
 
 FIG. 550. Sponge and 
 bucket probang. 
 
 FIG. 551. Cusco's throat- 
 forceps. 
 
 lous opening, with the tube, below the point of an incurable, impassa- 
 ble constriction. It provides for the introduction of food into the 
 stomach, and serves as a temporary palliative measure. 
 
 Results. It has been performed thirty-two times, in which about 
 sixty per cent of the patients perished. Of this number, twelve died 
 from the operation directly or from its sequels. 
 
 The removal of foreign bodies from the oesophagus is accomplished
 
 348 OPERATIVE SURGERY. 
 
 FIG. 552. Mathicu's throat-forceps 
 
 FIG. 553. Burgc's throat-forceps. 
 
 by probangs (Figs. 549 and 550) and various forms of long forceps 
 (Figs. 551, 552, and 553). 
 
 CHAPTER XIV. 
 
 OPERATIONS ON HOLLOW VISCERA IN CONTACT WITH SEROUS 
 
 SURFACES. 
 
 THE injuries of these organs which require surgical treatment 
 may result either from external violence, or become part of the pro- 
 cedure necessary for the removal of obstructions in the intestinal tube, 
 or of malignant growths from the duodenum, stomach, or intestines. 
 In these operations it is important : 1, to avoid all unnecessary hem- 
 orrhage ; 2, to prevent the escape of irritating matter into the abdom- 
 inal cavity ; 3, to unite the divided surfaces so that they shall remain 
 properly opposed, and be followed by perfect union ; 4, to avoid all 
 unnecessary shock and septic or irritating influences. The first indi- 
 cation is met by carefully avoiding any incisions through the line of 
 the established course of vessels, and by the use of needles which do 
 not possess cutting edges (as when their points somewhat resemble those 
 of the ordinary sewing-needle), but enter the tissues by causing their 
 separation. To meet the second indication requires a great degree of 
 caution irrespective of the knowledge of any established measures. The 
 lips of the wound should always be kept uniformly and well raised by 
 means of forceps ; or, by strong ligatures passed through their bor- 
 ders at suitable situations. If the nature of the case will permit, the 
 contents of the Discus should be removed before the operation is com- 
 menced, and at all times the serous surfaces must be protected from con- 
 tact with irritating matters, by means of broad, thin, antiseptic sponges 
 or other suitable agents moistened in a warm, mild, antiseptic fluid. 
 
 To fulfill the third indication, sutures of various forms and meth- 
 ods of application are employed ; the aim of all being to bring the 
 serous surfaces in contact, and maintain them so until firm union is
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 
 
 349 
 
 FIG. 554. Lcmbert's 
 suture. 
 
 established. To do this, it is necessary to roll the borders of the 
 wound inward, since the mucous surfaces will not unite to each other 
 (Fig. 554). The size of the wound has to do with its treatment. If 
 it be of large size, it may be advisable to connect it with the opening 
 in the abdominal walls, and allow the resulting 
 fistulous opening to close spontaneously. When 
 it is possible, however small the wound of the 
 intestine may be, it should be closed, or it may 
 permit the escape of irritating matters into the 
 abdominal cavity. The fourth indication is 
 very important, especially if the operation be 
 prolonged and tedious, or if the intestines be 
 removed from the cavity of the abdomen. The room in which opera- 
 tions on the abdominal contents are performed should be thoroughly 
 cleansed and fumigated when possible, and in every way made aseptic, 
 If its temperature can be raised to about 90 F., and the atmosphere 
 moistened with antiseptic vapors, the surroundings will be much im- 
 proved, especially if the abdominal contents are long exposed. If the 
 intestines be removed from the cavity, they must be surrounded by 
 cloths saturated with antiseptic fluids, and kept warm and moist by re- 
 peated applications of the same until they are replaced. The " toilet " 
 of the abdominal cavity must be cautiously and perfectly made before 
 it is closed, and suitable provisions for drainage established, if per- 
 nicious secondary local processes be apprehended. As a rule, the su- 
 tures should not include the mucous surface, but should extend down 
 to it. They should not be more than two lines apart, nor include 
 more than one line of the intestinal substance, and should be cut short. 
 
 Continuous 
 Suture. The 
 name defines ita 
 method of ar- 
 rangement. It 
 is exceedingly 
 useful in join- 
 ing the borders 
 of long cuts of 
 either a serous 
 or cutaneous 
 surface. In the 
 latter the stitch- 
 es are further 
 apatt than when 
 applied to se- 
 rous surfaces, and the cut surfaces of the wound are brought directly 
 in contact with each other (Figs. 555 and 80). 
 
 FIG. 556. Continuous suture. 
 
 FIG. 556. Lcmbert's suture.
 
 350 
 
 OPERATIVE SURGERY. 
 
 Lembert's Suture (Figs. 554 and 556). This form of suture is an 
 admirable one, easy of comprehension and of application. It can be 
 
 Fia. 557. Gely's suture, external appearance. 
 
 used indiscriminately in all wounds of serous membranes, either in the 
 continuous or interrupted forms. 
 
 Gely's Suture (Fig. 557). In this variety a long suture is selected 
 and armed with a needle at each end. The needles are inserted near 
 the angles of the wound, about two lines from the edges, and carried 
 along the interior of the bowel for a sixth of an inch, then brought 
 out precisely on the same level, so as to again appear on the peritoneal 
 surface. The sutures are then crossed, the right needle being passed 
 through the puncture made by the left, and conversely. If a knot be 
 
 made at each crossing, slip- 
 ping of the sutures will be 
 prevented. The number of 
 the crossings will vary with 
 the size of the cut. By 
 this method the edges of 
 the wound are thoroughly 
 inverted (Fig. 558), and all 
 danger of extravasation is 
 prevented. 
 
 Jobert's Method. When 
 the intestine is completely 
 divided transversely, its 
 lower end is turned or tucked in for a short distance, the upper end 
 pushed within it, and their serous surfaces are united by fine sutures 
 (Fig. 559). It will be necessary to separate the mesentery from 
 each extremity of the intestine for a short distance in order to per- 
 mit the coaptatiou just described (Fig. 560). If the mesentery 
 
 FIG. 558. Gely's suture, internal appearance.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 
 
 351 
 
 FIGS. 559, 560. Jobert's method. 
 
 be separated unnecessarily, sloughing of the intestine is likely to 
 occur. 
 
 Czerny-Lembert Suture. Two rows of sutures are employed in 
 this method, neither of which, however, is passed through the mu- 
 cous membrane (Fig. 561). The first series brings the edges of the 
 
 FIG. 561. Czcrny-Lembert suture. 
 a. Mucous coat. b. Muscular coat. 
 c. Serous coat. 
 
 Fio. 562. Gussenbauer's suture, a. 
 Mucous coat. b. Muscular coat. c. 
 Serous coat. 
 
 mucous membrane together ; the second, or external series, unites the 
 serous surfaces of the bowel. Owing to the eversion of the intestinal 
 structures, the first row can be introduced without difficulty. 
 
 Gussenbauer's Suture. By means of this form of suture the mu- 
 cous and serous structures of the intestine may be brought together 
 by one suture (Fig. 562). However, this stitch is complicated and 
 somewhat tedious, and affords no additional security to repay for the 
 delay and difficulty attending its use.
 
 352 
 
 OPERATIVE SURGERY. 
 
 OPERATIONS ON THE STOMACH. 
 
 It sometimes becomes necessary to open into the cavity of the stom- 
 ach in order to remove foreign bodies, or to establish a permanent 
 communication with it through the abdominal walls, for the purpose of 
 supplying alimentation. It is therefore very important to understand 
 its relations to the abdominal walls, and likewise to other contiguous 
 parts. It lies principally in the epigastric and left hypochondriac 
 regions. Its anterior surface is directed upward and forward, and is 
 in relation to the diaphragm and the under surface of the left lobe of 
 the liver, and, unless empty or adherent posteriorly, comes in contact 
 with the abdominal walls in the epigastric region. It is altered in its 
 
 position and rela- 
 tions by the act 
 of respiration, de- 
 
 * * 
 
 scending with in- 
 spiration and as- 
 cending with ex- 
 piration ; when 
 empty, it retires 
 posteriorly and is 
 covered by the left 
 lobe of the liver. 
 The convexity of 
 the stomach sel- 
 dom rises above a 
 line extending be- 
 tween the carti- 
 lages of the ninth 
 ribs. The trans- 
 verse colon lies at 
 its lower border 
 when the stomach 
 is moderately dis- 
 tended. 
 
 The identity of 
 the stomach is es- 
 tablished by the 
 knowledge of its 
 relation to the 
 under surface of 
 the liver and dia- 
 phragm, by its pale 
 color and great 
 size, and by the arrangement of the gastro-epiploic vessels. 
 
 FIG. 563. a, b. Left lobe of the liver, a. Cardiac end of 
 the stomach, c. Transverse colon, e. Ascending colon. 
 d. Descending colon. g, </, g. Sigmoid flexure.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 353 
 
 Gastrostomy. This term is applied to the operation of opening the 
 stomach through the abdominal wall and establishing a permanent 
 fistula to it. 
 
 Antiseptic precautions should be taken, and anaesthesia produced 
 by chloroform, as ether is more likely to cause vomiting. 
 
 Operation. Place the patient on the back, and make an oblique 
 incision on the left side, about two and one half inches in length, from 
 right to left, parallel with and one inch below the lower border of the 
 cartilage of the eighth rib, and terminating opposite to the ninth car- 
 tilage (Fig. 503, 1). The tissues composing the walls corresponding to 
 this incision are divided successively on a director, down to the perito- 
 neum. All bleeding points must now be closed and the peritoneum 
 opened, and its divided borders caught and drawn outward with long 
 ligatures, or forceps, which are permitted to lie on the external surface, 
 to prevent its retraction. The lower border of the left lobe of the liver 
 can now be seen. The thumb and forefinger of the left hand are then 
 introduced, and, guided by the under surface of the liver, readily grasp 
 the stomach. If possible, a portion of it should be brought through 
 the opening, or, guided by the thumb and finger, forceps may be in- 
 troduced and its anterior surface grasped and drawn through the open- 
 ing. It is very important at this time to be certain that the portion 
 drawn through be not the colon or some other organ. The dense 
 white appearance of the stomach, the arrangement of its superficial 
 vessels, and its size should serve to distinguish it from any other vis- 
 cus. Often, as soon as the peritoneum is divided, the entrance of air 
 into the abdominal cavity causes the stomach to retire upward and 
 backward, thereby interposing an annoying obstacle to grasping it. To 
 obviate this difficulty it has been recommended to pump air into the 
 stomach just before the beginning of the 
 operation through a tube carried down to 
 the obstruction, or to cause the entrance 
 of carbonic-acid gas, produced by chemical 
 action at the time, or to introduce the 
 fumes of ether by means of a tube. These 
 expedients are, however, hardly of sufficient 
 practical importance to merit the trouble 
 incident to their utilization. 
 
 As soon as the surgeon is satisfied that 
 the stomach is within his grasp, it is drawn 
 into the opening and fixed, by passing 
 through it in opposite directions two or 
 three long stiff needles (Fig. 564), allowing FIG. 564. Needles in position, 
 their extremities to rest upon the external surface of the abdomen ; 
 or, a strong ligature is passed through the center of the protruding por- 
 tion, is looped and given to an assistant. The parietal layer of peri- 
 23
 
 354 OPERATIVE SURGERY. 
 
 toncum previously grasped and drawn outward should now be care- 
 fully stitched with antiseptic silk or catgut sutures to the visceral 
 layer on the stomach, being careful not to carry the sutures entirely 
 through the wall of the stomach. Still further security is given to 
 the opposed surfaces by putting a row of stitches of strong antiseptic 
 silk through the whole thickness of the abdominal walls, and also 
 through the serous and muscular walls of the stomach. Two other 
 stitches may be introduced, so as to transfix the end of the wound only, 
 care being taken not to include the peritoneum. Finally, a ligature 
 is passed through the serous and muscular walls of the center of the 
 exposed portion of the stomach (if this was not done in the first in- 
 stance), and left hanging to be used as a future guide to opening the 
 organ in case the condition of the patient will admit of four or five 
 days delay, sufficient to permit adhesive union to take place between 
 the serous surfaces. If not, then the operation should be completed at 
 once. This is done by making a vertical incision about half an inch in 
 length through its coats into the cavity, care being taken to prevent the 
 escape of its contents, If troublesome hemorrhage be apprehended 
 from this incision, the opening can be made by a thermo-cautery. The 
 wound in the abdominal wall is reduced in size to correspond to that 
 of the stomach by stitches carried through its entire thickness. The 
 lips of the opening into the stomach are then united to those of the 
 abdominal opening, by antiseptic silk carried through the entire thick- 
 ness of both, being careful to oppose the mucous lining of the stom- 
 ach to the integument of the abdomen. 
 
 Fallacies. The colon may be mistaken for the stomach. However 
 the difference in color, extent, and muscular arrangement, together 
 with the difference in mobility, and the fixed relation of the stomach 
 to the under surface of the liver, should make the distinction easy. 
 Confusion may arise in distinguishing the cartilage of the eighth rib 
 from the contiguous ones. The seventh articulates with the sternum ; 
 the first one below it will therefore be the eighth. 
 
 Other external incisions differently located and variously shaped 
 may be employed ; such as, a curvilinear one with the convexity 
 toward the median line, extending from the seventh costal cartilage 
 downward and outward for nearly four inches, one through the left 
 linea semilunaris, or one along the outer side of the rectus, etc. That 
 which has been described in detail seems the most favorable from an 
 anatomical basis. 
 
 The results, however, are of necessity very unfavorable, since the 
 conditions calling for the measure are often of themselves speedily 
 fatal ; moreover, the delay in resorting to it frequently renders the pa- 
 tient unable to withstand the shock of the procedure. Two hundred 
 and seven gastrostomies are reported, from which sixty-one deaths 
 have resulted directly. In about one hundred and seventy of the whole
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 
 
 355 
 
 number fifty died from the direct effects and from the sequels of the 
 measure, making a death-rate of about thirty per cent. This is about 
 fourteen and a half per cent greater than when the operation was per- 
 formed for the removal of foreign bodies alone. When due to malig- 
 nant disease it only acts as a palliative measure, while more than sixty 
 per cent have recovered when performed for non-malignant cicatricial 
 obstructions. This operation, and also gastrotomy, is sometimes em- 
 ployed for making an opening into the stomach to remove a foreign 
 body which has entered it through the oesophagus. The line of in- 
 cision, and all the steps and precautions, are similar to those for gas- 
 trostomy proper. After the foreign body is removed, the opening in 
 the stomach is closed by catgut sutures, after the manner of intestinal 
 sewing, and returned to the abdominal cavity, and the opening in the 
 abdominal walls closed. The patient must be nourished by the rec- 
 tum, and all gastric disturbances quieted by anodynes. 
 
 Gastro-enterostomy. This is essentially a palliative operation, and 
 was performed first by Woelfler in 1881, since which time it has been 
 done upward of twenty times for advanced pyloric cancer and non- 
 malignant pyloric stenosis. When performed for the former reason, 
 about sixty-four per cent of the cases have died, while for the latter 
 but twenty-five per cent have died. 
 
 All the antiseptic precautions that surround abdominal surgery 
 (gastrostomy, enterectomy, etc.) should be observed. 
 
 Operation. An abdominal incision is made in the median line from 
 just below the tip of the ensiform cartilage downward nearly to the 
 umbilicus, and the abdominal cavity is entered in the usual manner. 
 The viscera to be 
 united (stomach and 
 jejunum) are caused 
 to present at the ex- 
 ternal opening, where 
 they are carefully iso- 
 lated from the abdom- 
 inal cavity and pro- 
 tected by warm, moist 
 antiseptic sponges. 
 The loop of intestine 
 to be attached to the 
 stomach is emptied by 
 gentle pressure, and 
 the intestinal contents 
 cut off from it by the 
 intestinal pincers, by 
 the fingers of an assist- 
 ant, or by strips of loosely tied iodoformized gauze. 
 
 FIG. 565. Gastro-enterostomy. 
 
 The stomach
 
 356 OPERATIVE SURGERY. 
 
 should have been emptied and thoroughly washed out with a salicy- 
 late-of-soda solution before the operation. An incision about an inch 
 and a half in length is made through the anterior -inferior wall of the 
 cardiac half of the stomach, down to the mucous membrane (Fig. 
 565). An incision of a similar size is then made on the intestinal 
 loop down to its mucous membrane, b. The lower borders of the cut 
 surfaces are placed in contact and united with a continuous suture of 
 silk or catgut, carried from without inward between the mucous and 
 muscular coats of the respective viscera, thereby causing the borders 
 of similar structures to be brought in contact with each other. The 
 mucous coats are then opened by scissors, taking care to prevent the 
 least extravasation into the abdominal cavity. The remaining por- 
 tions of the borders are now united in a similar manner to the first, 
 and the whole circumference of the wound is fortified by a second 
 row of either the continuous or interrupted suture, carried through 
 the serous coats only. 
 
 Duodenostomy, or the formation of a permanent artificial opening 
 into the duodenum through the abdominal Avail, has been suggested 
 as an alternative to pylorectomy. It has been performed three times, 
 with a fatal result in cuch case. It is not, at the present time, 
 thought to be a justifiable operation. 
 
 Jejunostomy has been recommended as a substitute for pylorec- 
 tomy. It is, no doubt, much more easily performed than duodenos- 
 tomy ; but the advantages in favor of gastro-enterostomy are too 
 numerous and important to admit of its being superseded by either 
 of the other operations. 
 
 Resection of the Pylorus. This operation has been quite frequently 
 employed since 1879 to relieve obstruction occurring at the pylorus, 
 due to malignant disease, and stenosis from other causes. While its 
 inception and performance are in keeping with the rapid strides made 
 in abdominal surgery in the past few years, the nature of the opera- 
 tion and the causes for which it is done must of necessity insure a 
 large number of deaths. The pylorus is in the epigastric region, be- 
 tween the median line and a line falling from the tip of the cartilage 
 of the eighth rib on the right side to the middle of Poupart's liga- 
 ment, and is in contact with the under surface of the right lobe of 
 the liver. 
 
 The duodenum, which is the next most important factor, is located 
 in the right hypochondriac region, being, of course, a direct continua- 
 tion of the pyloric extremity of the stomach. The normal relations, 
 however, will avail but little in connection with the abnormal size, 
 and the displacement attendant upon an already over-distended stom- 
 ach. All primary incisions must therefore be located so as to meet 
 the indications of the case in question. The difference in the outlines 
 of the stomach is noted, both in its distended and empty condition,
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 357 
 
 to better enable the surgeon to properly locate the abdominal incis- 
 ion. In some cases the greater curvature may reach the symphysis 
 pubis. 
 
 The patient is prepared by washing out the stomach daily with sali- 
 cylated water or any suitable antiseptic for four or five days prior to the 
 operation, the stomach-pump, or siphon, being employed for the pur- 
 pose. The intestinal canal is evacuated the day before the operation. 
 An anaesthetic is given, chloroform being preferable as less likely to 
 produce vomiting, and the patient is placed on the back in a good 
 light. The stomach should be thoroughly washed out before begin- 
 ning the operation. 
 
 Operation. An incision is made about four inches in length in 
 the median line, or parallel to the right costal margin (Fig. 563, 2), as 
 .nearly as possible over the displaced pylorus. The tissues are divided 
 carefully down to the peritoneum, and all bleeding stopped before this 
 membrane is divided ; an exploration with the finger is also made, 
 to determine, if possible, the exact location of the indurated portion, 
 after which the final opening is made to correspond to it. 
 
 If it be impossible to satisfactorily outline the organ, it may be 
 distended with fluid which must be withdrawn when the location of 
 the diseased portion is determined or with carbonic-acid gas ; even 
 the fumes of ether can be introduced as in rectal anaesthesia. The 
 peritoneum is cut, and the pylorus and such other portions as are 
 necessary are then drawn through the wound and isolated and sur- 
 rounded by napkins or large flat sponges wrung out in a warm anti- 
 septic solution. A large, flat, soft sponge, moistened with an anti- 
 septic solution, is then passed beneath the part to be removed, to 
 prevent the entrance of blood and other fluids into the abdominal 
 cavity. Strong ligatures may now be passed through the walls of the 
 viscus at three or four points outside of the proposed incision, so as to 
 raise the walls of that extremity as soon as it is divided, that its con- 
 tents may not escape. 
 
 The omenta are separated the necessary distance along the curva- 
 tures of the stomach by tying them in small portions and dividing them 
 between the ligatures. The pyloric extremity of the stomach is then 
 incised with strong, long-bladed scissors from above downward, and 
 from left to right, for about two thirds of its depth, through both 
 walls, at a point at least two thirds of an inch from the diseased growth 
 in its structure. The stomachal borders of this incision are then 
 joined by the Czerny-Lembert suture, the threads being located about 
 one-eighth inch apart. The pyloric extremity of the stomach is now 
 cut entirely across, and the resulting opening in the stomach should 
 correspond in its extent to the width of the duodenum, which should 
 now be cut completely across in the same manner as the stomach. The 
 divided extremity of the duodenum is carefully sewed to the opening
 
 358 
 
 OPERATIVE SURGERY. 
 
 in the stomach by the Czerny-Lembert suture, or such other form of 
 suture as may suit the surgeon. 
 
 The diseased growth should be removed with great care, and with 
 due regard to the preservation of the vascular supply of the viscera. 
 Sloughing of the gastric or duodenal margin of the wound or the walls 
 of the colon caused by disturbance of nutrition is one of the greatest 
 dangers. The pyloric, gastro-duodenal, and gastro-epiploica dextra 
 arteries and their branches should be preserved for this reason, when 
 this can be done, and the removal of the diseased tissues be still ac- 
 complished. 
 
 If any oozing occur from the cut surfaces, it may be controlled by 
 the protected blades of the T-shaped pincers (Fig. 566), etc. The 
 extent of the incisions, as well as their shape, will be governed by 
 
 the diseased tissue 
 to be removed. If 
 adhesions exist be- 
 tween the growth 
 and the contigu- 
 ous parts, they can 
 be separated if ex- 
 pedient ; if not, 
 
 FIG. 566. Cross-bar forceps. 
 
 no further attempt to complete the operation need be made, and 
 the abdomen should be closed. The respective extremities of the 
 
 FIG. 507. Abbe's intestinal pincers. 
 
 divided viscera can be well controlled by the fingers of an assistant 
 with or without the use of the intestinal pincers (Fig. 567). The 
 outline of the pyloric cut may be greater than the caliber of the re- 
 maining duodenum (Fig. 568). The caliber of the larger portion 
 must be reduced to a suitable size to be joined to its fellow, c, a to d,
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 359 
 
 e ; or c, b may be sewed until it shall conform in width to d, e, to which 
 it is sewed, thus transferring the pyloric opening to the greater 
 curvature of the stomach ; 
 the Czerny-Lembert suture 
 answers admirably for the 
 purpose ; or the borders of 
 the openings may be joined 
 by means of a double row of 
 the Lembert form of suture. 
 The first row should be car- 
 ried down to the mucous 
 membrane, and be inter- 
 rupted ; the second row 
 should be deposited outside 
 of the first one, and include FIG. 568. Outlines of incisions, 
 
 the serous membranes only. 
 
 This row may be continuous. After all bleeding is checked, and the 
 peritoneal cavity is thoroughly cleaned, the parts are returned and 
 the abdominal wound is closed in the usual manner. The patient is 
 then quieted by anodynes and nourished by the rectum during the 
 first three or four days, until fluid food can be given by the mouth. 
 The contraindications to the operation are : Old or weak patients ; 
 evidences of malignant secondary deposits ; existence of extensive ad- 
 hesions ; chronic incurable dilatation of the stomach, etc. 
 
 Results. Of the twenty- three cases reported by Rydigier in 1883, 
 five had recovered. Still, one of these died four months after the 
 operation from a return of the disease. At the present time pylorec- 
 tomy has been performed at least eighty-two times, with twenty-one 
 recoveries from the operation. Of thirty-six cases for carcinoma, seven 
 had recovered and two were doubtful. The prognosis is much better 
 in the colloid than other forms of carcinoma. In only about five per 
 cent of the cases were adhesions and enlarged glands absent. Ad- 
 hesions to the pancreas and enlarged glands of the great omentum 
 were most frequent. Twenty-nine cases are reported where it was 
 not deemed advisable to continue the operation, owing to exten- 
 sive adhesions, shock, etc. The time occupied in the operation is 
 modified by the complications, being from an hour and a quarter 
 to five hours. The rate of mortality from the operation is about sev- 
 enty-five per cent as the cases occur. If uncomplicated, it is fifty per 
 cent, heart failure, from shock, being the fatal element. The per- 
 centage of ultimately successful cases is but little above eight and a 
 quarter. 
 
 Loreta's Operation is divulsion of the pylorus by the fingers, or other 
 similarly effective agents. In this the abdominal incision is made to 
 correspond to the location of the disease as in the preceding operation ;
 
 360 OPERATIVE SURGERY. 
 
 or, if the condition will permit, it is commenced an inch and a half be- 
 low the ensiform cartilage and carried obliquely downward and out- 
 ward for four or five inches to within an inch and a half of the ninth 
 costal cartilage (Fig. 563, 2). The opening is sometimes made through 
 the linea alba. The abdominal incision is made with the same precau- 
 tions as in the preceding operation. The pyloric extremity of the 
 stomach is drawn out and an opening made into it between and at 
 equal distances from its two curvatures, about two and a half inches 
 in length, beginning an inch and a half from the situation of the 
 pyloric valve. The hemorrhage is then controlled ; the index-finger 
 is introduced through the pyloric valve and carefully rotated, with 
 pressure and counter-pressure. The second finger is introduced beside 
 the former in the same cautious manner, and so on until the constricted 
 portion is well distended. The wound in the stomach is then closed 
 by the Gely or Lembert suture, the parts are returned, and the ab- 
 dominal wound is closed as before. 
 
 The results of this operation are much more favorable than those 
 for excision of the pylorus, and it is entirely proper that dilatation 
 should be considered in connection with it ; the incision through the 
 abdominal walls being made with a view to excision, if it be malignant, 
 and divulsion if the stenosis be due to non-malignant causes. Divul- 
 sion has been performed eight or ten times, with a rate of mortality 
 varying from fifty to seventy-five per cent. 
 
 OPERATIONS ON THE GALL-BLADDER. 
 
 It occasionally happens that obstructions of the cystic duct and 
 distention of the gall-bladder from gall-stones or other causes give rise 
 to an abdominal tumor of considerable size, which. is dangerous on 
 account of the liability to rupture, and is distressing from the pain 
 and tenderness. 
 
 Cholecystotomy. This operation consists in cutting down through 
 the abdominal wall upon a tumor, caused by a distended gall-bladder, 
 and evacuating its contents. The incision is made, as a rule, over 
 the center of the tumor, parallel to the free border of the ribs. At 
 first it should be about three inches in length, large enough for ex- 
 ploration, after which, if need be, it can be enlarged. The various 
 layers composing the abdominal wall are divided on a director down 
 to the peritoneum, which should not be opened until all hemorrhage is 
 arrested. Two methods of procedure are now recommended : 1. As- 
 certain if the serous covering of the tumor be adherent to the parietal 
 layer of the peritoneum ; if such be the case, open into the tumor and 
 evacuate its contents. If it be not adherent, and the conditions of the 
 patient will permit, fill the wound with strips of antiseptic gauze or 
 marine lint. After five or six days sufficiently firm adhesions will have 
 been caused to permit the opening of the gall-bladder, which should
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 361 
 
 be done in the same manner and be treated in all respects as the simi- 
 lar step in the second method of procedure. 2. After hemorrhage is 
 arrested, divide the peritoneum cautiously, catching its free borders 
 by forceps, which are then allowed to rest on the surface of the abdo- 
 men. If the wall of the tumor be not adherent, introduce two fingers 
 through the opening into the abdominal cavity, and even the entire 
 hand if necessary, and examine the condition of the contiguous ab- 
 dominal organs, size of the tumor, nature of its contents, etc., care 
 being taken not to rupture it by the manipulation. If gall-stones be 
 found in the cystic or the common ducts, they should be dislodged if 
 practicable. If the tumor be distended with fluid, it should now be 
 aspirated, and then held firmly in contact with the external opening, 
 while an incision about an inch in length is made into it. Its fluid con- 
 tents must be carefully excluded from contact with the peritoneal lin- 
 ing, and also from the raw surfaces of the incision. This can be quite 
 satisfactorily accomplished by means of a narrow, trough-like arrange- 
 ment made of tin, gutta-percha, or other suitable material to conduct 
 the fluid beyond the wound. If the cut surfaces around the point to be 
 opened be smeared with carbolic acid and oil, and covered with small 
 pieces of antiseptic gauze, and the borders of the incision in the tumor 
 be quickly grasped with forceps and held upward, any danger of un- 
 wholesome contact of the fluid will be obviated. The distended gall- 
 bladder and its associated ducts are carefully examined, and all gall- 
 stones are removed with forceps. The edges of the opening in the 
 gall-bladder are now stitched to the abdominal incision, a drainage-tube 
 is introduced, and the whole is covered by an antiseptic dressing. The 
 resulting fistula will soon close if the common duct be not obstructed, 
 and the parts will resume their normal functions. If the wall of the 
 tumor be not adherent to the abdominal wall, it is recommended by 
 some after the evacuation of its contents that the opening be care- 
 fully stitched and the sac returned ; also that the sac be ligated 
 at its neck and removed. It can not be said, however, that these 
 procedures are as rational in all respects as the one more fully de- 
 scribed. 
 
 Results. Forty cases have been reported, of which ten were fatal. 
 The second method anticipates the dangers of rupture and the struct- 
 ural changes induced by over-distention, which are offset by those of 
 opening into the abdominal cavity ; the latter, however, when done 
 under antiseptic precautions, is rarely followed by an unfortunate 
 result. These facts emphasize the wisdom of an early operative in- 
 terference. 
 
 Cholecystectomy, or extirpation of the gall-bladder, is employed 
 instead of cholecystotomy when, by reason of the presence of a trouble- 
 some biliary abdominal fistula, malignant disease, or tumors of the gall- 
 bladder, the latter is rendered useless. If the opening through the
 
 362 OPERATIVE SURGERY. 
 
 abdominal walls be the same as in cholecystotomy, and the case is 
 found to be better adapted to cholecystectomy, the incision will then 
 require to be extended upward sufficiently to command the neck of 
 the sac. If, however, the latter operation be contemplated in the 
 beginning, the abdominal incision can be made in the right hypo- 
 chondrium, parallel to the lower border of the liver, and joined by a 
 second incision running along the outer border of the right rectus 
 muscle (Fig. 503, 3). The abdominal cavity is then to be opened, the 
 transverse colon and small intestines pushed down by a large sponge, 
 and the liver elevated, so as to bring the hepatic duodenal ligament 
 into prominence. The gall-bladder is easily separated from the liver, 
 the cystic duct exposed and ligatured in two places with carbolized 
 silk, and severed between them, the tumor removed, and the abdomi- 
 nal wound closed. 
 
 This operation, like the ones preceding it, should be done with full 
 antiseptic precautions. 
 
 Results. Cholecystcctomy has been done six times, with a death- 
 rate of fifty per cent. 
 
 The base of the gall-bladder has sometimes been connected to an 
 opening made in the duodenum to admit the discharge of bile into the 
 intestine, when this had been prevented from taking place by a perma- 
 nent stoppage of the common duct. Nothing definite can be said, as 
 yet, of its adoption as a practical measure in such cases. 
 
 Laparotomy, or Abdominal Section. This operation is employed to 
 overcome intestinal obstructions due to various causes, such as in- 
 vagination, adhesions, etc., to ligature arteries, and for the operative 
 treatment of penetrating wounds of the abdomen. Laparotomy should 
 be divided into two varieties : 1, the explorative operation ; 2, the op- 
 eration in entirety i.. e., the addition of enterotomy or enterectomy, 
 etc., for the relief of the trouble calling for the abdominal section. 
 
 Explorative Laparotomy consists in opening the abdominal cavity, 
 usually in the median line, sufficiently to permit the inspection and 
 examination of its contents for the morbid condition, and to determine 
 whether the culs-de-sac of the cavity contain blood or other extravasa- 
 tions. If nothing be found, or further operative procedure is not 
 required, the abdominal opening is then closed. 
 
 Results. The large number of abdominal sections performed, both 
 in this country and abroad, with favorable results, serves to establish 
 the belief that an explorative laparatomy, under favorable precau- 
 tions, does not expose the patient to any unusual dangers. 
 
 If it be performed for intestinal obstruction, the opening can be 
 made over the seat of obstruction ; but it is better to make it in the 
 median line below the umbilicus (Fig. 563. 4). It should be a free 
 incision, and of sufficient size to permit the easy introduction of the 
 hand, and should be made under strict antiseptic precautions. If any
 
 HOLLOW VISCERA IX CONTACT WITH SEROUS SURFACES. 363 
 
 difficulty be experienced in locating the seat of the trouble, or over- 
 coming it, the opening should be still further enlarged. Care must be 
 taken not to tear or injure the intestine. It is better, if the obstruc- 
 tion does not yield readily, to raise the obstructed portion out of the 
 opening, and surround it, along with such of the intestines as may es- 
 cape, with the Lister gauze, wet in a warm antiseptic solution, or with 
 large flat sponges treated in the same manner. As soon as the obstruc- 
 tion is relieved and the intestines are restored to their normal position, 
 the abdominal cavity is cleaned by warm antiseptic sponges, and the 
 external wound closed. 
 
 Results. The rate of mortality in all cases of this character is 
 about sixty-five per cent. The prognosis would be much better were 
 it not that the diagnosis is uncertain, or the operation objected to, 
 until the condition of the patient almost precludes a successful issue. 
 
 Enterotomy consists in opening the intestine above or at the point 
 of an obstruction, and, when the opening is low down, it may be at- 
 tached by its borders to the abdominal walls, thereby establishing a 
 fecal fistula. 
 
 This operation can also be done when the gut is gangrenous or 
 otherwise unfit to be returned. At the present time, in both of these 
 conditions, it is thought to be proper by some authorities to relieve 
 the obstruction by means of abdominal section, followed by enterec- 
 tomy or enteroraphy, and return the intestine into the abdominal 
 cavity. The final percentage of recoveries, however, is much greater 
 if a fecal fistula is established at first, which can afterward be closed 
 by the usual method or by enterectomy. 
 
 This particular form of enterotomy is commonly performed in 
 the right iliac fossa, since the intestines above the obstruction lie 
 principally in this situation. The intestines . above the obstruction 
 are filled ; those below are empty ; consequently the selection of the 
 proper one to open becomes easy on inspection. 
 
 In "Right Inguinal Enterotomy" (Nelaton), as this operation is 
 sometimes called, an incision is made an inch above Poupart's liga- 
 ment and parallel with it, beginning at the anterior superior spine of 
 the ilium and ending opposite the internal abdominal ring (Fig. 563, 
 5). The layers of the abdominal walls are divided consecutively on a 
 director, down to the peritoneum, which is opened, after all hemor- 
 rhage has ceased, for one inch and a half. The first intestinal loop 
 presenting is drawn through, provided it be not an empty one ; a long 
 thread is passed through the muscular walls and looped, and the in- 
 testine again returned and kept from the opening by a small-sized 
 carbolized sponge, to which a string is attached ; this is forced through 
 the opening and allowed to remain, while the peritoneum is drawn 
 outward and stitched to the integument. The sponge is then re- 
 moved, and the intestine pulled out by the looped ligature which has
 
 364: OPERATIVE SURGERY. 
 
 remained upon the abdominal wall. The coats of the intestine are 
 carefully united to the walls of the opening by a deep row of inter- 
 rupted carbolized silk or catgut sutures passed in the transverse axis 
 of the gut, through its serous and muscular coats, being entered two 
 or three lines from the border of the integumentary wound, and, after 
 including the gut, returned through the same border of the wound 
 from below upward, and tied. After the serous surfaces are accurate- 
 ly apposed by a row of stitches, the intestine is raised to a level with 
 the surface of the abdomen, and the space between it and the border 
 of the abdominal wound is packed with absorbent cotton or lint 
 saturated with carbolic acid and oil for the purpose of protecting their 
 surfaces from contact with any of the intestinal contents. The gut is 
 opened longitudinally for one inch, its edges being caught with pincers 
 as fast as cat. After the intestinal contents near the opening are 
 evacuated, a small sponge with a string attached should be pressed 
 into the opening in the gut to prevent any further escape while its 
 borders are being carefully sewed to the integumentary margin by the 
 continuous or interrupted suture. 
 
 The immediate results of this operation are better than those of 
 laparotomy in entirety, but the patient is subjected thereafter to the 
 annoyance of a fecal fistula. If the obstruction be due to a foreign 
 body in the gut, and its position be located, the intestine can be 
 incised, obstruction removed, wound of the intestine closed by the 
 Lembert or other suture, the gut returned, and the abdominal incision 
 closed. 
 
 Enterectomy consists in removing a segment of intestine and unit- 
 ing the divided extremities, which, when combined with abdominal 
 section, constitutes a laparotomy in entirety. Enterectomy is per- 
 formed for penetrating shot and stab wounds of the intestine, and for 
 the removal of malignant growths and gangrenous portions of the 
 same. The antiseptic precautions relating to the operator, to the 
 patient, and to the surgical surroundings should be of the most com- 
 plete kind, and, in addition thereto, the patient and the abdominal 
 viscera should be kept warm and the latter moist. Warmth and 
 moisture can be secured by operating in a thoroughly purified room, 
 charged with antiseptic vapor, and having a temperature of 98 to 
 100 Fahr. The warmth of the abdominal viscera can be quite well 
 maintained if they be surrounded by large, flat sponges or anti- 
 septic gauze moistened in warm solutions of mercuric bichloride 
 (1-10,000), carbolic acid (1-100), or Theirsch's fluid. If blood or 
 intestinal contents escape into the abdominal cavity, the site of the 
 injury causing it must be sought for and closed. All bleeding points 
 should be tied with fine catgut, no matter how insignificant the 
 bleeding may seem at the time ; for after the parts are returned 
 into the abdominal cavity, and their normal relations and tempera-
 
 HOLLOW VISCERA IX CONTACT WITH SEROUS SURFACES. 365 
 
 ture have been restored, a trivial oozing may become a serious hem- 
 orrhage. All wounds of the intestine, at other than its mesenteric 
 attachment, may be closed by the continuous suture of Lembert, 
 or by the Gely suture. Catgut or antiseptic silk may be used for 
 this purpose. A double row of sutures may be deposited, provided, 
 however, the closure does not reduce the caliber of the intestine 
 more than one third. If the wounds be too large or too closely as- 
 sociated to admit of closure, or if they be at the mesenteric border 
 of the gut, enterectomy or removal of the injured portion should 
 be done. The contents of the portion to be removed should be 
 pressed out into the uninjured portion of intestine, and its return pre- 
 vented by the intestinal pincers (Fig. 567), by the fingers of an assist- 
 ant, or by strips of iodoformized gauze tied loosely around the gut. 
 The incisions for the removal of the injured portions should be made 
 as closely as possible to the incoming mesenteric arteries, so that the 
 extremities of intestine will be well nourished. The mesentery may 
 be treated by one of the following methods : 1. A triangular portion 
 of it may be removed, its base corresponding to the length of the por- 
 tion of intestine excised, after which the gap is closed by bringing the 
 divided borders of the mesentery together and uniting them. 2. It 
 may be tied in small segments, about a quarter of an inch from the 
 intestine, with catgut, divided and allowed to remain free, or may be 
 sewed to the mesenteric border of the gut after it has 'been repaired. 
 3. The serous coat for a quarter of an inch each side of the mesen- 
 teric attachment may be divided and stripped from the subjacent 
 tissue, intestine excised, ends approximated, and the loop formed by 
 the serous slip closed by sutures. During the sewing the ends of the 
 intestine may be held by the fingers of an assistant or by introducing 
 a small, distended rubber bag. Pieces of stale bread may be made of 
 a size to support the ends during the sewing. The rubber bag should 
 be removed before the intestine is entirely closed, and care must be 
 taken or it will be sewed in position. The bread or large macaroni 
 tubes will escape from the natural opening. It is difficult to manage 
 these extremities and at the same time properly coapt the borders and 
 deposit the sutures so that effective and permanent union will be 
 secured, since the point above the obstruction will be distended by 
 air and fecal accumulation, while the portion below will be collapsed 
 and appear smaller than normal. The mobility of the extremities, 
 the danger of the escape of fecal matter, together with hemorrhage, 
 and the length of time necessary to triumph over the obstacles already 
 enumerated, bring about a degree of exposure which adds more to 
 the gravity of the operation than the division and removal of the 
 diseased tissue. Anything, therefore, which will expedite matters in 
 this respect must constitute a real advance in surgery. The instru- 
 ment devised by Mr. Treves, of London (Fig. 569), is certainly in-
 
 366 
 
 OPERATIVE SURGERY. 
 
 own language 
 
 genious, but does not seem to be sufficiently simple to become of 
 practical utility. It can not be better described than in Mr. Treves' 
 " The apparatus consists in the first place of two 
 clamps, B B, to secure the gut, E E, 
 above and below the point of resec- 
 tion. Each clamp is made of two 
 separate and light metal bars, pro- 
 vided with an India-rubber pad on 
 the surfaces that are in contact with 
 the gut. The clamp is two inches 
 and a half in length, and, one part 
 being placed beneath the gut and 
 the other upon it, the two are then 
 approximated by screws placed 
 at each end. By these means 
 the gut can be evenly and ac- 
 curately compressed with as 
 much or as little force as may 
 be thought fit. I first apply a 
 clamp to the gut one inch and a 
 half below the proposed resection- 
 line, and, having emptied the part 
 to be excised by squeezing its con- 
 tents upward, I apply the second 
 clamp at a similar distance beyond 
 the second resection-line, which will, 
 in most cases, insure an empty con- 
 dition of the part to be removed. 
 A triangular piece of mesentery 
 should then be excised, the base of 
 the triangle exactly corresponding 
 to the amount of gut to be re- 
 moved ; secure the divided vessels 
 and excise the diseased gut. The 
 clamps are now united with each 
 other by means of the long, narrow 
 reel-rods, A A, which are secured to 
 each clamp by a small screw. By 
 means of these bars the two clamps 
 can be evenly approximated, and 
 the divided ends of the gut brought 
 into accurate contact. If the screws 
 be now tightened, the bowel extrem- 
 
 Fio. 569. Troves' apparatus for en- 
 terectomy. 
 
 ities are held in a rigid frame, and can be turned or moved in any 
 direction without disturbing the contact of the divided ends. The
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 
 
 567 
 
 ends to be united will be easily commanded if a very thin India-rubber 
 bag, G, about three inches in length, of sausage-shape, that can be 
 distended by air to a large size, be inserted about the middle of its 
 long axis. Having blown out this bag till it was about the size of the 
 divided bowel, I inserted one end into the lower piece of the intestine 
 and the other end into the upper piece. The supply-tube, D, will 
 thus occupy the suture-line. After the bag is suitably distended the 
 sutures are applied all round the gut, and almost up to the interrup- 
 tion in the suture-line occupied by the tube that fills the bag. The 
 last sutures are then applied, but not tied, the bag exhausted of air 
 and withdrawn from the bowel through the interruption in the suture- 
 line." Two rows of sutures should be used the first an interrupted 
 Lembert of iron-dyed silk, extending to the mucous membrane ; 
 second, the continuous Lembert, including the serous surfaces only. 
 The Czerny-Lembert is entirely suitable for this purpose. Great care 
 is requisite to properly close the mesenteric border of the intestine. 
 A small artery is found here that often bleeds persistently. The en- 
 tire intestinal tract should be carefully examined for other injuries, 
 even though it be necessary to remove the intestines from the cavity 
 to do it. Severe intestinal contusions should be treated like pene- 
 trating wounds of the intestine. The "toilet" of the abdominal 
 cavity must be patiently and thoroughly performed by soft, moist, 
 antiseptic sponges. It is not enough to wipe off the intestines only, 
 but all the culs-de-sac must be examined, and all blood and other ex- 
 travasations, together with antiseptic fluids found therein, should be 
 sponged out and drainage provided if deleterious discharges appear 
 likely to be produced. The abdominal wound is dressed antiseptically. 
 
 .Results. The general result 
 shows a death-rate of about fifty 
 per cent. This is very satisfacto- 
 ry, when it is considered that 
 over ninety per cent of penetrat- 
 ing shot-wounds of the abdomen 
 die when treated expectantly. 
 When this operation is done for 
 causes that do not involve ex- 
 travasation into the abdominal 
 cavity, the death-rate is much 
 diminished. It is not advisable 
 to excise the intestine for malig- 
 nant disease if the mesenteric 
 glands be much involved, since 
 an artificial anus can then be 
 made with better prospects of 
 prolonging life. Fio. 670. Guide to colon.
 
 368 OPERATIVE SURGERY, 
 
 Left Lumbar Colotomy (Amussat). In this operation the descend- 
 ing colon is opened between the crest of the ilium and the last rib. 
 
 Linear Guide to the Operation (Fig. 570). Draw aline which shall 
 connect the anterior and posterior superior spinous processes of the 
 ilium ; draw a second line perpendicular to this, one inch posterior 
 to its center. This line marks the course of the colon. Draw a third 
 line four inches in length obliquely downward and outward, midway 
 between the lower border of the last rib and the crest of the ilium, 
 its center corresponding to the perpendicular one, parallel with the 
 lower border of the last rib. The third line marks the course of the 
 incision, half of which is behind the perpendicular line. 
 
 Muscular Guides. The outer border of the erector spinaa, also 
 the outer border and anterior surface of the quadratus lumborum. 
 
 Contiguous Anatomy. The colon at this situation is covered by 
 peritoneum at its anterior surface and sides ; its posterior internal 
 surface is not covered by this membrane. If the gut be collapsed, it 
 retreats toward the median line, behind the quadratus lumborum, and 
 is followed by its peritoneal covering. The collapsed condition of the 
 gut, therefore, exposes the peritoneum to greater danger of being in- 
 jured. When distended, it presses its peritoneum outward, and can 
 be readily seen projecting beyond the outer border of the quadratus 
 lumborum. The surfaces not covered by peritoneum are surrounded 
 by areolar tissue, which separates the intestine from the left crus of 
 the diaphragm, the left kidney, and anterior surface of the quadratus 
 lumborum ; and externally it is in contact with the small intestines. 
 The left kidney is situated posteriorly to it, and its lower extremity 
 can be easily felt at the upper border of the wound. The vessels 
 lying in the course of the incision are the abdominal branches of the 
 lumbar vessels. The ilio-hypogastric and ilio-inguinal nerves likewise 
 cross in front of the quadratus lumborum at this situation. 
 
 The. colon is recognized by its greenish color and its longitudinal 
 bands, which are three in number one anteriorly, which is covered 
 by peritoneum, a second corresponding to its attachment, the third or 
 lateral at its inner side. It is not quiet during respiration, although 
 it does not move upward and downward as the small intestines are 
 sure to do. It can not be raised, while the small intestines can. 
 Finally, if it be filled with air after the fascia lumborum is divided, 
 and the fat be pushed aside, it will become distended quickly and 
 assume a proportionately greater size than the small intestines. 
 
 Fallacies. The coign may be mistaken for a loop of small intes- 
 tine, also for the kidney, especially in the young subject. From the 
 former it is readily distinguished by the differences already given ; 
 from the latter, by the density of the structure of the kidney, its 
 rounded extremities, reniform shape, lobulated appearance, and the 
 upward and downward movements of the kidney with the respiratory
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 369 
 
 acts. If the preceding be not satisfactory, the introduction of a hypo- 
 dermic needle will demonstrate not only the density of the kidney, but 
 the absence of fecal matter and offensive gases. 
 
 If the conditions will permit, the bowel should be thoroughly 
 washed out before the operation is begun ; after which the patient is 
 etherized and placed on the right side, with a hard pillow under the 
 loin, so that the left side may be made more prominent. 
 
 Operation. An incision is made in the course of the line already 
 marked out, and carried through the integument, fascia, and thick 
 layer of fat usually found at this situation, down to and through the 
 latissimus dorsi muscle and the posterior fibers of the external oblique, 
 the internal oblique, and transversalis, which are divided upon a di- 
 rector, bringing into view (Fig. 571) the outer portion of the quad- 
 
 FIG. 571. Surgical relations of descending colon, a. spine of fourth lumbar vertebra, 
 b. Cartilage between third and fourth vertebrae, c. Umbilicus, d. Quadratus lumbo- 
 nim m. e. Psoas magnus m. /. External oblique m. g. Rectus muscle, h. Descend- 
 ing colon, covered anteriorly and externally by peritoneum, i. Transverse colon, j. 
 Aorta, k. Inf. vena cava. I. Ureter, m. Adipose tissue covered by the transversalis 
 fascia, n. Internal oblique muscle, o. Transversalis m. p. Reflection of peritoneum. 
 
 ratus lumborum inclosed within its compartment of the lumbar apo- 
 neurosis, which extends outward to become continuous with the trans- 
 versalis muscle. The aponeurosis is carefully divided upon a director, 
 and the fascia transversalis that lies beneath it is divided in a similar 
 manner, thus bringing into view the fatty areolar tissue that separates 
 the gut from the quadratus lumborum and the left crus of the dia- 
 24
 
 370 
 
 OPERATIVE SURGERY. 
 
 phragm. The fat is pushed aside by the finger and handle of the 
 scalpel, and the bowel distended with air, when its situation will 
 become positive. By the means already given, confirm its identity 
 before proceeding further. As soon as the gut is distended it will 
 appear at the opening, and perhaps even rise above its level ; roll it 
 outward with the finger from beneath the quadratus, cutting the outer 
 border of the muscle, if necessary, so as to reveal its inner aspect, 
 which is known by the longitudinal band ; seize it with a tenaculum 
 or forceps, and hold it upward while a stout, curved needle, armed 
 with a vvell-carbolized silk ligature, is passed deeply through the skin 
 and deeper tissues at one side of the perpendicular incision, about 
 four lines from the border, into and transversely through the intestine, 
 to emerge on the other side of the opening at a similar distance from 
 
 FIG. 572. Surgical relations of ascending colon. 1. Spinous process of fourth lumbar 
 vertebra. 2. Cartilage between third and fourth vertebrae. 3. Erector spinae m. 4. 
 Inferior vena cava. 5. Psoas magnus m. 6. Fascia lumborum. 7. Subcutaneous fat 
 and latissimus dorsi m. 8. Quadratus lumborum m. 9. Adipose tissue covered by the 
 transversalis fascia. 10. Cavity and wall of the ascending colon. 11. Internal oblique 
 m. 12. External oblique m. 13. Limits of peritoneal reflection. 14. Transversalis m. 
 15. Ureter. 16. Great omcntum. 17. Rectus muscle.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 371 
 
 the border of the wound ; this suture is drawn through, and each end 
 given to an assistant. The needle is then passed in a similar manner 
 at the opposite extremity of the incision, and its ends are also given 
 to an assistant (Fig. 573). All the space between the walls of the gut 
 and borders of the wound is then packed with lint saturated with 
 carbolic acid and oil. The gut is opened by a longitudinal or oblique 
 incision, about an inch and a half long (Fig. 574). The liability to a 
 
 FIG. 5*73. Sutures passed through colon. 
 
 FIG. 674. Hooking up sutures. 
 
 subsequent protrusion of the mucous membrane and of injury to the 
 peritoneum at the time is less with a longitudinal than with a trans- 
 verse incision. After the contents 
 of the bowel are evacuated, a 
 sponge, with a string attached, 
 should be pressed into the open- 
 ing to retain any remaining dis- 
 charge until the edges of the gut 
 have been stitched to the borders 
 of the wound. The finger or 
 hook should now be inserted into 
 the bowel, and the loops of the 
 ligature just passed be caught, 
 drawn out (Fig. 574), and divided 
 at the middle, when each one will 
 become two distinct sutures which, 
 after the oiled lint has been re- 
 moved and the wound cleansed, 
 can be tied (Fig. 575). The re- FIG. 575. Sutures tied.
 
 372 OPERATIVE SURGERY. 
 
 maining portion of the gut-wound is then stitched, sprinkled with 
 iodoform (Fig. 576), and a carbolized pad is bound over the open- 
 ing. This pad, together with the sponge, must 
 soon be removed to allow the escape of fecal mat- 
 ter. If malignant disease of the rectum be the 
 cause for the operation, it is recommended to bring 
 the intestine through the opening as far as possi- 
 ble, divide it, turn in the borders of the upper ex- 
 tremity of the lower portion, sew them together, 
 and drop it into the abdominal cavity. This plan 
 will prevent any fecal matter from passing down 
 the rectum and irritating the malignant growth. 
 
 FlG ' 8tkch~r Und The ll PP er P enin g is tlien carefully sewed to the 
 borders of the abdominal wound. Great caution 
 is necessary in taking these steps, or the peritoneal covering of the 
 colon will be torn through. If this accident should happen, close the 
 peritoneal opening with catgut sutures. Inflammatory products, and 
 even fecal matter, may collect below if great care be not observed. 
 
 Results. The rate of mortality from this operation is variously 
 estimated, being from twenty to thirty-eight per cent. Eecently Dr. 
 Bott reported two hundred and forty-four cases, with a death-rate of 
 a little more than thirty-one and one half per cent. 
 
 Right Lumbar Colotomy. In this operation the incision is made 
 at the right side. Its formation, however, is in all respects governed 
 by the same rules as the preceding. The caput coli is the portion to 
 be opened, and, owing to its size, can be more readily distinguished 
 than the colon on the left side of the body (Fig. 572). 
 
 The results are much less favorable, owing partly to the loss of the 
 function of the colon, and also to the more objectionable location of 
 the disease compelling the operation in this situation. 
 
 Left Inguinal Colotomy (Littre'). This operation consists in open- 
 ing into the sigmoid flexure of the colon by an incision into the left 
 iliac fossa through the abdominal walls, including the peritoneum. 
 
 Linear Guide to the Operation. Draw a line two inches in length 
 over the left iliac fossa, commencing about an inch internally to the 
 anterior superior spine of the ilium, and extending downward parallel 
 with Poupart's ligament (Fig. 563, 6). 
 
 Operation. The patient is placed upon his back, and an incision 
 made to correspond to the line given above. All hemorrhage is stopped 
 before the peritoneum is opened. As soon as the peritoneum is cut, 
 insert a small antiseptic sponge connected with a string, which will 
 prevent the escape of the intestines ; stitch the peritoneum to the 
 integumentary border ; withdraw the sponge, and draw out the intes- 
 tine which is located directly under the opening, and which can be 
 recognized by the peculiarly shaped fatty fringe attached to it. This
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 3^3 
 
 is then stitched to the external wound in the same manner as in the 
 lumbar region. In all respects the treatment is the same as for colot- 
 omy in other situations. 
 
 Results. Left inguinal colotomy is not as safe an operation as that 
 in the left lumbar region, since the peritoneum is directly involved. 
 
 The rate of mortality is from ten to twenty per cent greater. 
 
 Abscess in the Right Iliac Fossa. This abscess may be super- 
 ficially or deeply seated. If it be of the former character, it can be 
 opened readily. 
 
 Operation. If the development of a deep-seated abcess be sus- 
 pected, aspiration should be frequently performed to detect the earliest 
 existence of pus. If pus be found, make an incision four or six inches 
 in length, commencing an inch internal to and above the anterior 
 superior spinous process of the ilium, and extending downward parallel 
 with Poupart's ligament ; divide cautiously the various layers of the 
 abdominal wall on a director, and, when the abscess wall is reached, 
 insert an aspirating-needle again as a precautionary measure ; open 
 the cavity freely in the course taken by the needle ; wash it thorough- 
 ly, insert a drainage-tube, and allow it to heal from the bottom. 
 
 If pus be not present, the incision may be made, if expedient, and 
 the wound allowed to remain open, when, if pus form, its discharge 
 can be readily effected. 
 
 Results. This operation is to be earnestly commended to the at- 
 tention of all practitioners of medicine and surgery. The association 
 of typhlitis with abscess located in this situation, and the great danger 
 to the patient from a rupture into the abdominal cavity, emphasize 
 the necessity of an early diagnosis and a thorough treatment. The 
 prognosis is flattering when active measures are early and promptly 
 taken. 
 
 Artificial Anus, or Fecal Fistula. When the distal extremity of 
 the bowel is pervious and the fistula has served 
 its purpose, it should be closed. If the sep- 
 tum between the openings be shallow and 
 yielding, it can be forced back by means of a 
 sponge pressed against it and confined in po- 
 sition ; wooden plugs and lint are employed 
 in a similar manner ; failing in this, the sep- 
 tum should be grasped by a clamp or entero- 
 tome (Fig. 577), passed into the opening on 
 either side of it, and the blades firmly screwed 
 together. In a few days the constricted por- 
 tion sloughs, and the instrument is released. 
 The external opening usually closes spontane- 
 ously ; if not, a plastic operation may become ^ 57Y ._Enterotoine ap- 
 necessary. If these methods fail, the affection plied.
 
 374: OPERATIVE SURGERY. 
 
 may be cured by enterectomy, as was practiced by Kinloch, of South 
 Carolina, in 1863. 
 
 OPEEATIONS ON THE KIDNEYS. 
 
 The surgery of the kidney has made rapid strides within the last 
 few years. The accepted operations on this organ are nephrotomy, 
 nephrectomy, nephro-lithotomy, and nephroraphy or fixation of a 
 movable kidney. 
 
 Nephrotomy, Nephrotomy consists in opening into the kidney 
 through an incision in the lumbar region. The operation should be 
 preceded by the introduction of an aspirating needle, both to locate 
 and define the nature of the tumor. 
 
 Operation. The patient is placed in the same position as in lum- 
 bar colotomy. The incision is made in the same direction ; and in 
 other respects its location is similar, although it is often made nearer 
 to the last rib than in colotomy. A vertical incision, just outside the 
 quadratus lumborum, extending from a point immediately below the 
 last rib four or five inches downward, is preferred by some. The 
 same precautions preparatory to and attending the operation are re- 
 quired that characterize colotomy, and the tissues resting upon the 
 tumor are divided in the same manner. When the sac is reached it 
 should be aspirated to confirm the diagnosis. An opening is then 
 made into it, the contents evacuated, and the cavity washed out with 
 a solution of the bichloride of mercury, 1 part to 2,000 of water. 
 Carbolic solutions should be avoided, since carbolic-acid poisoning 
 seems more likely to occur from its use in this situation than else- 
 where. 
 
 Remove all calculi that may be present, and unite the edges of the 
 kidney to the wound, and allow it to heal by granulation ; or a drain- 
 age-tube is inserted and the external opening is closed by deep sutures, 
 and dressed antiseptically. 
 
 If the kidney structure be destroyed, or be the seat of malignant 
 disease, it is then wise to remove the entire organ. 
 
 Results. Nephrotomy has been practiced, for various causes, nearly 
 one hundred and twenty-five times, with an average mortality of about 
 twenty per cent. The death-rate after operations for calculous pye- 
 litis was about forty-three per cent, but for other causes in no case 
 did it reach eighteen per cent. 
 
 Nephrectomy. Nephrectomy consists in removing the kidney in 
 part, or entirely, from the body. The removal is indicated in cases 
 of a wounded or painful floating kidney, cystic kidney, hydro-nephro- 
 sis, pyelitis, with or without calculi, neoplasm, and urinary fistula 
 from a communication with the ureter. Before the operation is per- 
 formed, it should be ascertained, if possible, whether the other kidney 
 is present, and in a healthy condition.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 375 
 
 The primary incision may be made in the loin or through the ab- 
 dominal walls ; which is the better one is a matter as yet unsettled. 
 The character of the case will have much to do in determining this 
 point. If the tumor be movable, malignant, of large size and ad- 
 herent, or if it be suspected that the disease be bilateral, the abdomi- 
 nal incision is preferred, since it admits of the examination of the 
 other kidney. 
 
 The rate of mortality, however, favors the lumbar incision. 
 
 Lumbar Nephrectomy is to be done with every possible antiseptic 
 precaution. The primary incision is made usually in the same situa- 
 tion and direction as in nephrotomy, although the vertical one, in large 
 tumors, is highly commended. If the space will permit, the tumor is 
 isolated, and its pedicle tied en masse, or, what is better, the vessels 
 are secured separately. The ureter must always be tied, and the lower 
 extremity brought through the external opening. It often happens 
 that the size of the tumor and its adhesions to surrounding tissues re- 
 quire the opening to be enlarged. This can be done by extending it 
 toward the spine as well as in the opposite direction. If the opening, 
 when taken in conjunction with the additional space to be gained by 
 pushing upward the last rib, be inadequate, the rib can be resected 
 subperiosteally for three or four inches, and this will be found to 
 afford quite sufficient room. 
 
 After the removal of the tumor, the wound should be thoroughly 
 disinfected with a solution of carbolic acid or other suitable substance ; 
 ureter secured externally, and the opening closed* by deep sutures, and 
 dressed antiseptically. 
 
 Abdominal Nephrectomy. In abdominal nephrectomy the opening 
 into the abdominal cavity can be made in three situations : 1, the 
 most frequent situation is through the linea alba ; 2, at the outer side 
 of the rectus (linea semilunaris) ; 3, in the inguinal region. The first 
 two require that the peritoneum be divided : the last admits of a sub- 
 peritoneal removal, but can scarcely be employed except in well-marked 
 cases of movable kidney. In either case the abdominal opening is made 
 in the usual cautious manner, about six or eight inches in length, and 
 larger if the size of the tumor demand it. The hand is introduced, 
 tumor located and outlined, and the condition of the other kidney 
 noted. The diseased organ is then enucleated and raised through the 
 opening, its vessels and the ureter are tied separately with strong carbo- 
 lized ligatures, and are cut short, and returned. The opening remain- 
 ing in the peritoneum after the removal of the kidney can be closed 
 after all hemorrhage has ceased by uniting its divided borders with fine 
 catgut. The abdominal cavity is then cleansed of all foreign matter, 
 and its walls united and dressed autiseptically. If the ureter is to 
 be returned into the cavity of the abdomen, its extremity should be 
 thoroughly asepticized with the carbolic acid, or the bichloride of
 
 376 OPERATIVE SURGERY. 
 
 mercury solution. It is considered better, however, to attach it to 
 the abdominal opening. It is recommended to tie the vessels of the 
 pedicle before commencing the enucleation, thus lessening the danger 
 of hemorrhage. The advantages of an opening outside of the rectus 
 are said to be, less hemorrhage from the abdominal walls than when 
 the opening is made through the linea alba ; also, it brings the sur- 
 geon more directly on the tumor, its pedicle, and the ureter. If the 
 space from which the tumor has been removed be a large one and 
 show a strong tendency to bloody oozing from the surface, the perfo- 
 rated glass drainage-tube should be introduced, carried directly to the 
 bottom, and allowed to protrude through the abdominal incision. 
 The fluid which accumulates in the tube can be removed by carbolized 
 sponges under the antiseptic spray. Drainage may also be provided 
 by passing a small drainage-tube through the abdominal wall in the 
 lumbar region, communicating with the former site of the diseased 
 organ ; then the posterior peritoneal incision should be closed. 
 
 It is impossible to lay down more than the general means of pro- 
 cedure in this operation, since the conditions surrounding individual 
 cases often call for the employment of other than stereotyped rules. 
 
 Results. Of two hundred and thirty-three nephrectomies collated 
 by Prof. S. W. Gross, about forty-five per cent died. The mortality 
 from the lumbar incision was forty per cent, that from the abdominal 
 incision about fourteen per cent greater. Shock was the cause of 
 death in forty per cent of the entire number operated upon. 
 
 Nephro-lithotomy, or renal lithotomy, is the exploration of the pel- 
 vis of the kidney with a long needle, to ascertain the presence of cal- 
 culi within it. If calculi be present, they are removed with forceps, 
 through an incision made into the kidney. 
 
 Operation. The external opening is made similar to that for lum- 
 bar nephrotomy ; the kidney is exposed, calculus detected, and an in- 
 cision is made through the cortex into the pelvis in the long axis of 
 the kidney of sufficient size to remove it with suitable forceps. The 
 hemorrhage resulting from the division of the kidney structure is 
 quite severe at first, but is quickly controlled by pressure. The 
 wound in the kidney usually heals readily ; nevertheless, urine will 
 sometimes escape through it for ten or twelve days. With a view to 
 cause union of its structure, the lips of the kidney-wound have been 
 united by fine catgut sutures with favorable results. The external 
 wound is suitably drained, closed, dressed antiseptically, and the pa- 
 tient given demulcent drinks. 
 
 Results. All of the reported cases (six) of this operation have ter- 
 minated favorably. 
 
 Nephrorraphy (Fixation of a Floating Kidney). To accomplish 
 this purpose in cases where all ordinary means have failed, an incis- 
 ion is made from a little below the lower rib to the crest of the ilium,
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 377 
 
 along the outer border of the erector spinae, and down to the quad- 
 ratus lumborum. The same tissues are encountered in this as in the 
 Tertical incision of uephrotomy. There is a greater danger of hemor- 
 rhage, however, than from the oblique incision, as the vertical incis- 
 ion is made at nearly right angles to the lumbar vessels. As soon 
 as the fascia lumborum is divided, the kidney should be pushed into 
 the wound, the fascia transversalis slit up, the fatty capsule surround- 
 ing the kidney opened longitudinally, and its borders stitched to the 
 deep structures of the wound with eight or ten catgut or carbolized 
 silk sutures. The wound is then stuffed with carbolized gauze and 
 allowed to heal from the bottom ; the patient remaining in the dorsal 
 position until the healing is well completed ; after which, any of the 
 various forms of pads or other retentive apparatus may be applied to 
 retain it until the adhesions are thoroughly established. 
 
 Results. Nephrorraphy has been performed eighteen times, with 
 one death. In about forty-four per cent of the cases but little or no 
 relief was gained. Forty-one per cent die from nephrectomy for this 
 condition. 
 
 The subsequent giving way of the fixation point under the influ- 
 ence of movement, suggests the practicability of continuously wearing 
 some form of retentive apparatus. 
 
 Splenectomy, which consists in the removal of the spleen, has been 
 performed between thirty-five and forty times. It has not proved suc- 
 cessful, however, in any instance when practiced for leucocythemia. 
 When employed for displacement or simple hypertrophy, the results 
 are flattering, being in excess of fifty per cent. 
 
 Operation. An incision about eight inches in length is made at 
 the outside of the rectus or in the median line, its center corresponding 
 to the umbilicus ; the peritoneal cavity is opened in the usual manner, 
 the omentum and intestines displaced, and the tumor carefully raised 
 through the opening ; after which the vessels at the hilum, and those 
 of the gastro-splenic omentum, are clamped and tied. This omeutum 
 should be divided into several sections by transfixion, and each sec- 
 tion should be tied by two ligatures and divided between them. All 
 hemorrhage is stopped, and the abdominal wound closed either with 
 or without a drainage-tube, depending on the amount of prospective 
 oozing. 
 
 The spleen must be handled very carefully during the removal, or 
 it may be ruptured. 
 
 Paracentesis Abdominis. This procedure is an operation employed 
 to remove fluids from the abdominal cavity. The instruments neces- 
 sary are the scalpel and the trocar, Fig. 578 being an admirable ex- 
 ample of the latter. Fig. 579 represents the ordinary form, which 
 will meet all common indications. 
 
 The aspirator (Fig. 580) is cheap, durable, and efficient. The
 
 378 
 
 OPERATIVE SURGERY. 
 
 handy aspirator of Fitch (581) is not expensive, and can be used in 
 conjunction with the canula figured above. In either case the caliber 
 
 FIG. 578.' Wood- 
 Ilarris trocar. 
 
 FIG. 579. Trocar 
 and canula. 
 
 FIG. 580. Potain's aspirator. 
 
 C i 
 
 of the canula should be small enough to admit of the gradual dis- 
 charge of the fluid, for if it be 
 discharged too rapidly the dan- 
 ger of syncope will be immi- 
 nent. If the canula be sharp- 
 pointed, it can be introduced 
 without the aid of the scalpel, 
 after the presence of the fluid 
 has been determined by the aid 
 of the hypodermic syringe. 
 
 An anaesthetic is not neces- 
 sary. A local injection of a so- 
 lution of cocaine will suffice to 
 relieve all pain caused by the in- 
 
 FIG. 581. Fitch'a aspirator. 
 
 troduction of the needle. The
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 379 
 
 bladder and rectum should be emptied, and the abdomen carefully per- 
 cussed to determine the limits of dullness. The belly is then sur- 
 rounded by a broad, many-tailed bandage, having a small opening 
 in the center corresponding to the point of proposed puncture. If 
 unable to sit up, the patient is placed upon his side near to the edge 
 of the bed, but if his strength will permit, he can be placed in an 
 ordinary chair, with the body bent forward, and the head and arms 
 resting upon the back of another chair in front. 
 
 Operation. The 
 instrument is seized 
 firmly with the in- 
 dex-finger resting on 
 its upper surface (Fig. 
 582) to limit the ex- 
 tent of its introduc- 
 tion, and is plunged 
 quickly through the 
 wall of the abdomen 
 in the median line, 
 midway between the 
 umbilicus and pubes, 
 and the trocar is with- 
 drawn. As the fluid 
 escapes, the bandage 
 is tightened to facilitate the flow, as well as to support the patient. 
 The flow is permitted to continue until the fluid is removed, unless 
 the patient is threatened with syncope, when the trocar is withdrawn 
 at once. The puncture should be closed by a strip of adhesive plas- 
 ter, or, better, by a hare-lip pin, confined in the usual manner ; the 
 tails of the compressing bandages are then tied firmly to maintain the 
 pressure. Care is taken that no air be permitted to enter the cavity 
 of the abdomen. 
 
 Fallacies. A distended uterus or bladder, or a displaced or en- 
 larged liver, may be punctured. 
 
 If the canula be sharp-pointed, the intestines may be injured 
 during the withdrawal of the liquid. A blood-vessel of the abdomi- 
 nal walls may be injured by its introduction. If the uterus be dis- 
 tended from any cause, the puncture can be made through the right 
 or left semilunaris or above the limit of the distention. 
 
 OPERATIONS APPLICABLE TO THE VARIOUS CONDITIONS OF ABDOMI- 
 NAL HERNIA. 
 
 The operations on the various forms of hernias that are amenable 
 to operative procedures are : for the reducible hernia, an operation 
 for a radical cure ; for the strangulated, taxis, and division of the 
 
 FIG. 582. Introducing trocar.
 
 380 
 
 OPERATIVE SURGERY. 
 
 Fio. 583. Sac of a hernia. FIG. 584. Sac and contents. 
 
 constriction ; for the simple irreducible and obstructive forms, the 
 liberation of their contents, and their return to the proper situa- 
 tion. 
 
 A hernia may be defined to be the protrusion of a portion of the 
 contents of the abdomen through any opening in its walls. Each 
 protrusion is composed of a sac and its contents, surrounded by more 
 or less of the tissues composing the abdominal walls. With but few 
 exceptions all hernise possess a sac, and this sac, in every case, is com- 
 posed of the parietal peritoneum (Fig. 583). Only those viscera, such 
 
 as the caput coil, 
 colon, bladder, pan- 
 creas, etc., which 
 are not normally 
 surrounded by this 
 membrane, can form 
 a hernia without a 
 sac. The contents 
 of a hernial sac, in 
 the ordinary sense 
 of the term, then 
 consist of the small 
 
 intestine and omentum, either singly or conjointly (Fig. 584). If 
 the larger viscera escape, it will be exceptional, and probably de- 
 pend upon an abdominal wound. Such a condition is then called 
 a protrusion of this or that organ rather than a hernia of the same. 
 The normal appearance of the omentum and small intestines should 
 be given a careful study, that the operator may be able to determine 
 the various degrees of change in their appearance when subjected 
 to the different influences associated with hernial protrusions. The 
 granular appearance of the omental fat, together with its pale color 
 and extra fibrous structure, will distinguish it from the subserous 
 tissue fat. The omentum and gut, while in the sac, usually bear 
 the same comparative relation to each other as in the abdominal 
 cavity, the former being in front. The sac has a neck and a body ; 
 the shape and size of the latter depend upon the amount and density 
 of the surrounding tissues and the nature and compactness of its con- 
 tents. The neck is its constricted portion, and corresponds to the 
 opening through which it escaped ; its size is governed by the density 
 of the tissues by which it is surrounded, the age of the protrusion, 
 degree of traction, and compressibility of its contents. A knowledge 
 of the normal characteristics of the peritoneum is as essential to the 
 surgeon as is a knowledge of the peculiarities of the contents of the 
 sac. Its rough outer and smooth inner surfaces, the arrangement of 
 its vessels, and its transparency should be understood. It must not 
 be forgotten, however, that the physical appearance of the sac and its
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 381 
 
 contents become changed when long subjected to the vicissitudes at- 
 tending hernial protrusions. 
 
 The tissues composing the walls of the protrusion, or the " cover- 
 ings of hernia," vary according to its situation, rapidity of develop- 
 ment, and size. While they may readily be distinguished in their 
 proper places as component parts of the abdominal wall, yet, when 
 stretched around the body of a hernia and more or less changed from 
 the effects of pressure and extraneous influences, their identity often 
 becomes difficult of recognition. 
 
 In a recent hernia the cellular tissues and fat will vary but little 
 from their normal conditions ; in an old one, these tissues will be 
 much thinner than usual. In a recent protrusion the muscular fibers 
 of the cremaster will be exceedingly sparse and illy developed, while 
 in the older ones the influence of the coincident traction will lead to 
 their becoming well developed and of great diagnostic importance, not 
 only as to the depth of the incision, but the variety of the protrusion. 
 The transparent sac often becomes more or less opaque, and so con- 
 nected with the cellular tissue upon it as to be scarcely distinguish- 
 able from it. 
 
 It can be safely said that the changes in the appearance and the 
 anatomical relations of the component parts of a hernia, and the influ- 
 ences and processes to which it is subjected, may be so manifold that it 
 will present as varied and perplexing problems, requiring a speedy so- 
 lution, as any morbid condition of the body. 
 
 Prior to attempting any form of operation upon a hernia, it is 
 necessary that the surgeon be acquainted with the important blood- 
 vessels and their relation to the body, and more especially the neck of 
 the sac. He must know the bony landmarks, the ligamentous asso- 
 ciations, and the direction of the exit, else he will be unable to distin- 
 guish the variety of hernia or to manipulate its return. 
 
 OPERATIONS FOR RADICAL CURE. 
 
 Beaton's Operation. This consists in injecting into the inguinal 
 canal with a syringe, constructed for the purpose, ten or fifteen drops 
 of a mixture, composed of one half an ounce of Thayer's fluid extract 
 of quercus alba, prepared in vacuo, and fourteen grains of the solid 
 extract of quercus alba. Triturate with gentle heat until the solu- 
 tion is as perfect as possible. A grain of morphia to the ounce can 
 be added to alleviate the pain caused by the injected fluid. 
 
 The patient is placed on the back, contents of the sac returned, 
 and if necessary retained by the finger of an assistant. Locate the 
 external abdominal ring with the right forefinger passed upward and 
 outward, invaginating the scrotum ; press the left forefinger perpen- 
 dicularly upon the integument over the ring, using sufficient force to 
 press the integument together with the finger directly into the ring,
 
 382 
 
 OPERATIVE SURGERY. 
 
 thus leaving nothing between it and the external pillar but the in- 
 tegument and subjacent fascia. The syringe, already charged, is 
 taken in the right hand, and quickly introduced through the integu- 
 ment and fascia into the inguinal canal, closely hugging the external 
 pillar. The forefinger is then removed, and the needle carried care- 
 fully along the posterior surface of the aponeurosis of the external 
 oblique, for an inch or so, when the fluid is deposited, drop by drop, 
 in various portions of the canal, by moving the point around during 
 its withdrawal. A small portion should be deposited at the extreme 
 end of the canal ; the intercolumnar fascia and the pillars of the ex- 
 ternal ring should be well medicated. The needle is then withdrawn, 
 the opening sealed, compress and bandage applied, and the patient 
 kept in the dorsal position. If undue inflammation occurs, it is to be 
 treated in the usual manner. As a rule, the pain and tenderness will 
 disappear in two or three days, after which the patient is to be kept 
 quiet for ten days before attempting to walk, and then the part 
 should have proper support, which should be continued in use for six 
 or eight weeks, and even longer in the interest of discretion. 
 
 The results claimed for this method by its originator have not been 
 substantiated by the trials to which it has been subjected by many 
 careful and unprejudiced surgeons. It is, however, devoid of danger, 
 provided the fluid be not thrown into the peritoneal cavity, and is 
 rarely followed by suppuration. In a recent oblique hernia with a 
 small neck it is a harmless expedient, which often affords relief. It 
 must not be forgotten, however, that unless constant caution is ob- 
 served, the protrusion may recur. 
 
 The percentage of cures and failures are about the same thirty 
 per cent. In the remainder the result is indifferent. 
 
 Wiitzer's Method. The protruded parts are returned, and a fold 
 of integument is pushed as far as possible into the canal with the 
 
 index-finger of the 
 left hand ; the 
 cylindrical portion 
 of the instrument 
 (Fig. 585) is well 
 oiled and carried 
 into the cul-de-sac, 
 guided by the fin- 
 ger, which is slow- 
 ly withdrawn as 
 the instrument is 
 inserted. The dis- 
 tal extremity of 
 the instrument is 
 passed up to the internal ring, the needle projected, passing through 
 
 FIG. 585. Wutzer's apparatus.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 383 
 
 the neck of the sac and tissues of the abdominal wall ; the concave 
 cover is then screwed down and a cork fixed on the end of the needle. 
 The instrument is allowed to remain in position eight or ten days. 
 After the removal, the patient is kept in bed as much longer, and is 
 then permitted to get up, keeping the parts supported by a truss for 
 five or six months. 
 
 Agnelli's Modification. Evacuate the patient's bowels thoroughly 
 the day before the operation. Place him in a horizontal position, shave 
 and cleanse the parts, make an incision through the integument, com- 
 mencing at the external abdominal ring and terminating two inches 
 below it ; separate the integument from its 
 fascia! connections at either side of the incis- 
 ion, then invaginate the fascia and dartos, 
 pushing it to the outer extremity of the canal 
 by the index-finger, along which the instru- 
 ment is now passed. The instrument (Fig. 
 586) is introduced with its grooved blade 
 resting internally to carry the invaginated 
 integument to the outer extremity of the ca- 
 nal. The blades are then widely separated, 
 and the long needle, armed with a silver wire, 
 is inserted into one of the grooves of the inner 
 blade, and, guided by it, is passed through 
 the superimposed tissues, the end of the wire 
 grasped, needle withdrawn and directed by 
 the other groove through the tissues in the 
 same manner, causing the points of puncture 
 to be about half an inch apart. The wire 
 is then cut of sufficient length to be twisted 
 around a piece of cork, or bent, thus securely 
 fastening the apex of the invagination within 
 the canal. The sides of the inguinal canal 
 are now drawn together by three transverse 
 sutures half an inch apart, introduced by a 
 needle armed with stout silk thread, which 
 is passed between the blades of the instru- 
 ment. This should then be withdrawn, the 
 wound closed and dressed antiseptically, the 
 patient confined to the bed, and the bowels FIG. 586. Agnew's apparatus, 
 kept closed by opium to avoid straining. 
 
 The transverse sutures are allowed to remain in position for eight 
 or ten days, the silver one somewhat longer, the object being to cause a 
 firm agglutination of the invaginated plug to the surrounding tissues. 
 
 The results of this operation are flattering. If the cases be cor- 
 rectly reported, over eighty per cent are cured.
 
 384 
 
 OPERATIVE SURGERY. 
 
 Wood's Method. This consists in drawing together and retaining 
 the tendinous structures of the inguinal canal and pillars of the ring 
 by the means of a ligature, until the parts become united by effused 
 lymph. 
 
 The instruments required are a tenotome, semicircular needle at- 
 tached to a strong handle, and a silver-plated copper wire (Fig. 587). 
 
 The method of 
 procedure is suc- 
 cinctly portrayed 
 by Mr. Druit : 
 "The patient be- 
 ing tied on his 
 back, with the 
 shoulders well 
 raised, with the 
 knees bent, the 
 
 687.-Wood's apparatus. 
 
 FIG. 588. Tis- 
 
 ^""*& puboB cleanly 
 
 shaved, the rup- 
 
 ture completely reduced, and chloroform administered, an oblique in- 
 cision about an inch long is made in the skin of the scrotum over the 
 fund us of the hernial sac. The knife is then carried flatwise under 
 the margins of the incision so as to separate the skin from the deep 
 coverings of the sac, to the extent of about an inch, or rather more, 
 all around. The forefinger is then pressed into the wound, and the 
 detached fascia and fundns of the sac invaginated into the canal as 
 
 Fio. 689. Transfixing conjoined tendon. 
 
 represented in Fig. 588. The finger then feels the border of the in- 
 ternal oblique muscle, lifting it forward to the surface. By this 
 means the inner edge of the conjoined tendon is felt at the inner side 
 of the finger. The needle is then carried carefully up to the point of
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 385 
 
 the finger along its inner side and made to transfix the conjoined ten- 
 don, and also the inner pillar of the ring (Fig. 589). When the point 
 is seen to raise the skin, the latter is drawn over toward the median 
 line, and the needle made to pierce it as far outward as possible. 
 
 A small hook is bent on the point of the wire, inserted into the 
 eye of the needle, and drawn back into the scrotum and detached. 
 The finger is next placed behind the outer pillar of the ring and 
 made to raise that and Poupart's ligament as much as possible from 
 the deeper structures. The needle is now passed along the outer side 
 of the finger through Poupart's ligament a little below the deep her- 
 nial opening (Fig. 590), and the point is then directed to the skin 
 
 FIG. C90. Transfixing Poupart's ligament. 
 
 FIG. 591. Passing through or behind 
 the sac. 
 
 puncture before made. The outer end of the wire is hooked on to 
 the needle, and the wire is then drawn back into the scrotal puncture 
 as before, and detached. 
 
 Next the sac at the scrotal incision is pushed up between the 
 thumb and forefinger, and the cord slipped back from it, as is done in 
 taking up varicose veins. The needle is then passed across behind or 
 through the sac, between it and .the cord, entering and emerging at 
 the opposite ends of the scrotal incision, as shown in Fig. 591. The 
 end of the inner wire is again hooked on and drawn back behind the 
 sac. The needle may be made to pass through one or both of the pil- 
 lars at the same time close to their insertion. Both ends of the wire 
 25
 
 386 
 
 OPERATIVE SURGERY. 
 
 are then drawn down until the loop is near the surface of the groin 
 above, and they are twisted together down into the incision and cut off 
 at a convenient length. Traction is then made on the loop so as to 
 invaginate the sac and scrotal fascia well up into the inguinal canal. 
 The loop of wire is firmly twisted close down into the upper puncture 
 and bent downward to be joined to the two ends below in a bow or 
 arch, beneath which is placed a fine pad of lint (Figs. 592 and 593), 
 and the whole confined in position by a spica bandage. 
 
 FIGS. 592. 593. Invagination completed. 
 
 FIG. 594. Wood's rect- 
 angular pins. 
 
 Modification with Pins. For small hernise and hernias in children 
 Dr. "Wood employs a pair of rectangular pins (Fig. 594). With the 
 finger in the inguinal canal, as in the preceding operation, one pin is 
 
 made to pass through 
 the conjoined tendon 
 and the internal pillar 
 from above down- 
 ward, and the other 
 to pass through Pou- 
 part's ligament from 
 below upward (Fig. 
 595). 
 
 They should both 
 be caused to enter and 
 emerge at the same 
 point of cutaneous 
 FIG. 595. Passiup; the pins. puncture. The pins
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 337 
 
 are bent at a right angle at the blunt extremity, the angle being 
 looped. After the transfixion they are locked to each other and 
 twisted around to more closely entwine the included structures. 
 The ends of the pins are then cut off and the blunt extremities are 
 pressed against the abdominal wall, con- 
 fined in position, and allowed to remain 
 eight or ten days (Fig. 596). 
 
 The results obtained ~by this method, as 
 recorded by Dr. Wood, are most excellent, 
 seventy per cent being satisfactory ; be- 
 tween one and two per cent died. 
 
 These results have not, as yet, been du- 
 plicated by other operators. 
 
 Czerny's Method. Expose the sac by a 
 free incision in its long axis and separate 
 it from the surrounding tissues, isolate its 
 neck and tie it with a strong catgut liga- 
 ture. Amputate the sac below the liga- 
 tured point, push the stump into the ab- 
 dominal cavity, refresh the borders of the 
 opening, and unite them by a continuous 
 catgut ligature. 
 
 Results. Of the cases reported all but 
 one resulted in a satisfactory manner. It 
 
 is suggested by Prof. S. D. Gross that the method can be modified by 
 simply tying the sac as before and returning it to the abdominal cavi- 
 ty, which will expose the patient to no unnecessary danger. 
 
 It is recommended that the sac be twisted after tying its neck, 
 to excite adhesive inflammation. The lower end of the sac may 
 be drawn to the outer end of the inguinal canal by a ligature 
 extending from it through the abdominal walls, and the sac is then 
 fastened in place by tying the ligature around an antiseptic com- 
 press. 
 
 Tlie author has employed a method of treating the sac of ordinary- 
 sized hernia3, which he has not, as yet, seen described. After the 
 neck of the sac is tied, a looped ligature armed with a large needle is 
 carried through the lower extremity and tied. Two parallel incisions 
 are then made half an inch apart, the lower one being made half an 
 inch above the border of the internal pillar. They should correspond 
 in length to the width of the sac. The external pillar is treated as 
 nearly as possible in the same manner ; the first incision being located 
 a little below its upper border. The sac is first carried upward behind 
 the internal pillar, drawn through the upper slit, and returned through 
 the lower slit of the same pillar ; then it is carried behind the external 
 pillar, out through its upper slit, and returned again by being pushed 
 
 FIG. 596. Pins in position.
 
 388 OPERATIVE SURGERY. 
 
 inward through the lower slit of the pillar. The sac is drawn tight- 
 ly, the borders of the external ring are approximated and sewed with 
 catgut or silver wire, the stitches being carried through the walls 
 of the sac lying beneath. This " weaving " process not only thor- 
 oughly closes the external abdominal ring, but also introduces ad- 
 ditional layers of peritoneum in front of the weakened point of the 
 abdominal wall. 
 
 Results. Sufficient time has not yet elapsed since the first opera- 
 tion performed by this plan to admit of a positive expression of opin- 
 ion regarding the result. 
 
 Dowell's Method. Prepare the patient as in the preceding methods. 
 He is then placed in a recumbent posture with the shoulders elevated 
 and the limbs flexed. 
 
 Operation. Be sure the hernia is reduced. Invaginate the scrotal 
 tissues with the index-finger. Take the semicircular needle, especially 
 designed for the purpose, and arm it with a strong silken ligature. 
 The needle is entered one inch and a half above the external ring 
 and passed beneath and close to the tip of the finger and brought out 
 through the skin on the opposite side, near to Poupart's ligament. 
 This stitch passes through the integument, the aponeurosis of the ex- 
 ternal oblique, and the hernial sac near the posterior wall of the canal. 
 The needle is withdrawn till its point is disengaged from the tendon, 
 and is then carried over the point of the finger in close contact with 
 it, and pushed through the first puncture, situated near to Poupart's 
 ligament. By this procedure the loop is made to surround the in- 
 guinal canal, and both its extremities lie together in the primary 
 puncture. To one end of the silken ligature just passed attach a sil- 
 ver wire which is then drawn into the position of the former. Two 
 or more silver wires are introduced in a similar manner at different 
 situations along the canal. Each of these is then twisted over a 
 cylinder of antiseptic gauze placed upon the abdomen and the whole 
 is dressed antiseptically. The patient should be kept quiet in bed for 
 eight or ten days, upon a restricted diet, after which the stitches can 
 be removed ; and the patient allowed to walk, three or four days later. 
 
 Results. Dr. Dowell some time since reported ninety-six cases 
 treated in this manner, with eighty cures and sixteen failures. 
 
 In many cases of the so-called radical cures obtained by any method, 
 the fondest anticipations of the patient and surgeon are too often dis- 
 pelled by the return of the protrusion. To avoid this, if possible, an 
 easy-fitting truss should be worn for a long time afterward. The 
 direct methods can be employed in the treatment of all forms where 
 the neck of the sac can be reached and the borders of the opening ap- 
 proximated. 
 
 Radical Cure of Femoral Hernia (Wood). The same instruments 
 are required for operation upon femoral hernia as upon inguinal. The
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 389 
 
 patient is placed on the back with shoulders well elevated, and an inci- 
 sion an inch in length is made in the long axis of the protrusion 
 through the integument. The subjacent fascia is separated from the 
 integument and is pushed into the femoral opening with the index- 
 finger, which is placed at the inner side of the femoral vein to protect 
 it. The needle is passed upward through the sac, and is directed so 
 as to include with it the pubic portion of the fascia lata over the pec- 
 tineus muscle (Fig. 597, V). The point of the needle appearing at 
 the wound is then pushed upward and through Poupart's ligament 
 toward the nail of the invaginating finger. The skin of the groin is 
 drawn outward and pierced by the needle. A wire is passed through 
 the eye of the needle and is carried downward by its withdrawal. The 
 wire is removed and left in the wound, and the needle again carried 
 through the pubic portion of the fascia lat-a about an inch outside of 
 its preceding course, and upward through the falciform process of the 
 fascia lata and Poupart's ligament through the integumentary punct- 
 ure previously made (Fig. 597, a). The other end of the wire is 
 then inserted into the needle and pulled down as before. The lower 
 ends are then twisted together in the incision, the twisted end cut off 
 five or six inches long, and the upper external loop twisted firmly down 
 upon the integument (Fig. 598) and looped as before (Fig. 599). 
 
 FIG. 59*7. Passing needle through fascia lata. FIG. 598. Wire in position for twisting. 
 
 Umbilical Hernia. The instruments required are a stout needle, a 
 spoon-shaped concave director, and two pieces of stout silvered copper 
 wire, eight or ten inches in length (Fig. 600). The patient is placed
 
 390 
 
 OPERATIVE SURGERY. 
 
 on the back, the shoulders are raised, the thigh flexed on the abdo- 
 men, and the contents of tumor reduced. The spoon-shaped director, 
 b, with its concave surface uppermost, is pushed into 
 the highest portion of the opening, upon either the 
 right or left side, carrying the integument beneath 
 the free border of the tendinous outline of the open- 
 ing. The needle, d, is carried along the concave 
 surface and thrust through the invaginated integu- 
 ment, fibrous border, and also the superimposed 
 integument, after this has been drawn upward. 
 The end of the wire a, is then introduced into the 
 needle and drawn through the puncture. The 
 lower portion of the opening is pierced in the same 
 manner, the skin being drawn downward to cause 
 the needle to emerge at or near the puncture previ- 
 ously made. The second wire is then drawn through 
 in a similar manner. The operation is repeated 
 on the opposite side, the end of the needle being 
 introduced, first, at the puncture first made and carried along beneath 
 the integument situated between the fibrous boundaries of the open- 
 
 I'IG. 599. Wire 
 looped iu posi- 
 tion. 
 
 FIG. 600. Instruments for umbilical hernia. 
 
 ing, thence out through the tendinous border of the rupture as before 
 described. The extremities of the wire are then twisted until the 
 opening is closed, when they are cut of a sufficient length to be 
 hooked over a compress of lint and retained by adhesive plaster and a 
 bandage. 
 
 STRANGULATED HERNIA. 
 
 Strangulation is a condition induced in the sac by a constriction 
 located at the neck or within the sac itself, which obstructs the circu- 
 lation entirely or in part, thereby exposing the contents of the con- 
 stricted portion to the danger of gangrene. The operations for its 
 relief are taxis and hemiotomy, the latter sometimes being called 
 kclotomy, and in common parlance "an operation upon strangulated 
 hernia,."
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 391 
 
 Taxis. This consists in returning the constricted viscus to the ab- 
 dominal cavity through the channel of its escape by manipulation 
 aided by force of gravity and the relaxation of the constricting agen- 
 cies. As a rule it will be found that strangulation occurs to a protru- 
 sion of long standing, where the patient has become self-educated in 
 the practice of returning it. It therefore follows, when the case is 
 brought to the attention of the surgeon, that the patient has made 
 persistent but ineffectual efforts to reduce it ; under these circum- 
 stances the outlook for the surgeon's success is not brilliant. He 
 should first diagnosticate the variety of hernia, that his efforts may be 
 intelligently directed ; also its condition, that his efforts may do no 
 further injury to the parts or cause harmful procrastination. If mod- 
 erate effort be not sufficient to return it, a hypodermic injection of 
 morphia may be given near the seat of the constriction, and the pa- 
 tient kept in a warm bath, with the pelvis elevated, until the com- 
 bined influences are felt on the general system. It can thus often be 
 returned without difficulty, either by the patient or surgeon, the for- 
 mer being less liable to employ harmful force because of the pain pro- 
 duced. If these measures fail, and if the strangulation be of recent 
 date and the symptoms not urgent, the patient is then thoroughly 
 dried, surrounded by warm wraps, placed in a bed with its foot well 
 elevated, and hot applications applied to the parts. These measures 
 are of themselves often sufficient to cause its return. If they fail, 
 then taxis is repeated with or without an anaesthetic. If an anaes- 
 thetic is used, it should be with the understanding that a failure at 
 reduction will be followed by an immediate operation. 
 
 Taxis is practiced by elevating the hips, relaxing the tissues, and 
 endeavoring to return the part first which escaped last, in the direc- 
 tion of the channel through which it came. Empty the bowels and 
 bladder, flex the thigh upon the body, abduct and rotate it inward to 
 relax the muscular and fibrous tissues about the groin, grasp the tumor 
 with the right hand, and draw it downward carefully to disengage its 
 neck and at the same time to give to it the proper direction for reduc- 
 tion. Gentle, uniform, and continuous pressure is then made upon it 
 by the right hand, while the thumb and fingers of the left steady the 
 upper extremity. If successful, in a few moments the surgeon will be 
 conscious of a slight gurgling noise, followed by a diminution in its 
 size and tension. This is caused by the escape of gas or fecal matter, 
 and will soon be followed by the return of the entire protrusion. 
 Properly directed taxis should not be continued longer than fifteen or 
 twenty minutes, when the herniotomy should be proceeded with. If 
 it be improperly directed, the sooner stopped the better. 
 
 If taxis be applied to a femoral protrusion, if it be a complete one, 
 it must not be forgotten that it is necessary to first press downward, 
 and then backward and upward. It not infrequently happens that a
 
 392 
 
 OPERATIVE SURGERY. 
 
 large femoral hernia is mistaken for an inguinal one, and efforts are 
 directed to returning it through the inguinal canal. 
 
 Kelotomy. The instruments required for this operation are the 
 ordinary scalpel, thumb-forceps, and artery-forceps, scissors, hernial 
 knife (Figs. 601 and 602) and hernial director (Fig. 603), hypodermic 
 
 FIGS. 601, 602. Hernial knives. 
 
 syringe, ordinary grooved director, needles, and the materials for com- 
 plete antiseptic treatment. The steps of the operation may be logic- 
 ally divided into six : 1, division of the tissues ; 2, recognition of the 
 
 sac ; 3, opening of 
 
 FIG. 603. Levis' director. tion of the contents ; 
 
 5, division of the 
 stricture and return of the protrusion ; 6, closure of the wound. 
 
 Division of the Tissues. After the patient is etherized, and the 
 parts are shaved and cleansed by scrubbing, and suitably placed in a 
 good light, an incision two or three inches in length is made through 
 the integument, by transfixion or otherwise, in the long axis of the 
 tumor. The remaining structures, forming the wall of the sac, are 
 picked up one after another with the thumb-forceps at the lower angle 
 of the wound and nicked, the grooved director is pushed beneath each 
 one, and it is then divided with the knife or scissors. The possibility 
 of recognizing the different layers will depend very largely on the length 
 of time the hernia has existed, as well as upon the amount of exter- 
 nal irritation to which it has been subjected. It is exceptional, how- 
 ever, when many of the layers can not be easily recognized, especially 
 those of a muscular character and the dense fascia. As the sac is ap- 
 proached, the question which will most annoy the surgeon is, which 
 is the sac ? am I without or within it ? The sac is recognized by the 
 various layers and their anatomical characteristics ; the fascia trans- 
 versalis, which surrounds it and is separated from it by the fatty sub- 
 serous tissue, is quite liable to be mistaken for the peritoneum. The
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 393 
 
 fascia is dense, opaque, non-translucent, and always present. If a 
 similar tissue has not been divided before, this, then, can not be the 
 sac. A minute opening should be made through it at the lower por- 
 tion of the wound, a grooved director passed beneath it, and its divis- 
 ion carefully made. The next layer is the subserous fat, which is often 
 quite well marked. If the surgeon with hesitation divides the fascia 
 transversalis under the impression that it is the sac, he will become 
 somewhat reassured by mistaking the subserous fat for the omentum 
 in the protrusion. This feeling of security will be quickly dispelled, 
 however, when he attempts to find the intestine, or to return the sup- 
 posititious omentum. 
 
 Recognition of the Sac. It is globular in form, of a bluish color, 
 and often transparent. A sense of fluctuation is often discernible 
 at its lower portion. It 
 can be pinched up be- 
 tween the thumb and 
 finger, and its smooth 
 serous surfaces can be 
 rubbed together, if they 
 be not adherent to its 
 contents. This is diag- 
 nostic. The intestine 
 may be pinched up in ftGSt 604, 605. Opening the sac. 
 
 the same manner before 
 
 the sac is opened, when it will quickly and easily escape the grasp on 
 account of the smooth opposed serous surfaces. If a needle be intro- 
 duced, a drop of fluid will escape ; this is characteristic of a hernial 
 
 sac. Finally, if the membrane be ex- 
 amined, it will be found to surround 
 and limit the protrusion, being mova- 
 ble only as a whole, denser than the 
 intestine, and devoid of its external 
 serous surface. The sac is now to be 
 picked up with the thumb-forceps at 
 the fluctuating point, or the point 
 where the drop of fluid escaped, and 
 a small slit made in it with the knife- 
 point held at right angles to the for- 
 ceps (Fig. 604). If fluid be present it will then escape. A grooved 
 director is inserted (Fig. 605) and an opening made of sufficient size 
 to admit the index-finger, which is introduced to determine with cer- 
 tainty the tissue just cut, as well as the location of the constriction 
 (Fig. 606). If the finger be in the sac, it will come in contact with 
 smooth surfaces, and, after division of the constriction, can be 
 passed through the neck of the sac into the abdomen. If the fin- 
 
 FIG. COG. Introducing the finger.
 
 394: OPERATIVE SURGERY. 
 
 ger be without the sac, it can not be passed upward without being 
 arrested. The existence of cysts in the line of incision may con- 
 fuse the surgeon. If, however, the finger be introduced into them, 
 their non-serous lining and limited extent will expose the fallacy. 
 The sac is now opened sufficiently to expose its contents to a careful 
 scrutiny, that the propriety of returning them may be carefully con- 
 sidered. 
 
 Examination of the Contents. Under all circumstances there will 
 be more or less injection of the vessels. If the constriction be recent 
 or slight, the changes in the imprisoned tissues will not be great ; but 
 when severe or long continued, the intestine will be of a more or less 
 purple or blackish color, with isolated ecchymoses. The bowel may 
 present this appearance, and yet may possess sufficient vitality to re- 
 cover. The color is not of as much importance in determining the 
 presence of gangrene as the inability to restore the circulation after 
 division of the stricture by the aid of warm fomentations. If the 
 bowel be pricked or slightly scarified and no blood flows ; if sensi- 
 bility be absent and the part becomes cool ; if its luster be destroyed 
 and its structure be softened and crackling, it should not be re- 
 turned. If to all these be added the odor of gangrene, it should be 
 opened to afford exit to its contents and be treated with warm 
 fluid carbolized dressings. It is considered good practice at the 
 present day to excise a circular portion of the intestine correspond- 
 ing to the gangrenous part and unite the extremities as described 
 under the head of enterectomy. If the omentum be gangrenous 
 or bulky, ligature it near the mouth of the sac and cut it off ; if 
 not, it can be returned. If the contents be adherent to each other 
 or to the sac, the adhesions may be ruptured if of recent date. It is 
 often necessary, however, to sever them with the knife or scissors, and 
 in doing so, the vessels should be ligatured with fine catgut as soon 
 as seen. When the adhesions are very firm and limited, the corre- 
 sponding portion of the sac may be dissected off and returned with 
 the bowel. 
 
 Division of the Stricture. The constricting agency may be with- 
 out or within the sac, the former being the more frequent site. If 
 without, it may be divided before or after the sac is opened, the latter 
 being the almost universal custom. If the hernia be a small one, and 
 strangulation have lasted but a few hours without stercoraceous vomit- 
 ing or other severe symptoms, and be composed of intestine alone, the 
 constriction may be divided external to the sac. This can be readily 
 done by passing beneath the constricted tissues of the neck of the sac 
 the hernial director of Levis (Fig. 603), which is cautiously carried 
 upward until the constricting band falls into the notches at either side 
 of the groove ; a probe-pointed bistoury or the ordinary hernial knife 
 is then carried along the groove, and the structure divided (Fig.
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 395 
 
 607) ; not freely, but just sufficiently nicked to permit the return 
 of the intestine. When the gravity of the case requires the con- 
 striction to be divided within the sac, so that its contents may be 
 examined, the finger is carried up to 
 the point of the obstruction, followed 
 quickly by the director, which is em- 
 ployed as in the preceding instance. 
 The edge of the knife should be di- 
 rected away from important vessels 
 and the extent of the cut be only suf- 
 ficient to relieve the constriction. If 
 the gut be gangrenous, great caution 
 must be observed in cutting the band, 
 or the adhesions may give way and 
 allow the bowel to re-enter the abdom- 
 inal cavity. If gangrene of the gut be assured, it is better not to 
 divide the constriction, since to do so not only exposes the patient 
 to the danger of the return of the gangrenous gut into the abdomi- 
 nal cavity, but also to the entrance of discharges from the wound. 
 As soon as the bowel is returned, stop all hemorrhage, unite the 
 wound with catgut carried through the sac, introduce a drainage- 
 tube, apply a compress, dress antiseptically, raise the foot of the bed, 
 and quiet the patient with an opiate. 
 
 FIG. 607. Dividing the constric- 
 tion. 
 
 FIGS. 608, 609. Oblique inguinal hernia. 
 
 Strangulated Inguinal Hernia. A hernia in this situation may be 
 direct or indirect, either of which may be complete or incomplete. In 
 the indirect or oblique form (Figs. 608 and 609), if it be a complete 
 hernia, it enters at the internal abdominal ring, passes downward and
 
 396 
 
 OPERATIVE SURGERY. 
 
 forward to, and through, the external ring. The constricting agent 
 external to the sac may be located at either the internal or external ab- 
 dominal rings, and rarely in the inguinal canal. The manner of cutting 
 down upon the sac, and of detecting and dividing the constriction, is 
 described under the general considerations. If the seat of the constric- 
 tion be at the internal ring, it should be divided upward and outward 
 to avoid the epigastric artery which runs along its inner border (Figs. 
 609, 4 and G10). In fact, in the oblique variety the incision upward 
 
 FIG. 610. Course of epigastric artery. 
 
 and outward is always to be made irrespective of the situation of the 
 constriction. The only fallacy that may arise is that of mistaking the 
 direct for the indirect form. In recent cases this can hardly occur, 
 but in those of long standing, where the traction upon the neck of 
 the sac of the oblique form has drawn it inward in front of the point 
 of the exit of the direct variety, it is quite difficult and often impossi- 
 ble to distinguish between them. If the neck of an oblique hernial 
 sac be dragged inward, it causes the epigastric vessels to be pressed di- 
 rectly against its inner and also to encroach upon its upper and lower 
 borders. Under these conditions, if the stricture be divided agreeably 
 to directions often given parallel with the course of the epigastric 
 vessels or even upward and slightly outward, these vessels will be in 
 imminent danger of injury. 
 
 If, upon the other hand, the protrusion be of the direct variety, 
 and the incision be made upward and outward, under the impression 
 that it is a displaced indirect form of hernia, the epigastric vessels will
 
 HOLLOW VISCERA IN CONTACT WITH SEROUS SURFACES. 397 
 
 FIG. 611. Direct inguinal hernia. 
 
 then be exposed to peril (Fig. 611, 6). It is readily seen, therefore, 
 that great caution should be employed in distinguishing between the 
 two, prior to cutting the constriction. 
 It is practically impossible to discrim- 
 inate between them until the coverings 
 of the sac are examined. The oblique 
 variety has for a covering the cremaster 
 muscle, which can readily be distin- 
 guished in an old hernia. This muscle 
 never forms the covering of a direct 
 hernia except when it passes to the 
 outer side of the conjoined tendon ; 
 then its coverings are similar to those 
 of the oblique form. It therefore fol- 
 lows, from the anatomical relations, 
 that when the cremaster does not form 
 a covering the constriction should be 
 divided upward and inward that is, 
 away from the epigastric vessels. If it 
 forms one of the coverings, then the constriction must be cut upward 
 and outward, provided there be no evidence that it is a direct hernia 
 which has escaped to the outer side of the conjoined tendon. This 
 latter condition of affairs is fortunately rare, and this fact, when taken 
 in connection with the location of the tumor at its incipiency, should 
 settle the question between the two. If, however, it be impracticable 
 to settle the doubt, dull the edge of the knife by drawing it across a 
 nail or stone, and then proceed carefully to nick the neck of the 
 constriction in an upward direction. If the constriction be at the 
 external abdominal ring, it matters little in which direction the cut is 
 made ; however, to simplify matters, the direction upward and out- 
 ward should still be adhered to. The methods of examination of the 
 contents of the sac and their reduction, together with the subsequent 
 treatment, are sufficiently considered in the preceding pages. If the 
 protrusion be incomplete, the treatment is similar, and the matter 
 simplified by the inability to confound the direct with the indirect 
 varieties of this form. 
 
 Strangulated Femoral Hernia. The protrusion in this instance 
 escapes at the femoral or crural ring at the inner side of the femoral 
 vein (Fig. 612), then passes along between the vein and Gimbernat's 
 ligament, and the inner boundary of the femoral canal for about 
 half an inch, to the upper portion of the saphenous opening through 
 which it escapes, and in many instances passes upward and rests upon 
 the falciform process of that opening (Fig. 613). The two com- 
 mon points of constriction are : Gimbernat's ligament, and the sharp 
 border of the falciform process of the saphenous opening. The im-
 
 398 
 
 OPERATIVE SURGERY. 
 
 portant boundaries of the upper extremity of the crural canal are : 
 within, Gimbernat's ligament, and without, the femoral vein, sur- 
 
 FIG. 612. Location of the femoral canal. 
 
 rounded by its sheath. Throughout the course of this canal the 
 femoral vein lies at the outer side. The distinctive coverings of this 
 protrusion are : the cribriform fascia, crural sheath, and septum cru- 
 rale, together with the subserous tissues. The important vascular 
 relations are those of the femoral vein and the obturator artery. Tax- 
 is should not be employed in femoral hernia as long as in inguinal, 
 since the constricting influences are greater, and the neck of the sac 
 much smaller. I must again refer to the fact that a femoral hernia, 
 which extends upward toward Poupart's ligament, sometimes reaching 
 above it, may be mistaken for one of the inguinal variety, and that the 
 efforts at reduction are directed to returning it through the external 
 abdominal ring, instead of pushing it downward, backward, and up- 
 ward, as is necessary to effect a reduction. 
 
 Operation. The part should be washed, shaved, and disinfected ; 
 patient placed on the back, thigh flexed and rotated outward, bladder
 
 HOLLOW. VISCERA IN CONTACT WITH SEROUS SURFACES. 399 
 
 emptied, patient anaesthetized, and an incision made in the long axis 
 of the tumor. The integument and superficial fascia should be care- 
 
 FIG. 613. Saphenous opening. 
 
 fully divided, thus exposing the cribriform fascia, which in fleshy 
 subjects is loaded with fat. This, with the glands connected with it, 
 especially if the latter be enlarged, forms a mass often difficult to un- 
 derstand. The glands should be pushed aside, and the remainder of 
 the structure carefully divided. It can hardly be mistaken for any- 
 thing but the omentum, or the deeper layer of fatty tissues. The 
 absence of the sac will readily expose the fallacy of the former, and 
 the nature of the latter will be soon recognized. 
 
 The femoral or crural sheath comes next in order. It is dense, 
 like the fascia transversalis, of which it is a prolongation, and might 
 be mistaken for the sac did it not present those appearances of a dif- 
 ferent character, which have already been described. The septum cru- 
 rale, if the protrusion be large, will hardly form one of its coverings ; 
 if it does, its texture will be much diminished in thickness, and some- 
 what blended with the subserous tissue. It sometimes happens that 
 the small lymphatic gland, which normally exists between the subserous 
 tissue and the septum crurale, can be distinguished, which, of course,
 
 400 
 
 OPERATIVE SURGERY. 
 
 FIGS. 614, 615. Course of obturator artery. 
 
 settles all doubts as to the identity of the tissues under inspection. 
 The careful use of the knife and director soon exposes the sac with 
 its characteristic appearance. It should be opened at the lower ex- 
 tremity with the precautions previously enjoined, and the stricture 
 sought for and divided. If it be, as is usual, at the free border of the 
 falciform process, flex the thigh, rotate it inward, and then, if it is 
 proper, and no further obstruction exists, the protrusion can be re- 
 duced. If the constriction be at the free border of Gimbernat's liga- 
 ment, this, too, must be nicked. It is necessary to remember, before 
 
 attempting this, 
 that the obtura- 
 tor artery, once 
 in three and one 
 half cases, arises 
 from the epigas- 
 tric, and al- 
 though it usual- 
 ly lies in contact 
 with the vein in 
 its descent (Fig. 
 
 614), and is, therefore, out of danger, yet it not infrequently curves 
 inward along the free margin of Gimbernat's ligament (Fig. 615), thus 
 nearly encircling the neck of the sac, and is therefore in great danger 
 of being cut. The knife should be made quite dull, and the ligament 
 nicked superficially in several places. The tip of the little finger may 
 then be inserted and the artery felt for ; if not discovered, the nicking 
 may be repeated, or firm traction with the finger against the ligament 
 may be made, so as to tear or stretch it. This vessel has been severed 
 ten or twelve times during the operation, but in each instance the 
 bleeding was controlled without a fatal result. Ligation and com- 
 pression were the principal expedients resorted to. After the return 
 of the protrusion, the wound is closed and dressed antiseptically. 
 
 Femoral hernise do not always follow the course just described ; 
 they take, though rarely, anomalous courses, sometimes appearing at 
 the outer side, or behind the femoral vessels. They have been known 
 to pass through Gimbernat's ligament. It is important to know that 
 in all the anomalous cases the neck of the sac lies closely associated 
 with the epigastric artery alone, or, together with the obturator, and 
 troublesome and often fatal haemorrhages may be caused unless care 
 is taken in dividing the constriction. 
 
 Strangulated Umbilical Hernia. If the symptoms be not urgent, 
 it is recommended that taxis be continued longer in umbilical hernia 
 than is considered admissible in other forms of hernial strangulation, 
 owing to the greater death-rate attending herniotomy in this situation. 
 In the employment of taxis the patient lies upon the back, with the
 
 OPERATIONS UPON THE ANUS AND RECTUM. 401 
 
 shoulders raised and the thighs flexed. The location and size of the 
 opening can often be defined by the finger before the viscus is returned. 
 The seat of the strangulation is usually at the upper border of the open- 
 ing. The taxis pressure should be directed upward and backward to cor- 
 respond to the line of its escape. The incision for the operation is made 
 to suit the shape and size of the tumor. All the tissues are divided 
 on a director, and the upper border of the opening sought for, since 
 it is at this situation that the constriction is most frequently seated. 
 If it be possible, the stricture should be divided without opening the 
 sac, and the contents returned, if they be not gangrenous. If the 
 stricture be without the sac and the contents in an uncertain condi- 
 tion, a small opening, just large enough to admit of inspection, can 
 be made through the sac. If the stricture be within, the only recourse 
 is to relieve it through as small an opening in the sac as possible. If 
 the intestine be gangrenous, the constriction must not be divided, for 
 to do so will allow the wound discharges to run into the abdominal 
 cavity, even though the intestine remain outside. 
 
 Strangulated Obturator Hernia. The viscus follows the course of 
 the obturator vessels in its escape from the pelvis, and lies beneath 
 the pectineus and obturator muscles. It is usually small and not de- 
 tected during life. 
 
 The incision for its relief is made over the tumor at the inner side 
 of and parallel to the femoral vessels. The constriction has been 
 found in the fibers of the pectineus muscle ; and it is usually neces- 
 sary to divide some fibers of this muscle in order to expose the open- 
 ing through which it has escaped. The relation of the obturator ves- 
 sels to the neck of the sac varies, being equally frequent at the outer 
 and inner sides; never in front, and occasionally behind it. If the 
 constriction be found at the foramen, it will require much caution to 
 divide it without implicating these vessels. 
 
 CHAPTER XV. 
 
 OPERATIONS UPON THE ANUS AND RECTUM. 
 
 Examination of the Anus. Place the patient in either one of four 
 positions: 1, in the knee and elbow position ; 2, upon the back; 3, 
 upon the right side, with the knees drawn upon the abdomen ; 4, or 
 cause the patient to kneel upon a chair and lean over its back. 
 
 The position most commonly employed is upon the back in the 
 lithotomy attitude. The one, however, which is most comfortable and 
 26
 
 402 
 
 OPERATIVE SURGERY. 
 
 at the same time most delicate, is upon the side. It is hardly neces- 
 sary to add that the surgeon should be familiar with the normal char- 
 acteristics of the parts, not those alone relating to the appearances, 
 but to their sensibility and density as well. On inspection, not only 
 will the presence of the anal opening be noticed, but the wrinkled 
 appearance of the contiguous integument, the condition of the blood- 
 vessels bordering upon it, but also the white line at the muco-cuta- 
 neous junction will be seen, which indicates the interval between the 
 internal and external sphincters. The instruments necessary to prop- 
 erly examine the anus and rectum consist of variously formed specula 
 constructed for that especial purpose, which may often be wisely sup- 
 plemented by those intended for vaginal examinations (Figs. 616, 617, 
 
 FIG. 616. Bivalve specu- FIG. 617. Williams' rec- 
 lum. tal speculum. 
 
 FIG. 618. Allingham's rectal 
 speculum. 
 
 and 618). Sims' speculum, or a simulated pattern of it, made by 
 bending the handle of an ordinary tablespoon at a suitable angle, will 
 be found to be of much use. Any form of speculum which possesses 
 ample power of adjustment will serve the purpose well. 
 
 Imperforate Anus. This condition depends upon a layer of tissue 
 of variable thickness which exists between the normal site of the ex- 
 ternal opening and the lower extremity of the rectum. It may be 
 simply a thin layer of fibro-cellular tissue, which by its projection in- 
 dicates the nearness of the loaded bowel. In these cases, the emotions 
 of the child may be noted by the movements of the interposed mem- 
 brane, and a positive diagnosis can be made by a hypodermic puncture. 
 If the septum be thin, a longitudinal or crucial incision, or even a
 
 OPERATIOXS UPON TI1E ANUS AND RECTUM. 
 
 403 
 
 FIG. 619. Absence of anus. 
 
 simple puncture, followed by the careful introduction of a well-oiled 
 finger, will be a sufficient operative interference, especially if after- 
 ward the extremity of a suitable 
 sized rectal bougie be occasionally 
 introduced. If the membrane be 
 of sufficient density to interpose an 
 obstacle after its division, it should 
 be trimmed away, care being taken 
 to not include the proper structure 
 of the opening. 
 
 Absence of the Anus (Fig. 619). 
 In this deformity all trace of the 
 opening is absent ; and the median 
 raphe may extend continuously from 
 the scrotum to the tip of the coc- 
 cyx. The fibro-cellular interval may 
 be thin or of extreme thickness. If 
 thin, the previously detailed signs 
 of imperforate anus may be evident. 
 
 If they be not present, the occlusion is then of considerable thickness, 
 and may even involve the entire length of the rectum itself. 
 
 The operation for its relief consists in first placing the patient, 
 properly anaesthetized, in the dorsal position. Then introduce a sound 
 into the bladder, if the patient be a male, into the vagina if a female, 
 and make a vertical incision in the median line from just behind the 
 scrotum or vagina to the tip of the coccyx, continue it cautiously 
 upward and backward, shortening each succeeding cut, and carefully 
 feel for the fluctuating extremity of the gut. It is sometimes located 
 posterior to the central line and must be sought for near the hollow of 
 the sacrum. During the entire progress of the dissection the situation 
 of the vagina or urethra must be marked by the location of the sound 
 previously introduced. When the dark-brown, fluctuating extremity 
 of the gut is detected, the introduction of a hypodermic needle will 
 settle all doubt. The gut-end should then be seized by a pair of strong 
 toothed forceps (Fig. 620), and drawn firmly downward, while its con- 
 nections with the surrounding tissues are separated by the scissors and 
 fingers. As soon as the cul-de-sac is drawn down to a level with the 
 external opening, pass two short ligatures transversely through the 
 sides of the wound, one through its anterior and one through its pos- 
 terior portion, transfixing the anterior and posterior portions of the 
 bowel in their passage. Protect the raw surfaces with lint saturated 
 with carbolized oil, then open the sac between the ligatures and allow 
 its contents to escape ; after having thoroughly cleansed it, remove the 
 lint, draw the ligatures through the opening in the bowel by means of 
 a hook, cut and tie them, as in the operation for lumbar colotomy.
 
 404 
 
 OPERATIVE SURGERY. 
 
 The mucous membrane should be closely adjusted to the integument, 
 in order to secure perfect union and prevent the contact of the raw 
 
 FIG. 620. Byrne's rectal forceps. 
 
 surfaces with the discharges. If it be impossible to draw the end of 
 the gut down to the external opening, it can be incised at its lower 
 extremity, and the discharges allowed to escape over the lower sur- 
 faces, which are kept opened by the use of the bougies ; or, the coc- 
 cyx can be removed, as recommended by Verneuil, and the extremity 
 of the bowel drawn through the gap and united to the integument as 
 before. 
 
 Fistula in Ano, A fistula here, as elsewhere, is a sinus, which in 
 
 this case leads into the cavity of an ab- 
 scess located near to the rectum. It 
 may be either complete or incomplete ; 
 if of the latter variety, it may be an in- 
 complete internal or external fistula 
 (Fig. 621). The complete form is the 
 most frequent. In the case of a sus- 
 pected fistula, before making an exami- 
 nation evacuate the bowel by a cathartic 
 and an enema ; place the patient on the 
 back or side, and introduce the well- 
 oiled index-finger of the hand corre- 
 sponding to the side of the patient pre- 
 senting the external opening. The end 
 of the finger will often detect a nipple- 
 like projection in the bowel, indicating 
 the internal opening. If a flexible probe 
 be then introduced through the external opening, it can with a little 
 care be carried into the lumen of the rectum (Fig. 622). Sometimes, 
 
 FIG. 621. .4, R. Anus and rectum. 
 B. Complete fistula. C. Incom- 
 plete internal fistula. D. Incom- 
 plete external fistula.
 
 OPERATIONS ON THE ANUS AND RECTUM. 
 
 405 
 
 however, the end of the probe will be felt separated from the finger by 
 only the thin mucous lining of the gut ; this may be due to the inabil- 
 ity to find the internal opening, or to its non-existence. In either case 
 the thin wall should be 
 perforated by the instru- 
 ment, thus producing a 
 complete fistula. It not 
 infrequently happens that 
 more than one opening, E, 
 F, communicates with the 
 original abscess (Fig. 623, 
 D), and also that the mu- 
 cous membrane is under- 
 mined to a considerable ex- 
 tent above a previously ex- 
 isting abscess (Fig. 624, A). 
 It is of importance to re- 
 member that the introduc- 
 tion of the finger and the 
 probe often produces such a 
 degree of contraction of the 
 sphincter as to prevent the 
 passage of the probe with- 
 out great difficulty along 
 the sinus into the gut ; therefore the attempt to pass it should not 
 be made until the muscular contraction ceases. It may be advisa- 
 ble to paralyze the 
 sphincter by over- 
 distention before di- 
 viding the sinus ; 
 this causes the parts 
 to remain at rest, 
 adding to the com- 
 fort of the patient 
 and hastening re- 
 covery. It can be 
 accomplished by in- 
 serting the thumbs 
 through the anus 
 back to back, flexing 
 the first joints and 
 FIGS. 623, 624. Variations of fistula in ano. withdrawing them, 
 
 or by the use of a 
 speculum designed for that additional purpose (Fig. 625). 
 
 The accepted method of treatment, namely, that of laying open 
 
 FIG. 622. Probing a fistula.
 
 406 
 
 OPERATIVE SURGEEY. 
 
 the sinus, can be practiced by 
 direct incision, by ligature, or 
 by the galvano-cautery. The 
 first method is the one most 
 commonly employed. For this 
 purpose the bowel should be 
 thoroughly evacuated by a brisk 
 cathartic on the day preceding 
 the operation, and be followed 
 by light diet. On the day of 
 the operation it should be thor- 
 oughly cleansed by one or two 
 copious enemata. 
 
 Operation by Direct Incis- 
 ion. Place the patient on the 
 back, give an anaesthetic, pass 
 the finger into the bowel as be- 
 fore described, introduce a grooved director through the sinus into 
 the bowel ; if the end can be turned out (Fig. 626), then divide the 
 sinus upon it ; if not, press it against the finger, and pass a probe- 
 pointed bistoury along the groove into the bowel ; after which, the 
 director may be withdrawn, the point of the bistoury pressed against 
 the finger (Fig. 627), and the sinus cut outward with the point thus 
 protected. The finger may be replaced by a wooden director intro- 
 duced into the bowel, and the division made upon it (Fig. 628). The 
 
 FIG. 625. Thebaud's dilating speculum. 
 
 FIGS. 626, 627, 628. Dividing fistulas. 
 
 scissors may be employed instead of the knife, either with or without 
 the grooved director (Fig. 629). Whenever the depth of the sinus de- 
 mands the division of the entire thickness of the internal sphincter, 
 it should be done at right angles with the course of the fibers, to 
 avoid, as far as possible, the danger of incontinence of flatus and fasces. 
 While each sinus should be opened, still, when possible to avoid 
 it, the sphincter should be divided in but one situation, in order that 
 its integrity can be the better restored ; and, when practicable, a small 
 portion of the circular fibers should be preserved with the same object
 
 OPERATIONS ON THE ANUS AND EECTUM. 
 
 407 
 
 FIG. 629. Allingham's scissors and director. 
 
 in view. It is not necessary to divide the walls of the abscess above 
 the opening into the gut, since the drainage and loss of power due to 
 the division of the tissues below permits a rapid 
 healing of this portion. As soon as the sinuses 
 are opened, their pseudo-membranous linings can 
 be scraped or touched with a thermo-cautery, all 
 hemorrhage stopped, the cut packed with oakum, 
 marine lint, or iodoformized gauze, a T-bandage 
 applied, patient placed in bed with limbs ex- 
 tended, and morphia or opium freely given to re- 
 lieve all irritation and to produce constipation of 
 the bowels. The food should be light, and not of 
 a nature likely to leave a residue. In ten days or 
 two weeks make use of a mild cathartic in con- 
 junction with a copious enema. 
 
 Incision with Closure. If the extent of the 
 sinus will permit it, the entire track may be re- 
 moved and the resulting wound closed by catgut 
 sutures, carried deep enough to bring the walls of 
 the wound in contact. Two sets of sutures may 
 be employed ; one, a superficial set, which shall 
 bring the borders of the mucous membrane to- 
 gether, while the second should unite the deeper 
 structures. In this manner union by first inten- 
 tion may be secured, thus shortening the period 
 of recovery and obviating all danger of fecal incon- 
 tinence dependent upon the incomplete closure, 
 which sometimes occurs when the cut is deep and 
 is permitted to heal from the bottom. If, how- 
 ever, there be a cavity at the upper end of the si- 
 nus, or if any portion of the track be not dissected 
 out, the recovery by rapid healing will be retarded 
 if not entirely prevented. FIG 630 ._ Allingham , 8 
 
 Treatment oy Ligaturing. The elastic hga- ligature-carrier.
 
 408 OPERATIVE SURGERY. 
 
 ture is the only one worthy of consideration. It consists of a rubber 
 cord about one tenth of an inch in diameter. This is carried through 
 the sinus into the gut by an appropriate instrument (Fig. 630), the 
 inner extremity drawn out through the anus and tied, after any integ- 
 ument which might be included in its grasp has been divided, to pre- 
 vent the pain and delay incident to the division of its peculiar struct- 
 ure. A strong silk thread can be substituted for the more elaborate 
 apparatus shown in Fig. 630. This, after being passed through the 
 sinus and attached to the rubber cord, can be employed to carry it 
 into position. It is sometimes difficult to tie a knot in the rubber 
 cord securely. Still, this can be accomplished easily by tying the first 
 half of the knot over a silk ligature placed at right angles to the 
 course of the elastic one, and then tying the silk ligature firmly around 
 the half-knot. This holds the elastic cord securely while the knot is 
 completed. The elastic ligature will cut its way through in six or 
 eight days. 
 
 This method possesses some advantages over that by incision, 
 among which may be noted that, in simple cases, little or no pain is 
 inflicted, and the patient can walk out-doors without any especial 
 danger. 
 
 Nervous persons will often submit to it when they will not to the 
 knife. There is no bleeding, which is of advantage when the larger 
 vessels may be implicated, or when an undue tendency to hemorrhage 
 exists. It is the best method in phthisical patients, for manifest 
 reasons. It can be employed in all cases where but a single sinus 
 exists ; if, however, a second be present, the result must of necessity 
 be unsatisfactory, as this involves a repetition of the operation or the 
 use of the knife. 
 
 The galvano-cautery does not secure better results than incision, 
 and is much more cumbersome in its application ; still, it is useful 
 when dangerous hemorrhage is apprehended. 
 
 Surgical Anatomy of the Rectum. The length of the rectum is 
 from six to eight inches, the latter being the length of advanced life. 
 It has various curves. The first, an inch and a half in length, extends 
 from the anus to near the prostate, and is directed upward and for- 
 ward, a fact which should be remembered in the introduction of 
 instruments. The second portion follows the curve of the sacrum, 
 and is about three inches in length ; the greater portion of this is 
 covered by peritoneum, it being reflected upon it at a point about two 
 and one half inches above the anus in front, and about five inches 
 behind, when the bladder and rectum are empty ; if filled, the dis- 
 tance is increased about an inch. The anterior surface of the lower 
 part of this portion is intimately associated with the base of the blad- 
 der, vesiculas seminales, and prostate body in the male. In the female 
 the posterior wall of the vagina is in front. The third curve extends
 
 OPERATIONS ON THE ANUS AND RECTUM. 409 
 
 from the middle of the third piece of the sacrum to the left sacro- 
 iliac synchondrosis. This portion is almost entirely surrounded by 
 serous membrane. The vessels having surgical associations with the 
 rectum are the superior, middle, and inferior hemorrhoidal arteries. 
 The first is the most important ; it runs between the rectum and the 
 sacrum, a little to the left of the median line, to within about four or 
 four and a half inches of the anus. Its branches run parallel with 
 the long axis of the bowel down to the anus, and can be best avoided 
 by longitudinal incisions. 
 
 For a rectal examination the patient is placed in one of the many 
 positions previously cited. The bowel should be thoroughly emptied 
 and cleansed prior to the attempt. One or two fingers, or even the 
 whole hand, may be introduced, or the tube may be inspected through 
 the various forms of specula. 
 
 If the examination is made with the index-finger, it should be well 
 oiled and inserted with a semi-rotary motion, allowing the remaining 
 fingers to lie in the median line between the buttocks. In this man- 
 ner, by the use of moderate force, the lower four or five inches of the 
 organ may be examined. The introduction of the middle finger along 
 with the index-finger will somewhat increase the range of examina- 
 tion, especially if the patient be requested to bear down. 
 
 The introduction of the whole hand must be done with great cau- 
 tion in order not to lacerate the bowel or the peritoneum enveloping it. 
 For this purpose the patient is placed upon the back, anesthetized, 
 bladder emptied, and the services of a person with a small hand, not 
 exceeding eight inches in circumference, are enlisted. The hand 
 should be well oiled, and a conical form given to it by applying the 
 thumb to the palmar surface of the approximated fingers., The tips 
 of the fingers are then inserted by a semi-rotary motion, which is 
 slowly continued until the whole hand enters the bowel. After the 
 entrance of the hand, the fingers are to be moved in various direc- 
 tions to ascertain the caliber of the gut, and, at the same time, favor 
 the circulation of the imprisoned hand. 
 
 If the hand meets a narrowing of the bowel at a distance of three or 
 four inches above the anus, but little force should be used, as the peri- 
 toneum, which is connected with the gut in this situation and is the 
 cause of the narrowing, may be ruptured. If the hand be small, it 
 not unfrequently happens that the sigmoid flexure may be passed, the 
 descending colon entered, and the kidneys, uterus, and great vessels 
 may be examined through it. It is, however, extremely fatiguing to 
 the examiner ; still, the discomfort experienced should not lead the 
 surgeon to relax in the least the degree of caution necessary to the 
 safety of the patient. 
 
 Prolapsus Ani. Prolapsus ani occurs in two distinct varieties : 
 first, as a partial or complete prolapse of the mucous membrane alone
 
 410 
 
 OPERATIVE SURGERY. 
 
 (Fig. 631) ; second, as a prolapsus implicating the deeper tissues, often 
 attended by invagination (Fig. 632). The aims in the operative treat- 
 
 FIG. 631. Prolapsus ani. 
 
 FIG. 632. Prolapse with invagination. 
 
 ment of the former consist in producing adhesions of the mucous 
 membrane to the tissues beneath it, and a narrowing of the orifice of 
 the anus by stimulating the function of the sphincter. The adhe- 
 sions may be established by clamping and destroying isolated portions 
 of the mucous membrane, or by removing similar portions of it by 
 the ligature or the galvano-cautery. If piles be present, they should 
 be ligaturqd, as this will alone often effect a cure. The application 
 of Paquelin's cautery, longitudinally or at isolated points, to the pro- 
 lapsed part, after its return, is an excellent method of procedure, and 
 this, when combined with rest in the horizontal position and the pro- 
 duction of fluid evacuations, as adjuvants to the treatment, will usually 
 effect a speedy and satisfactory cure. 
 
 Operation. The patient must be anaesthetized, placed in the knee- 
 elbow position, the prolapse reduced, and the parts exposed by the 
 Sims' speculum. Then four or five longitudinal stripes about three 
 inches in length are made with the point of a cautery at a dull-red 
 heat, at equal intervals apart, and terminating externally at the border 
 of the true skin. The number, size, and depth of the eschars made 
 will depend on the age of the patient and the severity of the case. In 
 the infant, two or three a line or two in width may be sufficient. The 
 older the patient and the severer the case, the deeper should be the 
 eschars. The possibility of reanimating the sphincter is somewhat 
 uncertain, yet the medical expedients directed to the restoration of 
 paralyzed muscles may be employed with some success. The anus
 
 OPERATIONS OX THE ANUS AND RECTUM. 
 
 411 
 
 may be narrowed by removing elliptical-sh'aped pieces from the mu- 
 cous membrane and uniting their raw surfaces ; and also, by linear 
 eschars made in a manner similar to that for prolapsus ani. 
 
 Expedients of this kind, while they frequently fail of curing, gen- 
 erally give marked relief to the patient. 
 
 The second or complete variety of prolapse exists in three forms : 
 1. In which the external surface is devoid of a sulcus ; in this, the 
 prolapse follows as the result of the continuous traction exerted by 
 long-standing prolapse of the^mucous membrane. Peritoneum exists 
 in the tumor, and sometimes also a loop of intestine (Fig. 633). 2. 
 In which a sulcus exists at the 
 base of the tumor, at the bot- 
 tom of which the lining mem- 
 brane of the gut can be felt as 
 it is reflected from the invagi- 
 nated protrusion. 3. In which 
 the finger, when introduced 
 into the anus beside the tu- 
 mor, fails to detect any evi- 
 dence of the reflection of the 
 mucous membrane of the rec- 
 tum upon the tumor, because 
 the imagination is extensive, 
 involving the colon, caput coli, 
 and sometimes the ileum it- 
 self. 
 
 All three varieties must 
 first be reduced ; sometimes 
 this is accomplished with great 
 difficulty, especially when an 
 acute case is complicated with 
 evidences of strangulation of 
 the protruding portion. 
 
 Place the patient in the 
 knee-elbow position, and endeavor carefully to return the part first 
 which escaped last, and, if necessary, the external sphincter can be 
 divided. If this fail, renew the effort by reducing the part first that 
 escaped first. If the case be a severe one, the mucous membrane of 
 the protrusion can be painted with a solution of cocaine, and even an 
 anaesthetic may be given. To the treatment of the third variety of 
 prolapse must be added the copious injection into the bowel of fluids 
 or gases, the introduction of the hand, etc. 
 
 The after-treatment of the first two forms of the second variety 
 is substantially the same as that for the first variety, except it should 
 be more vigorously and persistently applied, and the patient be con- 
 
 CSP 
 
 FIG. 633. Complete prolapse, with peritoneum. 
 R. Rectum. B. Bladder. S. Sacrum. P. 
 Tubes. U. Uterus. V. Vagina. CSP, 
 Cavity of the peritoneal sac.
 
 412 OPERATIVE SURGERY. 
 
 fined to the recumbent position and be required to use a bed-pan. 
 It is not advisable in any of the forms of prolapse to resort to the 
 direct removal of the protruding portion by means of the knife or 
 ligature until all other methods have been faithfully tried and have 
 failed. 
 
 In the third form of the second variety the question of laparotomy 
 must be considered ; and the answer to the question as to whether it 
 should be performed or not, will depend largely on the symptoms and 
 conditions of the case. Its early performance, however, improves the 
 prognosis for recovery. 
 
 Cancer of the Rectum. Excision of the rectum and colotomy are 
 the only operative measures of radical importance employed in this 
 disease. 
 
 Rectotomy, or External Proctotomy. Place the patient in the 
 lithotomy position, empty the bladder, expose the posterior wall of 
 the rectum by a Sims' speculum, and, with the Paquelin cautery, or 
 with a knife, make an incision through the diseased mass at the pos- 
 terior aspect of the gut, about four inches in length, carrying it 
 downward through the sphincters. The ecraseur may be employed, 
 introducing the chain by means of a trocar passed from the tip of the 
 coccyx upward behind the mass, thence into the gut, and dividing the 
 included structures slowly. Rectotomy is only a palliative measure, 
 enabling the bowel to discharge its contents more readily and with less 
 pain. lodoformized dressings, combined with frequent cleansing, 
 comprise the local after-treatment. 
 
 Excision of the Rectum. Excision of the rectum, either as a cura- 
 tive or a palliative measure, is, at the present time, a generally accepted 
 surgical procedure. It can be stated as a conservative precept, how- 
 ever, that if the upper limit of the growth can not be easily reached 
 with the index-finger, its removal should not be contemplated, owing 
 to the contiguity of the peritoneum. Still, even under these circum- 
 stances, if the mucous membrane be involved alone, the diseased 
 structure can be stripped off without entering the peritoneal cavity. 
 If contiguous viscera be involved, or the pelvic lymphatic glands be 
 enlarged, the expediency of the operation is decidedly questionable. 
 Prior to the operation the entire length of the intestinal tract should 
 be thoroughly evacuated, and the rectum cleansed by antiseptic ene- 
 mata. A large antiseptic sponge, with a string attached, is then 
 pushed up the bowel beyond the disease, to prevent soiling the opera- 
 tion field. The bladder is emptied, and a sound carried into it to 
 guide the operator in making the anterior dissections. An anaesthetic 
 is administered with the patient in the dorsal position, after which the 
 position may be changed to conform to the convenience of the opera- 
 tor. The entire operation should be conducted with strict antiseptic 
 precautions.
 
 OPERATIONS ON THE ANUS AND RECTUM. 413 
 
 Volkmanri's Method. This surgeon has described three different 
 operations, intended to meet as many different phases of the disease : 
 
 1. For Removal of a Circumscribed Growth. Dilate the anus, 
 pull down the diseased portion, and remove it by an incision so di- 
 rected that when closed the caliber of the bowel will be diminished as 
 little as possible. If the sphincter have been involved, its fibers should 
 be united after the removal of the growth, and deep drainage provided. 
 If the growth be above the sphincter, after uniting the borders of 
 the wound, deep drainage must be made by allowing the tube to pass 
 through or beneath the sphincter. 
 
 2. For Removal of a Growth involving the Circumference of the 
 Boivel, but not the Anus. Divide the anus forward into the perineum 
 and backward to the tip of the coccyx, the latter incision extending 
 to the lower limit of the disease. The morbid growth is dissected 
 out by means of the knife, scissors, fingers, etc. ; the healthy mucous 
 membrane above is carefully stitched to that below, and deep drain- 
 age is provided behind and in front, and the antero-posterior prelimi- 
 nary incisions are carefully closed. 
 
 3. For Removal when the Disease involves the Circumference of 
 the Bowel, and Part of or the Entire Anus. Make the preliminary in- 
 cisions as in the second class, and carry a circular incision around the 
 anus, outside of the sphincter, from which the dissection is carried 
 upward parallel with the gut to the upper limits of the morbid growth, 
 which is drawn down, the healthy mucous membrane above it stitched 
 to the cutaneous border, and the disease removed. Deep drainage is 
 then provided, the parts are carefully united, and the wound tam- 
 poned with iodoform gauze. If, in case the structure of the bowel is 
 to be cut transversely, as when the morbid growth is being completely 
 separated, the healthy portion be transfixed and tied by several catgut 
 ligatures before the final separation, all danger of hemorrhage from 
 this source is avoided. 
 
 Lately, Volkmann has recommended the entire removal of the exter- 
 nal sphincter, whether it be diseased or not, as he believes the growth 
 is less liable to return than when it is left. If it be found difficult to 
 draw down the mucous membrane of the bowel sufficiently to readily 
 unite it to the external cutaneous opening, it should be permitted to 
 remain above, and the exposed surfaces below it sprinkled with iodo- 
 form or naphthaline, and packed around with antiseptic gauze. A 
 tube of suitable size to discharge flatus and even fecal matter may be 
 then passed up and confined in position. By these simple expedients 
 the raw surfaces may be kept quite clean. 
 
 The prostate, and even the base of the bladder, have been removed 
 in conjunction with the diseased rectal tissue, but there is little, if 
 anything, to be said in support of this measure. 
 
 Cripp's Method. Make the posterior incision by passing a curved
 
 414 
 
 OPERATIVE SURGERY. 
 
 bistoury into the rectum and bringing its point out at the tip of the 
 coccyx, cutting all the intervening tissue. Separate the parts suffi- 
 ciently to put the tissue on the stretch, and make lateral incisions 
 from the posterior cut around to the median line in front, on each 
 side, either without or within the anus, according to the location of 
 the disease. These cuts should reach into the ischio-rectal fossae, and 
 each one be completed in its turn. The dissection is carried above 
 the point of the disease in the usual manner, the bowel drawn down- 
 ward, and the morbid growth removed with an eeraseur. 
 
 Maisonneuve* s Method. A circular incision is made around the 
 anus, through the integument and subcutaneous tissue, and a long, 
 strong needle, bearing at its point a ligature one foot in length, is 
 passed upward through the external incision outside the bowel into 
 the gut above the growth. The loop of the ligature is seized at the 
 eye of the needle and drawn out of the anus, while the needle retraces 
 its course, thus depositing a double uncut ligature, one end hanging 
 by the anus, the other lying in the primary incision. A sufficient 
 number of ligatures are thus deposited, at equal distances from each 
 other, to include the entire circumference of the gut. A strong 
 whipcord, about six feet in length, is now passed through the loops 
 hanging from the anus, leaving an interval of about ten inches be- 
 tween each loop. The ligatures are then drawn outward by seizing 
 the extremities in the external cut, thereby drawing the whipcord 
 through the openings made in the bowel by the receding ligatures. 
 Each loop of the whipcord is allotted in turn to an Eeraseur, and the 
 portion of the rectum included by it is cut through. 
 
 Results. The rate of mortality following this operation is from 
 twenty to twenty-five per cent. The operation is a proper one, under 
 
 favorable conditions, and will pro- 
 long the life of eighty per cent of 
 the patients, and effect a cure in a 
 small proportion of them. 
 
 Stricture of the Rectum. Ordi- 
 narily a stricture of the rectum is 
 treated upon substantially the same 
 principles as a stricture of the ure- 
 thra : the repeated use of rectal 
 bougies passed in the direction of 
 its curvatures ; nicking its edges 
 with a probe-pointed knife ; divul- 
 sion, elastic distention, rectotomy, 
 and, finally, if the stricture be high 
 up, colotomy. 
 
 Imperforate Rectum (Fig. 634). 
 FIG. 634. imperf orate rectum. This form of occlusion varies in
 
 OPERATIONS ON THE ANUS AND RECTUM. 
 
 415 
 
 thickness, and is usually situated within half an inch of the anus, 
 
 which is normal. If the structure be thin, it will be influenced by 
 
 the emotions of the 
 
 child and depressed by 
 
 the superimposed fecal 
 
 accumulations. 
 
 Operation. A radi- 
 ating incision, with its 
 center corresponding to 
 that of the obstruction, 
 can be made through 
 the tissues, the contents 
 of the gut evacuated, 
 the flaps trimmed off, 
 and the opening main- 
 tained by the occasional 
 introduction of a well- 
 oiled bougie. Some- 
 times the occlusion is 
 so thick as to raise the 
 question as to the pres- 
 ence or absence of the 
 gut above. The sig- 
 moid flexure may term- 
 inate in a blind point, 
 while the rectum below 
 is marked by an impervious cord (Fig. 635). An attempt should 
 always be made to find the blind extremity, which is done by intro- 
 ducing a sound into the bladder and carefully seeking, by aid of the 
 scissors and finger, for the cul-de-sac above. In doing this, the 
 established relation which the rectum bears to the curve of the sa- 
 crum must be carefully regarded, and the fibrous trace of the rectum 
 sought after. If the abdomen of the patient be pressed upon, any 
 existing tumor above will be made more distinct and tense. If the 
 cul-de-sac be found, the diagnosis should be still further strength- 
 ened by exploring it by means of a hypodermic syringe or a small 
 aspirating needle carried into its posterior aspect. If fecal matter 
 or offensive gases be detected, the blind extremity of the gut is drawn 
 carefully downward toward the external opening, and held in this 
 position by forceps or by a loop of thread passed through its apex 
 while it is opened carefully, the incision into it being guided by the 
 exploring needle, which is allowed to remain for that purpose. After 
 the contents are evacuated and the parts are thoroughly cleansed, 
 a sponge with a string attached to it is pushed up the bowel to 
 prevent any further escape of fecal matter while the extremity of 
 
 FIG. 635. Rectum ending in blind pouch.
 
 416 
 
 OPERATIVE SURGERY. 
 
 the bowel is being sewed to the surface below if practicable, to the 
 cutaneous border. When this step is impracticable, the after-treat- 
 ment should be the same as that following excision of the rectum. 
 If the extremity of the bowel be not found, colotomy must be per- 
 formed. Not infrequently the rectum communicates with the bladder, 
 and even the glans penis, conditions which are determined by the fecal 
 character of the urine. In these cases the bowel should be sought 
 for, and, when found, drawn down and stitched as before, and the 
 fecal canal kept open by the frequent introduction of a well-greased 
 finger or a suitable bougie. The fistulous openings are closed with 
 catgut, suitable drainage provided, and the contents of the bladder 
 evacuated at short intervals, to prevent its distention during the heal- 
 ing process. 
 
 CHAPTEK XVI. 
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 THE cavity of the bladder may be explored by catheters, sounds, 
 
 and searchers ; its outer surface by rectal and abdominal palpation. 
 
 Catheters can be practically divided into the soft rubber, silk, gum- 
 
 FIG. 636. Mcrcier's 
 double elbowed 
 catheter. 
 
 FIG. 637. Mcrcier's 
 elbowed catheter. 
 
 FIG. 638. Self-re- 
 taining catheter. 
 
 FIG. 639. Holt's 
 self-retaining 
 catheter. 
 
 elastic, and metal varieties. The first two varieties are extremely flex- 
 ible, and are most innocent instruments in the clumsiest hands (Figs.
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 417 
 
 636, 637, 638, 639, 642, and 643). It is sometimes necessary that a soft 
 rubber catheter be provided with a guide in order to properly direct it 
 as well as to overcome any slight impediment in its course (Figs. 640 
 
 and 641). The gum-elastic and 
 metal instruments are too fa- 
 miliar to all to require a de- 
 scription, except such of them 
 as have been especially modified 
 for distinct purposes. 
 
 Introduction of a Catheter or 
 Sound into the Bladder. Select 
 an instrument of a suitable 
 curve and size ; place the pa- 
 tient on the back, with the 
 shoulders somewhat raised, and 
 the thighs slightly flexed on the 
 abdomen, and rotated outward 
 to relax the abdominal muscles ; 
 warm and smear the instrument 
 
 
 
 FIG. 640. FIG. 641. Otis' 
 
 Keyes' catheter-guide, 
 catheter- 
 guide. 
 
 FIG. 642. Oli- 
 vary gum cath- 
 eter. 
 
 FIG. 643. Velvet-eye catheter. 
 
 with oil or vaseline ; stand on the left side of the patient ; grasp the 
 penis with the middle and ring fingers of the left hand and raise it 
 vertically. The catheter or sound is then taken lightly between the 
 thumb, index, and middle fingers of the right hand and introduced 
 into the meatus, held open by the left index-finger and thumb. The 
 instrument and penis should now be carried close to the body in the 
 27
 
 418 
 
 OPERATIVE SURGERY. 
 
 line of the groin. The penis is then gently drawn over the instru- 
 ment, which at the same time is carefully pushed, or allowed to enter 
 by its own weight, into the canal. After about five inches of the 
 instrument have disappeared, the outer extremity should be carried 
 toward the median line of the body of the patient and elevated 
 slowly to a vertical position, when its weight will usually cause 
 the advancing end to pass beneath the pubes (Fig. 644), after which 
 the upper extremity is depressed between the thighs, causing the 
 point to enter the bladder (Fig. 645). Not infrequently the end 
 
 FIG. 644. Passing catheter. 
 
 will hitch upon the triangular ligament as it passes beneath the 
 arch of the pubes. This can be obviated by raising the point of 
 the instrument at this situation by the finger pressed firmly against 
 the median line of the perineum, accompanied by upward traction 
 as the point is being advanced ; in a word, causing the instrument 
 to hug the roof instead of the floor of the canal. The beginner is 
 apt to carry the handle of the instrument between the thighs too 
 soon, causing the beak to be reversed in front of the pubes. Un-
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 419 
 
 der no consideration must violence be employed in introducing a 
 catheter, ars non vis being an almost traditional axiom in this con- 
 nection. The surgeon should always follow the advancing end of the 
 instrument with the mind's eye, aiming to keep it in the axis of the 
 urethral curve. The first approach of the instrument to the perineal 
 
 FIG. 645. Catheter entering bladder. 
 
 portion of the urethra not infrequently causes a contraction of the 
 muscles of this region, which interposes an effectual temporary obsta- 
 cle to its advancement. If, however, the patient's attention be en- 
 gaged in conversation or otherwise diverted from the procedure, while 
 at the same time the end of the instrument is pressed continuously 
 and carefully against the obstacle, it will soon give way and enter the 
 bladder without further trouble. If it be a catheter, the flow of urine 
 usually announces its entrance into the bladder. However, if the eye 
 of the catheter be obstructed, or a sound be introduced, the exact 
 situation of the instrument may be determined by rotating it on its 
 long axis ; when, if the beak be in the viscus, its extremity will 
 describe the arc of a circle around its shaft as a center ; if not, then 
 the shaft will describe a circle around its beak. If the bladder be 
 empty or contracted, the impinging of the beak upon its walls may 
 deceive the beginner and also cause the patient much pain. The in- 
 troduction of the index-finger into the rectum will aid in guiding the 
 instrument into the bladder, and determine the fact of its entrance as 
 well. Hot fomentations to the abdomen, together with an anodyne 
 and a ten-grain dose of quinine, should be employed if a urethral 
 chill be feared. The injection into the urethra of a weak solution 
 of carbolic acid and oil after the passage of the sound is thought to 
 sometimes prevent urethral chills.
 
 420 OPERATIVE SURGERY. 
 
 Retention of Urine. Ketention of urine depends upon some ob- 
 struction to its egress, located at the neck of the bladder, or in the 
 course of the urethra ; also upon paralysis of the muscular coats of 
 the bladder, or upon both combined. 
 
 The indications are met by overcoming the obstruction or restoring 
 tone to the bladder. If the obstruction be due to stricture, and it be 
 permeable, catheterization will effect ready relief. It is important to 
 know, however, that the bladder should not be entirely emptied of its 
 contents, but that only a sufficient amount of urine should be drawn 
 to afford complete relief from all pain and tension. If it be completely 
 emptied, its walls will collapse from want of support, causing conges- 
 tion of its lining, and, in all probability, the catheter will be required 
 at the next attempt at urination. If but a third or a half of the con- 
 tents be withdrawn, the bladder will probably expel its contents 
 properly at the next act of micturition. If it be impossible to intro- 
 duce an ordinary catheter, even of a small size, recourse must then be 
 had to the filiform bougies (Fig. G46) or whalebone guides (Fig. 647). 
 
 FIG. 646. Filiform bougies. 
 
 The latter are more commonly employed. The patient is placed in 
 the dorsal position, an anaesthetic given, unless the bladder be much 
 distended as then there is danger of its rupturing during the strug- 
 gles of the patient. If anaesthesia be necessary under such a circum- 
 stance, it is advisable to relieve the bladder of some portion of the 
 fluid by supra-pubic aspiration. If one be not 
 x entirely familiar with the use of the whalebone 
 guides and the retention catheter, local or gen- 
 
 s^. eral anaesthesia is not advisable, as then the pa- 
 
 , tient's sensations can not be consulted, and great 
 
 _ .. harm might arise from their use. 
 
 Introduction of Whalebone Guides. The ure- 
 
 FIG. 647. Goulcy's , .. 
 
 whalebone guides. thra is forcibly filled with sweet-oil by means of 
 a syringe, and the end of the penis grasped to re- 
 tain it as long as possible, leaving sufficient room at the meatus 
 for the introduction of a whalebone guide. The guide is carefully 
 introduced, and if its point becomes engaged in a lacuna, it is with- 
 drawn a little and again carried onward with a rotary motion. If it 
 enters a false passage, it is allowed to remain there, while another 
 guide is passed by its side. If a second enters the false passage, it is 
 treated in a similar manner, and so on until four or six, or even more, 
 are contained in the canal, some of which have the spiral and others
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 421 
 
 the straight end foremost. Each one is then 
 taken separately and pressed onward with or 
 without the spiral twist, always remembering 
 to use no force, else the small points may 
 pierce the mucous membrane of the urethra, 
 or enter and perforate Cowper's ducts. As 
 soon as all the side openings are closed by the 
 extremities of the guides, one guide will be 
 found to have entered the stricture, and with 
 a little coaxing will pass into the bladder, 
 which is known by the painless ease with 
 which it can be moved in and out. The 
 others are then withdrawn, and the end of the 
 one remaining is passed through the eye of a 
 tunneled sound (Fig. 648), or, .what is better, 
 the tunneled catheter (Fig. 649). This guide 
 serves to direct the passage of the instrument 
 into the bladder, which should be done cau- 
 tiously, as the guide may be cut by the eye of 
 the instrument, causing it to double and lead 
 the end of the catheter astray. The instru- 
 ment is known to have entered the bladder if 
 urine 'flows from it, or if its innermost ex- 
 tremity can be turned from side to side. After 
 the requisite amount of urine is withdrawn, 
 a tunneled sound of larger size may be passed 
 in a similar manner as the catheter, after 
 which the guide can be taken out and an 
 ordinary steel sound of small size carefully 
 introduced to insure a channel of sufficient 
 capacity to admit the ready entrance of an 
 instrument thereafter. 
 
 Aspiration of the Bladder. The contents 
 of the bladder can be removed by aspiration 
 by introducing the aspirating needle into it 
 above the pubes, at the point indicated for the 
 
 passage of a trocar (Fig. 657). This, however, is a temporary measure 
 only. The same can be said of tapping per rectum. These are 
 important expedients to enable the surgeon to gain time for the 
 
 performance of 
 g^^^.-fl external perineal 
 
 urethrotomy. 
 Rupture of 
 
 the Bladder 
 
 FIG. 649. Gouley's tunneled catheter and guide. Rupture OCCUrs 
 
 FIG. 648. Gouley's tunneled 
 sound.
 
 422 OPERATIVE SURGERY. 
 
 most frequently on the posterior surface, involving the peritoneum, 
 and allowing the urine to escape into the abdominal cavity. When 
 the rupture occurs anteriorly, the extravasated urine infiltrates the 
 perineum and the anterior walls of the abdomen. 
 
 Free incisions to relieve the extravasation and the performance of 
 cystotomy, together with the opening of the abdomen in the median 
 line laparotomy to remove the urine contained in its cavity, are the 
 practical operative procedures. 
 
 Cystotomy. This operation consists in opening into the bladder 
 through the median line of the perineum, as in the median operation 
 for stone. Place the patient on the back, evacuate the rectum, intro- 
 duce a grooved staff into the bladder, and with a sharp knife make an 
 incision in the median line about two inches in length, terminating 
 about half an inch in front of the anus ; by repeated applications of 
 the knife the staff is reached and the membranous urethra opened 
 backward to the apex of the prostate. Introduce a small probe into 
 the bladder by way of the groove in the staff, withdraw the staff cau- 
 tiously, introduce the index-finger into the bladder along the probe as 
 a guide, and distend the neck of the bladder sufficiently to cause the 
 urine to escape as fast as it flows into the bladder. The prostatic 
 structure must be well dilated, else it will soon return to its normal 
 condition and require a repetition of the dilating process. The pros- 
 tate may be incised on either one or both sides, as in lateral and bi- 
 lateral lithotomy ; it is necessary to do so to maintain the patency of the 
 opening for any length of time. Cystotomy is now quite frequently 
 performed as an ultimate expedient in obstinate cystitis in both sexes. 
 In the female the incision is made into the bladder through the 
 vagina. 
 
 Prognosis. The operation implies about the same danger to life 
 as the median operation for stone in the bladder. 
 
 Digital Exploration of the Bladder. This procedure is resorted 
 to for the purpose of detecting encysted calculi, polypoid and other 
 morbid growths, and to settle many vexatious questions relative to 
 the bladder cavity. It must of necessity be preceded by a prelimi- 
 nary cystotomy. 
 
 In order to properly accomplish the purposes of an exploration, 
 anaesthesia to complete muscular relaxation is essential ; the finger-tip 
 must enter the bladder, which should be empty and be depressed by 
 supra-pubic pressure. 
 
 Instruments such as forceps, scoops, curettes, etc., of various sizes 
 and patterns, can then be introduced into the organ to remove the 
 offending agent. 
 
 After the operation the bladder is washed out, and a large-sized cath- 
 eter is introduced through its neck to drain it of its contents for four 
 or five days, and the occurrence of hemorrhage carefully watched for.
 
 OPERATIONS OX THE URINARY BLADDER. 
 
 423 
 
 Prognosis. The digital exploration of the bladder of itself im- 
 plies no especial danger to the patient if the kidneys be sound, but 
 cystotomy and removal of morbid growths, especially of a villous char- 
 acter, by crushing or curetting, may, in the latter, give rise to severe 
 if not fatal hemorrhage, or cause death from blood-poisoning. This 
 operation is reported to have been performed frequently, but the re- 
 sults are not sufficiently definite to enable one to estimate a percent- 
 age, although they are such as to establish the entire justice of the 
 measure in severe cases. 
 
 Extroversion of the Bladder. In extroversion of the bladder the 
 anterior wall of the bladder and abdominal parietes are absent, while 
 the posterior and inferior portion of the bladder protrudes through 
 the opening in the abdominal wall on account of the pressure of the 
 viscera behind it. Various measures have been attempted to establish 
 a more feasible channel for the escape of urine, none of which, how- 
 ever, have afforded any practical benefit. Mr. Simon made an at- 
 tempt to connect the ureters with the rectum, but with indifferent 
 success. Floyd and 
 Johnson attempted 
 to establish a fistu- 
 lous communication 
 between the bladder 
 and rectum by 
 means of setons, 
 but the patient died 
 shortly after from 
 peritonitis. The 
 methods by auto- 
 plasty are the most 
 rational, and have 
 in many instances 
 afforded substantial 
 relief. 
 
 Dr. F. F. Mau- 
 ry's Operation. 
 Make a curvilinear incision, with the convexity upward, on each side, 
 extending from the outer third of Poupart's ligament downward and 
 inward below the scrotum to the middle of the perineum, at which 
 point they become joined (Fig. 650). This flap, 1, is dissected upward 
 over the scrotum to the root of the penis, which is slipped through a 
 valve-like incision made at its base, thus permitting the urine to 
 escape without coming in contact with the raw surfaces. A second 
 or abdominal flap is now raised transversely across the abdomen, ex- 
 tending upward from below the umbilicus. The lower flap, 1, is then 
 turned upward to bring its cutaneous surface in contact with the mu- 
 
 FIG. 650. Maury's operation.
 
 424 
 
 OPERATIVE SURGERY. 
 
 FIG. 651. Bijrelow's method. 
 
 cous surface of the bladder (Fig. 651, 2), and the cuticle is removed 
 from all portions of it that are to be placed in contact with freshened 
 
 surfaces. The edges 
 of the lower flap are 
 then beveled and car- 
 ried under the upper 
 flap, to which they are 
 united by catgut su- 
 tures. This method 
 offers the best results 
 in operations upon 
 males. Bigelow dis- 
 sected off the mucous 
 membrane of the ex- 
 posed bladder down to 
 a line with the ure- 
 ters, constructed lat- 
 eral flaps from each 
 inguinal region (Fig. 
 651, a, b), united them 
 in the median line and 
 above (Fig. 652), and thereby secured a perfect result. 
 
 Wood's Method (Fig. 653). This is best adapted to female subjects, 
 and consists in mak- 
 ing a central or um- 
 bilical flap, a, and 
 turning it down- 
 ward over the blad- 
 der, after which a 
 flap is made from 
 each groin, I, c, and 
 carried inward over 
 the everted central 
 one and united in 
 the median line to 
 the other (Fig. 654). 
 This arrangement 
 brings the integu- 
 mentary surface of 
 
 the central flap in contact with the mucous surface of the bladder, 
 and the raw surfaces of the central and lateral flaps are apposed ; the 
 uncovered raw surface above being allowed to heal by granulation. 
 
 Dr. Pancoast raised two flaps, one from each inguinal region, 
 joined them together in the median line, and allowed the raw external 
 surface to cicatrize. 
 
 FIG. 652. Bigelow's flaps united.
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 425 
 
 -Wood's method. 
 
 FIG. 654. Wood's method, 
 in position. 
 
 Flaps 
 
 Ayres covered the opening by turning down an umbilical flap with 
 its raw surface uppermost ; this surface, together with that from which 
 it was taken, was covered by two broad flaps dissected 
 from the abdomen at both sides, of sufficient width 
 to fill the gap when joined together in the median 
 line. 
 
 Results. Some fifty-five cases have been oper- 
 ated upon by one method or another, with the sat- 
 isfactory results of forty-three successful cases. Four 
 were failures, and eight fatal. 
 
 Puncturing the Bladder (Fig. 657). Puncturing 
 the bladder is done to relieve the organ from over- 
 distention. It can be done above or below the 
 pubes, and through the rectum. 
 
 It may be performed with the ordinary curved 
 trocar (Fig. 655), or with the aspirator, the latter be- 
 ing the safer and more satisfactory. 
 
 Above the Pubes (Fig. 657). Place the patient 
 
 FIG. 655. Rectum trocar. 
 
 FIG. 656. Buck's 
 rectum trocar.
 
 426 
 
 OPERATIVE SURGERY. 
 
 on the back ; outline the distended bladder by percussion ; explore 
 the tumor with a hypodermic needle if a doubt exists as to its nature. 
 
 FIG. 657. Puncturing the bladder. 
 
 Select a small straight or curved trocar, the latter being the better ; 
 make the skin tense about an inch above the pubis, and push the tro- 
 car through the median line with its convexity upward. An initia- 
 tory incision through the skin is often made with a sharp knife which 
 permits the easier entrance of the trocar. An injection of cocaine 
 may relieve the patient of the pain caused by the introduction of the 
 trocar. 
 
 Under the Pubes. If the bladder be small and shrunken behind 
 the pubes, or the prostate be too large to admit of the rectal puncture, 
 the penis can be pulled downward, and a small curved trocar, with the 
 concavity upward, passed just beneath the arch of the pubis into the 
 viscus. 
 
 Through the Rectum (Fig. 657). Place the patient in the lithoto- 
 my position ; introduce the left index-finger into the rectum ; locate 
 the vesiculae seminales and base of the prostate ; place the end of the 
 finger between the former, allowing it to rest upon the base of the 
 prostate ; along the palmar surface of the finger, a curved trocar (Figs. 
 655 and 656) is then carried just above the base of the prostate, and
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 427 
 
 pushed into the bladder ; the canula may be tied in position, or a soft 
 catheter substituted therefor, by passing it through the canula. 
 
 The almost universal practice of using some form of aspirator, and 
 the superiority of this instrument over the trocar, are fast consigning 
 the latter to an honorable remembrance only. 
 
 STONE 1ST THE BLADDER. 
 
 This morbid condition is quite common, and usually is accom- 
 panied by well-marked and characteristic symptoms. Sometimes, 
 however, calculi of inordinate size, and with unusual asperities, are 
 attended by only trifling man- 
 ifestations. When it is sus- 
 pected that a stone may be in 
 the bladder, the proof of its 
 presence is sought by aid of a 
 searcher. There are various 
 patterns of this instrument 
 (Figs. 658, 659, and 660). The 
 one devised by Thompson is 
 most commonly employed. It 
 can be used for the double 
 purpose of regulating the 
 amount of water in the blad- 
 der, by injection or by out- 
 flow, thereby better accommo- 
 dating the bladder-walls to the 
 remaining function of this in- 
 strument sounding for stone. 
 
 Sounding. The time se- 
 lected should be when the pa- 
 tient is suffering the least from 
 the bladder difficulty. If the 
 patient be a child, an anaes- 
 thetic should be given ; if an 
 adult, only when he is ex- 
 tremely restless from the pain. 
 Two or three ounces of a two- 
 per-cent solution of cocaine 
 have been employed success- 
 fully in the bladder to relieve 
 the pain and irritation of 
 sounding and even of crush- 
 ing. The urine of one or two hours' secretion should be allowed to 
 collect in the bladder, or its equivalent, four or five ounces of warm 
 water, should be injected before attempting the sounding. 
 
 FIG. 658. 
 Thompson's 
 searcher. 
 
 FIG. 659. Lit- 
 tle's searcher. 
 
 FIG. 660. Gou- 
 ley's searcher.
 
 428 OPERATIVE SURGERY. 
 
 Place the patient on the back with the hips raised, the operator 
 standing upon the right side. Introduce the searcher in substantially 
 the same manner as that employed to introduce a lithotrite (page 429); 
 then push it carefully to the posterior wall of the bladder, with the 
 beak upward ; withdraw it slightly to give easy play to the end, and 
 then carefully turn the beak from side to side, until the lateral walls 
 of the bladder are touched by it. This is done by rotating the instru- 
 ment on its long axis between the thumb and finger. In this manner 
 the whole inner surface of the bladder is examined, the instrument 
 being withdrawn each time a sufficient distance to accomplish this 
 object thoroughly. As soon as the beak comes in contact with the 
 neck of the bladder it can be withdrawn. If the prostate be enlarged, 
 the handle should be depressed, and the beak turned toward the floor 
 of the bladder and rotated from side to side while it is being gradually 
 withdrawn. This manoeuvre will be quite sure to detect the stone if 
 it be lodged behind that body. 
 
 If a stone be not detected, it is better to make a second and even 
 a third examination before positively asserting that none is present. 
 Five or ten minutes is quite sufficient time to employ at one sitting. 
 If the presence of stone be detected, the number, size, and the proba- 
 ble consistency should be determined. After the searching is com- 
 pleted, apply warmth to the hypogastrium, give an anodyne along with 
 ten grains of quinine, and keep the patient quiet. 
 
 The ability to detect the "click" from small fragments by aid of 
 the searcher is greatly enhanced by the attachment of the so-called 
 " lithophone." This attachment can be extemporized by taking a piece 
 of rubber tubing, twenty-five or thirty inches in length with an eighth- 
 inch caliber ; double one end upon itself and place it against the 
 handle of the searcher, allowing also the tubing continuous with it to 
 lie along the handle, or push it into the open end of the handle of the 
 searcher. The other extremity is then placed in the ear directly, or 
 connected to it by the medium of an otoscope. The ability to detect 
 fragments of an almost infinitesimal size is said to be thus attained. 
 The washing process of litholapaxy may also cause the "click." 
 
 Lithotrity, litliolapaxy , and lithotomy are the only practical meth- 
 ods of relief in the male. 
 
 Lithotrity is the reducing of stone to fragments so minute as to 
 allow of their easy escape with the urine through the urethra. 
 
 The instruments used to effect the reduction are called lithotrites, 
 of which there are several varieties (Figs. 661, 664, and 667). The 
 ones devised by the ingenuity of Thompson, Bigelow, and Keyes 
 are most frequently used. For this operation the patient should be 
 in a good condition, and the urethra of suitable size to admit the 
 lithotrites ; he is required to hold the urine for an hour or two, and 
 is then placed upon the back with the pelvis elevated ; the older the
 
 OPERATIONS ON TEE URINARY BLADDER. 
 
 429 
 
 patient, the greater the elevation should be. An ansesthetic may be 
 given, and should be administered if it be the intention to triturate 
 the entire mass at one sitting ; or, if the patient be irritable, or the 
 bladder over-sensitive. 
 
 Introduction of the Litliotrite. The operator having chosen and 
 well oiled a suitable instrument, stands upon 
 the right side of the patient, taking the penis 
 in the left hand, inserts the beak and draws 
 the member upward upon the instrument, 
 which is tightly grasped by the right. The 
 handle is then slowly raised until the shaft be- 
 comes vertical, when it is transferred to the 
 left hand, and the fingers of the right are placed 
 on the perineum to follow the angle of the 
 beak as it advances. The weight of the in- 
 strument will cause it to sink low enough to 
 permit the beak to engage the opening of the 
 triangular ligament, through which the urethra 
 passes. A little careful manipulation, aided by 
 
 Fio. 662. Fcnestrated jaws. 
 
 FIG. 661. Thompson's 
 lithotrite. 
 
 FIG. 663. Non-fenestrated jaws. 
 
 the right hand on the perineum, will cause it to enter this portion 
 of the canal, when the handle of the instrument should be taken by 
 the right hand, and allowed to fall slowly of its own weight between 
 the thighs. If the instrument be now slightly pressed upward, its 
 upper extremity will be found to be disengaged, and can be easily ro-
 
 430 OPERATIVE SURGERY. 
 
 tatcd upon its long axis. If the prostate be enlarged, it increases the 
 length of the deepest portion of the urethra, and interposes an ob- 
 stacle to its progress. The handle should not, therefore, be depressed 
 so rapidly during the latter stage, and the instrument must be pushed 
 farther upward. Under no consideration should any undue force be 
 used. The weight of the handle is of itself sufficient, unless under 
 proper control, to cause laceration of the soft urethral tissues. 
 
 The instrument is pressed upward in the line of its entrance until 
 it reaches the posterior wall of the bladder, unless its course be sooner 
 interrupted by the stone, when the beak is turned from the stone and 
 the male blade withdrawn ; then the separated blades are turned 
 toward the stone, which is seized and fixed. The beak is now turned 
 upward care being taken to observe that the mucous lining of the 
 bladder is not caught and the fragment crushed. The blades are 
 again separated and turned sidewise to catch the resulting fragments, 
 which manoeuvre is continued until the sitting is completed. 
 
 During the crushing, the female blade must be held firmly and 
 remain entirely passive, and the blades should only be separated suffi- 
 ciently to admit the stone between them. If the beak be not turned 
 away from the stone before it is opened, the stone may be displaced 
 by the separation of the blades. While it is true that, in a large ma- 
 jority of cases, the plan of action just described will suffice, still, in 
 those where the prostate is enlarged, or an excavation exists at the 
 base of the bladder from another cause, it may become necessary to 
 reverse the beak of the instrument, causing it to look toward the rec- 
 tum. To do this properly, the handle of the instrument is depressed 
 until the beak is elevated sufficiently to allow of its revolution with- 
 out impinging upon the walls of the bladder. If the simple revers- 
 ing of the instrument does not bring it in contact with the stone, the 
 beak should then be turned in various directions with care. Another 
 manoeuvre, which in the case of small stones located behind the pros- 
 tate will often prove successful, consists in drawing the reversed beak 
 outward until it nearly touches the prostate, and then separating the 
 blades by pressing the female blade backward until it strikes against 
 the posterior wall of the bladder, the male blade being held firmly in 
 position ; raise the handle until the female blade rests lightly upon 
 the floor of the bladder, then draw it forward to join the male blade, 
 lightly touching the floor in its course. If a stone lies in the line, it 
 will be touched, and, moreover, the mucous membrane will not be 
 pinched. It is better that the blades be smooth in these reversed 
 movements. 
 
 During this antero-posterior manipulation the neck of the bladder 
 should be carefully preserved from any unnecessary contact with the 
 instrument. "When the sitting is completed the blades must be 
 screwed firmly together, that the instrument may be withdrawn with-
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 431 
 
 out injury to the urethra. Each sitting, if without anaesthesia, should 
 not exceed five or ten minutes ; with it, a sitting can be prolonged 
 until an ordinary calculus is reduced to fragments. The intervals of 
 the crushing will depend upon the size of the stone, its hardness, and 
 more frequently the effect of the crushing upon the patient. Inas- 
 much as the conditions differ greatly, it is impossible to lay down 
 
 FIG. 665. Bigelow's non-fenestratcd blades. 
 
 
 FIG. 666. Biirelow's fenestrated blades. 
 
 FIG. 664. Bigelow's 
 lithotrite. 
 
 FIGS. 667, 668. Keyes' modified blades.
 
 432 
 
 OPERATIVE SURGERY. 
 
 any stereotyped rules. 
 
 FIG. 669. Thompson's washer. 
 
 The surgeon should not repeat the operation 
 until the subsidence of the irrita- 
 tion produced by the previous at- 
 tempts. Villous growths of the 
 bladder, and deformities which in- 
 terpose a mechanical obstruction, 
 are the principal contraindications 
 to lithotrity. After the completion 
 of the sitting the patient is given 
 an anodyne, and hot fomentations 
 are applied to the abdomen, and he 
 is caused to remain in the recum- 
 bent posture for twenty-four hours 
 subsequent to the operation, even 
 to the extent of lying on his side 
 during micturition. 
 
 Results. The rate of mortality 
 is about eleven per cent. 
 
 Rapid Lithotrity, or Litholapaxy. The crushing and washing 
 out of a stone at a single sitting has supplanted the ordinary lithot- 
 rity. 
 
 Fro. 670. Bigelow's washer. 
 
 The instruments usually employed in this procedure are the litho- 
 trites of Thompson or Bigelow, as shown in Figs. 661 and 664, the 
 latter being in common use. The blades of lithotrites differ in their 
 grinding surfaces from a simple roughening to a well-marked denticu-
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 433 
 
 lation. The blades of Bigelow's instruments present appearances pe- 
 culiar to themselves (Figa. 665 and 666). The instrument used by 
 
 FIG. 671. Otis' washer, ready for use. 
 
 FIG. 672. Otis' washer, inverted. 
 
 Dr. Keyes is of a stronger pattern than is usually employed, and is 
 provided with a large wheel at the end, that a greater force may be 
 quickly applied. The blades are 
 fenestrated (Figs. 667, 668), and 
 are so constructed that they can not 
 clog. The operator should possess 
 lithotrites of two or three sizes and 
 of different patterns, to enable him 
 to comply with the demands of in- 
 dividual cases, as modified by the 
 hardness and size of the stone, size 
 of the urethra, etc. For crushing 
 large and hard stones, a fenestrated 
 blade should be employed. If the 
 stone be small and friable, the blades 
 may be roughened only, with the 
 28 
 
 FIG. 673. Bigelow's evacuating catheter.
 
 434: 
 
 OPERATIVE SURGERY. 
 
 male blade much the smaller. A non-fenestrated or " scoop " litho- 
 trite can be used to crush the smaller fragments. The larger and 
 
 harder the concre- 
 tion, the stronger 
 should be the in- 
 strument employed. 
 In addition to the in- 
 struments for crush- 
 ing, the operator 
 provided 
 
 be 
 
 must 
 
 with an evacuator 
 or washer. The 
 Thompson washer is 
 admirable (Fig. 
 669), and the latest 
 pattern by Bigelow 
 leaves but little to 
 be desired in this 
 respect (Fig. 670). 
 Otis' washer is sim- 
 ple, cheap, and effi- 
 cient (Figs. 671, 
 672). 
 
 The evacuating- 
 tubes of Bigelow 
 (Fig. 673), or their 
 modifications, com- 
 plete the outfit. The 
 spiral-tipped tube 
 of Warren (Fig. 674) 
 and the straight, 
 open-ended one of 
 Keyes (Fig.. 675), 
 are thought to fa- 
 cilitate the discharge of the detritus, while in the latter instance es- 
 pecially the lining membrane of the urethra is not exposed to injury 
 from a fragment lodged in the eye of the instrument during its with- 
 drawal from the bladder. The size of the tube commonly employed 
 varies from 16 to 18, English scale. 
 
 The contraindications to the operation are of a limited number. 
 It is not admissible, if the bladder be sacculated and affected by 
 cystitis, or if it be ulcerated, or intolerant of the presence of instru- 
 ments. Repeated and severe chills following the introduction of in- 
 struments into the urethra and bladder contraindicate the operation. 
 If the organ contain morbid growths, or, if the patient be feeble, es- 
 
 FIG. 674. Warren's 
 spiral-tipped evac- 
 uating catheter. 
 
 FIG. 675. Keyes' 
 straight tube and 
 guide. 
 
 FIG. 676. Keyes 
 curved tube and 
 guide.
 
 OPERATIONS ON THE URINARY BLADDER. 435 
 
 pecially if the stone be large and hard, crushing should not be at 
 tempted. 
 
 The preparatory treatment consists in alleviating all symptoms de- 
 pendent upon the existence of the stone, and in preparing the urethra 
 for receiving the instruments by increasing its size if necessary, and 
 subduing any undue sensibility of it. 
 
 Operation. An assistant, besides the one to administer the ether, 
 must be present to empty the washer and adjust it. The bladder 
 should contain four or five ounces of fluid, which condition is best 
 obtained by causing the patient to retain the urine for two or 
 three hours prior to the operation ; or, if it be empty, a similar 
 amount of tepid carbolized water must be injected. If the contents 
 of the bladder be offensive, empty it and wash it out with a tepid 
 solution of borax, a drachm to the pint, before beginning the opera- 
 tion. 
 
 The patient is placed on the back, complete anaesthesia secured to 
 insure perfect quiot, pelvis elevated, thighs slightly flexed and rotated 
 outward. 
 
 The method of introduction of the lithotrite, and the process of 
 catching and crushing the stone, are similar in this operation to the 
 ordinary method, except that the crushing process is interrupted by 
 the introduction of the evacuating catheter as soon as the stone is 
 well broken. This may be within five or ten minutes after the intro- 
 duction of the lithotrite, depending, of course, upon the success at- 
 tending the efforts of the operator. A well-oiled evacuating catheter 
 is then passed down to the prostatic urethra, and the washer is at- 
 tached while it is in this situation to avoid the entrance of air into 
 the bladder. The air in the catheter while it is thus located will, if 
 water be forced gently into it, pass upward through the water in the 
 washer and remain in the air-trap above, after which the evacuating- 
 tube is carried on into the bladder. If, now, the elastic, half-filled 
 bulb be alternately compressed and expanded, the changing current 
 thus produced will wash the fragments from the bladder, and their 
 weight will precipitate them into the glass receiver beneath. If all 
 the fragments be not removed which can be ascertained by the intro- 
 duction of a searcher the process of crushing is again resorted to, 
 and the resulting comminutions treated as before until the entire 
 stone is removed. The last fragments not infrequently elude the 
 grasp of the instrument, and, were it not that they can be heard 
 to strike the evacuating catheter when the water is drawn upward, 
 their existence might not be known. If the curved tube be used, 
 the beak should be turned from side to side to present its eye to 
 different aspects of the bladder, while the square-ended tube of 
 Keyes is passed just beyond the neck of the bladder, and its exter- 
 nal extremity is well lowered between the thighs. It is better some-
 
 436 
 
 OPERATIVE SURGERY. 
 
 times to allow these fragments to remain until the patient has re- 
 covered from the operation, and then seek for them again, than to 
 continue indefinitely the attempt to secure the last one at the first 
 sitting. Very small fragments which escape detection are not infre- 
 quently passed with the urine within four or five days after the oper- 
 ation. 
 
 The limit of time to which the first crushing may be prolonged is 
 not an arbitrary one ; an hour or two is not unusual, and even a 
 longer time may be employed. However, an hour is a safe rule to 
 adopt. 
 
 After the operation the patient is kept quiet in bed and well 
 wrapped ; if retention occurs, it is relieved by 
 a catheter. 
 
 Sequels. Litholapaxy has various sequels 
 rigors, retention of urine, cystitis, impaction 
 of stone in the urethra, pyaemia, atony of the 
 bladder, suppression of urine, etc. all of 
 which should be treated on general principles. 
 Under ordinary circumstances the patient will 
 be up and around at the end of a week or ten 
 days. 
 
 Results. The rate of mortality is about 
 three and one half per cent. 
 
 Combined Crushing and Evacuating In- 
 strument. The idea of the possible utility of 
 such an instrument suggested itself to me 
 some time since, after a somewhat annoying 
 effort on my part to seize the " last fragment," 
 the existence of which could be easily and 
 quickly demonstrated by the characteristic 
 click against the eye of the evacuating cath- 
 eter during the washing-out process. I also 
 recalled the fact that, on other occasions, the 
 suction-force of the washer had been tempo- 
 rarily arrested by the closure of the eye of the 
 evacuating catheter by a fragment of calculus. 
 The male blade of an ordinary lithotrite is 
 modified to fit the anterior or concave wall of 
 the ordinary evacuating catheter, which is 
 lined with a brass tube. The washer can be 
 easily connected with the catchers of the in- 
 strument, as shown by the cut (Fig. 677). 
 It is not expected that this instrument can 
 
 supplant the lithotrite. The idea is to crush 
 FIG. 677. The author's . , ,. ... ,.,, 
 
 combined instrument the stone at the first introduction of the lith-
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 437 
 
 otrite as effectually as practicable, and to introduce the combined 
 instrument instead of the ordinary evacuating catheter. By means 
 of this the detritus is removed from the bladder, and such of the re- 
 maining fragments as are caught in the throat of the instrument are 
 crushed and likewise removed. It thus becomes possible to avoid 
 the interchange of instruments incident to repeated crushings. With 
 an assistant to manipulate the washer, the operator can devote his 
 entire attention to crushing the fragments caught in the throat of the 
 instrument. 
 
 When applied to an extemporized bladder it worked admirably, 
 and seemed to require only the perfecting influences of repeated and 
 practical applications to create for it a place among the recognized 
 appliances for the performance of litholapaxy. 
 
 Perineal Lithotrity. A stone may be crushed by gradual or rapid 
 lithotrity through an opening in the perineum. Perineal lithotrity 
 has, as yet, been rarely adopted as a primary method of treatment, 
 
 Fio. 678. Dolbeau's method, first step. 
 
 but rather as an expedient to facilitate the removal of a stone too 
 large to be removed through the incision made for the purpose of a 
 simple lithotomy. It has been advocated as a substitute for lithotomy, 
 because the crushing and the use of the washing apparatus can be
 
 438 
 
 OPERATIVE SURGERY. 
 
 FIG. 679. Dolbeau's method, second step. 
 
 substituted for the incision through the deeper parts. Still, the with- 
 drawal of an ordinary sized stone can hardly compare, in point of 
 
 Fio. 680. Dolbeau'a method, third step.
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 439 
 
 danger, to the repeated introduction of instruments and the necessary 
 prolongation of the operation of crushing through an open wound. 
 However, it is, without doubt, an expedient which should be more fre- 
 quently adopted, especially for the removal of large stones through an 
 opening too small to admit of their safe withdrawal. 
 
 FIG. 681. Gouley's lithoclasts. 
 
 Professor Dolbeau systematized this method. The incision is made 
 through the perineum, as in median lithotomy, after which the dilata- 
 tion is divided into three steps, the dilator of Mr. Dolbeau being 
 employed. The frst step consists in the dilatation of the tissues 
 down to the groove in the staff (Fig. 678) ; the second, the dilatation 
 of the tissues nearly through the neck of the bladder (Fig. 679) ;
 
 440 
 
 OPERATIVE SURGERY. 
 
 third, the withdrawal of the staff and carrying the dilator in suffi- 
 ciently to thoroughly dilate the neck of the bladder (Fig. 680). 
 
 The dilatation in all the steps must be done carefully, and in ac- 
 cordance with the resistance encountered. After it is completed a 
 lithoclast (Fig. 681) of suitable size is introduced, and the stone 
 
 fragmented, after which it 
 comes away with the urine. 
 A small reverse current of 
 carbolized water thrown into 
 the bladder will wash the 
 fragments out. 
 
 The results, while yery 
 satisfactory, are not equal to 
 those of litholapaxy. 
 
 Lithotrity in the Female. 
 The absence of the prostate 
 body, and the shorter and 
 larger urethra of the female, 
 combine to secure a more 
 complete emptying of the 
 bladder, and also lessen the 
 liability in the female to the 
 formation of vesical calculi. 
 A stone in the female bladder 
 can not be grasped with the 
 same facility as that in the 
 male, owing to the difference 
 in the normal shape and sur- 
 roundings of the bladder, and 
 to the pathological modifica- 
 tions to which its cavity is 
 subjected, due to its connec- 
 tions with the uterus and va- 
 gina, and their physiological 
 and pathological variations 
 caused by child-bearing and 
 its sequels. The greater lia- 
 bility to a sacculated base 
 requires that the instrument 
 be reversed more frequently 
 
 than in the sterner sex. The operation can, however, be readily per- 
 formed, and, aside from the slight variations in the manoeuvres neces- 
 sary to catch the stone, differs but little from that in the male. 
 
 Lithotomy. Lithotomy is the operation for the removal of stone 
 from the bladder by cutting. The varieties of incision in common use 
 
 FIGS. 682, 683. Dolbeau's dilator.
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 441 
 
 are classed as the lateral, median, and bilateral, together with the 
 occasional employment of the supra-pubic method. 
 
 Lateral Lithotomy. Lateral lithotomy is employed in preference 
 to the median, when the stone is too large to be easily removed through 
 
 FIG. 685. Dupuytren's knife. 
 
 FIG. 686. Blizard's knife. 
 
 FIG. 687. Blunt gorget. 
 
 FIG. 688. Scoop and conductor. 
 
 the dilated prostate. The instruments necessary for the operation are 
 a staff of suitable size, with the proper curve and a deep groove upon 
 its convexity which approaches its right lateral aspect as it nears the 
 extremity of the beak (Fig. 684) ; a bistoury with a stout blade and 
 handle, a solid shank, a sharp point, and a cutting edge of about two 
 inches in length ; a probe-pointed knife the one devised by Bliz- 
 ard being the best and, if the perineum be deep, due to obesity, the 
 gorget may be selected ; forceps of various sizes and shapes to seize the 
 stone, one of which should be arranged with crossed handles to avoid 
 stretching the parts about the neck of the bladder when the stone is 
 grasped. It is likewise well to be provided with a small lithoclast, for 
 the purpose of breaking those stones too large to be extracted with
 
 442 
 
 OPERATIVE SURGERY. 
 
 safety ; a scoop to dislodge the remaining fragments of stone (Fig. 
 692), and a syringe to wash from the bladder any small fragments that 
 
 FIG. 689. Straight 
 forceps. 
 
 FIG. 690. Curved 
 lithotomy forceps. 
 
 FIG. 691. Dol- 
 beau's lithoclast. 
 
 Fio. 692. 
 Luer's scoop. 
 
 may remain (Fig. 693). Davidson's syringe can be used, but is less 
 satisfactory than one designed for the purpose. The chemise or 
 shirted canula (Fig. 694) is useful to control hemorrhage. At least 
 five assistants should be present. To one of these the staff should be 
 intrusted ; the lower limbs may be held by two others, either with or 
 without the limbs being confined by the anklets (Fig. 695). The 
 hands and feet may be bandaged together satisfactorily for the pur- 
 pose. Of the remaining assistants, one should attend the instru- 
 ments, and the other the sponges, etc. The more modern device for 
 separating the lower limbs and exposing the perineum will be of 
 great service (Fig. 696). 
 
 Operation. Shave and disinfect the parts, empty the rectum with
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 443 
 
 an enema, administer an anaesthetic, draw the patient down to the 
 edge of the table, and confine the extremities. The staff is then in- 
 troduced and the stone found ; a diagnosis 
 which should be verified by others present. 
 If the stone be not detected, the staff should 
 be withdrawn, and its presence and location 
 determined by the searcher. These points 
 must likewise be confirmed by others. 
 
 If the stone be 
 not found at all, the 
 operation must be 
 deferred. 
 
 The principal as- 
 sistant, who holds 
 the staff, should sat- 
 isfy himself that the 
 sound touches the 
 stone, although it is 
 not necessary that it 
 be pressed against it 
 during the opera- 
 tion. The holder of 
 the staff should stand 
 at the patient's left 
 and press it firmly 
 beneath the pubes 
 with the right hand, 
 while the integu- 
 ment of the perineum is made tense by drawing up the scrotum with 
 the left. The convexity of the staff is easily felt in the perineum. If 
 the perineum be 
 thin the groove 
 may be distinctly 
 defined. Some sur- 
 geons have advised 
 that the staff be 
 pressed against the 
 perineum instead of 
 the pubes, to bet- 
 ter define its out- 
 line. However, it 
 is a matter of little 
 importance which 
 course is taken, so 
 long as the pubes FIG. 695. Pritchard'a anklets and wristlets. 
 
 FIG. 603. Van Buren's 
 debris syringe. 
 
 FIG. 694. Chemise cath- 
 eter.
 
 OPERATIVE SURGERY. 
 
 is hugged by the instrument while the incision is being made into the 
 bladder. The surgeon should sit upon a low stool, and, before begin- 
 ning the incision, carefully map out the location of the bulb, and the 
 point where the incision is to begin, also determine the outlines of the 
 rami and tuber ischii. He then introduces the index-finger of the left 
 hand into the rectum, locates the apex of the prostate, and determines 
 its relations to the sound: The finger is withdrawn, disinfected, and the 
 groove in the staff again located. The incision is commenced a little to 
 the left of the median raphe, from an inch and a quarter to an inch and 
 a half in front of the anus. The point of the knife is made to enter 
 the groove at the second or third cut, being guided by the nail of the in- 
 
 FIG. 696. Clover's crutch applied. 
 
 dex-finger of the left hand. The perineal incision is made from three 
 to three and a half inches in length, and carried obliquely downward, 
 midway between the tuber ischii and the verge of the anus (Fig. 708, b). 
 The urethra is then freely opened, and the probe-pointed bistoury 
 substituted for the scalpel ; or, the blunt extremity of the Blizard's 
 knife is engaged in the groove when, -the surgeon, taking the han- 
 dle of the staff in the left hand, lowers it somewhat, and holding 
 it firmly carries the knife toward the bladder, depressing its handle
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 445 
 
 slightly to correspond to the curve of the staff. If he were to push 
 the knife downward and backward without depressing its handle, the 
 point would leave the staff and pass behind the bladder, a fact which 
 would not be discovered until the withdrawal of the knife and the at- 
 tempt to pass the finger into the bladder. As soon as the end of the 
 knife is stopped by the termination of the end of the groove in the 
 staff, its handle is depressed, the edge turned still more, and the deep 
 tissues severed from within outward by its withdrawal, care being taken 
 to make the incision through the prostate more horizontal than that 
 of the perineum (Fig. 697). The flow of urine which follows assures 
 the operator of successful entrance to the bladder. 
 
 It is recommended to press the point of the scalpel firmly against 
 the groove in the staff with the right hand, seize the staff with the 
 left, depress the handle of the staff and the knife at the same time, to 
 the same extent, and thus convert them for the moment into one in- 
 strument which is pushed into the bladder. This course is often fol- 
 lowed, and will prevent the escape of the point of the knife from the 
 groove. It is more difficult, however, to properly lateralize the knife 
 
 in its passage through the pros- 
 tate in this than by the former 
 method ; besides, it is much 
 less elegant. The purified in- 
 dex-finger of the left hand is 
 now passed carefully into the 
 bladder along the staff, which 
 is then withdrawn. The neck 
 of the bladder is dilated by the 
 finger, the stone reached, and 
 its diameter estimated, if it has 
 not been done before. If it 
 exceeds an inch in diameter, 
 the right side of the prostate 
 should be nicked by introduc- 
 ing a knife along the finger. 
 The forceps are now passed in 
 #s the finger is withdrawn, and 
 the stone carefully grasped in 
 the short diameter. If one 
 blade of the forceps be pressed 
 upon the floor of the bladder, and the instrument opened, the stone 
 will often roll properly within its grasp. However this may be, un- 
 usual caution must be employed not to bruise the contracted walls 
 of the empty viscus. If the stone be grasped in its long axis, it should 
 be dropped and the direction corrected by the finger carried into the 
 bladder. The change in direction may sometimes be accomplished by 
 
 FIG. 697. Lateral incision of prostate.
 
 446 OPERATIVE SURGERY. 
 
 carrying two fingers into the rectum, separating and pressing them 
 upward against the bladder, thereby compressing its sides and creat- 
 ing a furrow running antero-posteriorly, into which the corresponding 
 long axis of the stone will drop. When properly grasped it is with- 
 drawn by steady traction made in the line of the incision through the 
 perineum. Lateral movements can be made with direct traction. If 
 inordinate traction be deemed necessary for its removal, it should be 
 crushed, after which it can be easily extracted. Too great traction 
 may tear off the neck of the bladder, or lacerate the tissues beyond 
 the limits of the prostate ; still, tearing is safer than extensive cut- 
 ting, since the plexus of veins is less liable to be injured by it. As 
 soon as the calculus is removed, its surface is examined for facets, 
 which indicate the presence of still one or more calculi in the bladder. 
 Having removed all the calculi, irrigate the bladder with tepid car- 
 bolized water to remove all blood-clots and whatever detritus may be 
 present. If earthy matter exist in the bladder, it may be necessary to 
 remove it with a scoop. If the stone be encysted, it is very difficult 
 and often impossible to remove it. It may be grasped with the for- 
 ceps with or without nicking the confining structure ; in either in- 
 stance great care and judgment must be exercised. If arterial hemor- 
 rhage occur, it may be checked by ice-pressure, by the devices pre- 
 viously illustrated, or by the ligature ; if these fail, the serrefine forceps 
 (Fig. 54) may be clasped to the bleeding point and allowed to remain. 
 The tying in of a tenaculum, or acupressure, will check it ; venous 
 hemorrhage may be controlled by the chemise catheter or some other 
 similar expedient. After the operation place the patient in bed with 
 a rubber cloth beneath the hips, separated from the body by cloths, 
 to collect the urine and indicate the occurrence of hemorrhage. The 
 temporary introduction of a catheter or drainage-tube into the blad- 
 der through the wound in the perineum is not commonly practiced. 
 
 FIG. 698. Smith's lithotome. 
 
 Give light and stimulating diet, alkaline drinks, and treat all sequels 
 on general principles. 
 
 Results. The rate of mortality ranges from six to ten per cent.
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 447 
 
 The operation just described is the one usually employed. There 
 are, however, instrumental modifications which, in the opinion of 
 some, may deprive it of the little danger that may arise even with a care- 
 ful adherence to the details. The instrument devised some years ago 
 by Dr. Smith, of Baltimore, and successfully employed by him and 
 others (Fig. 698), is worthy of mention. It consists of a rectangular 
 staff with a well-rounded angle, and is deeply grooved on its horizontal 
 portion, and provided with an indicator attached to the shaft by means 
 of a hinge. The indicator is 
 likewise rectangular and ter- 
 minates in a lance -shaped 
 blade. The indicator can be 
 adjusted by sliding it up and 
 down the staff ; or various 
 sizes of the instrument may 
 be employed to meet indi- 
 vidual differences. The staff 
 is introduced and held by an 
 assistant in the usual man- 
 ner, and the cutting extrem- 
 ity of the indicator is ap- 
 plied to the median line and 
 pushed through the tissues, 
 until it lodges in the groove 
 of the staff. The probe- 
 pointed gorget is then passed 
 into the groove and lodged 
 in the channel on the staff, 
 along which a cut is made 
 into the bladder. A probe- 
 pointed bistoury may be sub- 
 stituted for the gorget. The 
 single and double lithotomes 
 (Figs. 699 and 700) have their 
 advocates. They are, how- 
 ever, in a small minority 
 when compared with the 
 number of adherents of the 
 scalpel and grooved staff. 
 
 Median Lithotomy. Me- 
 dian lithotomy is applicable 
 
 to cases having one or more small stones half an inch or so in diam- 
 eter, and in advancing puberty. In this method there is less danger 
 from hemorrhage, much better control of the urine from the first, and 
 the wound heals rapidly. If the stone be larger than was anticipated, 
 
 FIG. 699. Dupuytren's 
 double lithotome. 
 
 FIG. 700 Hutchinson's 
 lithotome.
 
 448 
 
 OPERATIVE SURGERY. 
 
 the temptation to use violence during the extraction is great. It is 
 claimed that this method may be followed by stricture of the urethra, 
 
 FIG. 701. Little's lithotomy staff. 
 
 Fm. 702. Mar- 
 koe's staff. 
 
 FIG. 703- Rectangu- 
 lar staff. 
 
 and also that the mouths of the seminal ducts are more likely to be 
 injured than by the other methods. The general precautions to be 
 
 employed in all 
 
 ^^^^~ ^^^^= a forms of lithot- 
 
 omy are men- 
 tioned more fully 
 in connection with 
 
 FIG. 704. Little's director. 
 
 the lateral opera- 
 tion. 
 
 The instruments required are the staff, director, and knife. The 
 staffs vary somewhat in the shape and depth of the grooves. The
 
 OPERATIONS ON THE URINARY BLADDER. 
 
 449 
 
 ones devised by Drs. J. L. Little (Fig. 701) and T. M. Markoe (Fig. 
 702) leave nothing to be desired. The rectangular variety (Fig. 703) 
 can be used in lieu of the curved one, although it is rarely employed in 
 this country. The director devised by Dr. Little is an admirable instru- 
 ment (Fig. 704), but is by no means essential to a successful operation. 
 
 FIG. 705. Little's lithotomy bistoury. 
 
 A stout, straight, sharp bistoury, double-edged at the point (Fig. 705), 
 for making the perineal incision, makes the especial outfit complete. 
 
 Operation. Confine the patient in 
 the lithotomy position (Fig. 696) ; intro- 
 duce the staff, placing the end of the 
 beak in contact with the stone ; pass the 
 left index-finger into the rectum, and 
 locate the apex of the prostate just 
 where the staff enters it ; introduce the 
 point of the knife into the median line 
 of the perineum half an inch in front 
 of the anus (Fig. 708, a), with the long 
 cutting edge . uppermost, and push it 
 carefully upward to the apex of the 
 prostate, guided by the finger in the rec- 
 tum, into the groove of the staff. The 
 knife is advanced sufficiently toward the 
 bladder to nick the apex of the prostate, 
 after which it is carried forward to di- 
 vide the membranous portion of the ure- 
 thra. The external incision should be 
 from one and a quarter to one and a half 
 inch in length, care being taken to avoid 
 the bulb of the urethra. The director is 
 then passed into the bladder along the 
 staff, and the neck of the bladder moder- 
 ately dilated by separating the two. The 
 staff is then withdrawn, and the index- 
 finger of the left hand carried through 
 the neck along the director with a semi- 
 rotary motion to complete the dilatation. 
 The forceps are then introduced, the 
 stone caught at its short diameter, and 
 removed by steady, gradual traction, 
 
 which may be accompanied by rocking movements, but never by a ro- 
 tation of the instrument on its long axis while grasping the stone. 
 29 
 
 FIG. 706. Wood's staff and 
 bisector.
 
 450 
 
 OPERATIVE SURGERY; 
 
 Various instruments have been devised to dilate the prostate in 
 this and other methods calling for the procedure (Figs. 682 and 683), 
 
 all of which an- 
 swer the purpose 
 well, but are by 
 no means essential 
 FIG. 707. Wood's bisector. to the safe per- 
 
 formance of the 
 
 operation. After the removal of the stone, stop all hemorrhage, seek 
 for any remaining calculi, wash out the bladder, place the patient in 
 bed with the limbs extended, administer an anodyne, and maintain 
 quietude. 
 
 Bilateral Method. The preliminary preparations, the precautions, 
 and general arrangements in this are similar to those necessary in the 
 other methods. The special instruments are the grooved staff, and 
 the bisector, so intimately associated with the name of the late Prof. 
 James K. Wood (Figs. 706 and 707). 
 
 Operation. Make a semilunar incision across the perineum, three 
 fourths of an inch in front of the anus, beginning midway between 
 the anus and the tuberosity on the right side, and terminating at 
 a similar point on the opposite side (Fig. 708, c). The convexity 
 
 of the cut is directed 
 forward. The several 
 tissues are divided down 
 to the membranous ure- 
 thra, which is opened 
 and the beak of the in- 
 strument inserted in 
 such a manner as to 
 cause the beveled edges 
 of the bisector to be up- 
 permost. After moving 
 the beak backward and 
 forward, to be certain it 
 is well lodged in the 
 groove, it is then firmly 
 pressed against the groove of the staff, and, with the staff held firmly, 
 it is carried into the bladder. They may be, practically, converted 
 into a single instrument by pressing them firmly together and carry- 
 ing them both in at the same time, being careful to depress the. handle 
 of each to the same degree. 
 
 Fallacies. The bisector may be carried behind the bladder if any 
 tissues exist between the groove and its probe-pointed extremity, or if 
 the handle be not depressed to conform with the long axis of the staff. 
 The anterior wall of the rectum may be cut. Avoid this accident by 
 
 FIG. 708. External incisions in perineal lithotomy.
 
 OPERATIONS OX THE URINARY BLADDER. 
 
 451 
 
 inserting the index-finger of the left hand into the bowel when the 
 primary incision is being made, and drawing the anterior wall back- 
 ward while the cut is being completed. 
 
 TJie results obtained by this method in the hands of Dr. "Wood 
 were equal to, if not better than, those previously given in connection 
 with the other methods of cutting for stone. 
 
 Nelaton's Modification. Nelaton modified the first step of the 
 bilateral method, with the view of lessening the danger of cutting the 
 bulb and the wall of the rectum. He introduced the left index-finger 
 into the rectum, placed the end of it against the apex of the prostate, 
 and steadied the anterior border of the anus with the thumb of the 
 same hand. He then made a semilunar incision in front of the anus, 
 the extremities of which were four fifths of an inch from the opening, 
 and the greatest convexity three fifths of an inch from it. The dissec- 
 tion was continued, layer by layer, the wall of the rectum and the 
 bulb being carefully avoided, until the membranous urethra was 
 reached and opened, and the cutting instrument introduced. The 
 same object was accomplished through a transverse incision an inch 
 and a quarter in length, with its center located three fifths of an inch 
 in front of the anus. 
 
 Medio-Lateral Operation. This method was devised by Buchanan, 
 of Glasgow. 
 
 The instruments necessary are a rectangular staff with a broad 
 groove in its left side, and a narrow, straight knife with a long edge. 
 The staff is introduced, and the prominent staff-angle adjusted to cor- 
 respond to the muco-cutaneous junction on the anterior verge of the 
 anus in the median line. 
 
 The instrument is then firmly held with the handle inclined toward 
 the abdomen, and the tissues 
 are penetrated by the knife, 
 held horizontally and with 
 the edge turned to the left, 
 until the groove in the staff 
 is reached (Fig. 709); then 
 the knife is pushed forward 
 into the bladder upon the 
 staff. As it is withdrawn, an 
 incision three fourths of an 
 inch long is made downward 
 and outward toward the fore 
 part of the tuber ischii. This 
 
 incision is completed by being continued directly downward about half 
 an inch. If necessary, it can be extended. 
 
 Results. A little over ten per cent are reported to have died after 
 operations by this method. 
 
 FIG. 709. Medio-lateral method.
 
 452 
 
 OPERATIVE SURGERY. 
 
 Medio-Bilateral Operation. This method was brought to the notice 
 of the profession by Civiale, and has since been championed in this 
 country by Dr. "W. F. Briggs, of Nashville. The staff for the median 
 method is introduced with the patient placed in the usual position ; 
 the rectum is drawn backward by the finger, and an incision made 
 through the median line into the staff an inch and a half in length, 
 beginning about half an inch in front of the anus. 
 
 The lithotome (Fig. 710, a) is then introduced into the groove, car- 
 ried into the bladder, the blade expanded half an inch, and the instru- 
 ment withdrawn, enlarging the wound on either side a quarter of an 
 inch throughout. The wound is then dilated and the stone removed 
 in the usual manner. If too large, it may be crushed. The author 
 has modified Briggs' instrument somewhat by introducing an inde- 
 pendent guiding stem, which leaves the cutting blades uninterfered 
 with during the withdrawal of the instrument from the bladder (Fig. 
 710, 
 
 FIG. 710. Briggs' modified lithotome. 
 
 Results. Prof. Briggs reports his mortality as at the rate of one in 
 thirty-seven cases operated upon. These are certainly astonishing results. 
 
 Supra-Pubic Lithotomy. The supra-pubic or high operation was 
 done first by Frere Come, about 1560. Since this time it has found 
 favor at several epochs, and is now again being strongly advocated by 
 prominent surgeons. The various relapses of the method depended, 
 without doubt, more upon the determination of its exponents to make 
 it an exclusive operation, than upon its own intrinsic defects. 
 
 The following are a few of the many conditions said to call for 
 this method : Great prostatic hypertrophy ; inability to extract the 
 stone through the perineum on account of its size ; encysted stone, 
 large stone with a contracted bladder surrounding it firmly ; imper- 
 meability of the urethra. The practical objections to it may be limit- 
 ed to these two operation on an obese patient, and one with a con- 
 tracted bladder containing a small stone. The possibilities of urinary 
 extravasation which is rare and of cutting the vesico-abdominal 
 reflection of peritoneum, are the practical dangers.
 
 OPERATIONS ON THE URINARY BLADDER. 4.53 
 
 Operation. Place the patient on the back, and anesthetize to 
 complete insensibility to overcome the contractility of the bladder. 
 This is first washed out, and then moderately distended with a warm 
 four-per-cent solution of boric acid. The amount injected will de- 
 pend on the capacity as well as the irritability of the organ ; usu- 
 ally six or seven ounces will suffice. The rectal balloon is next 
 introduced the ordinary colpeurynter will do and distended with 
 warm water sufficiently to raise the bladder well above the pubes. 
 An incision three or four inches in length is then made in the median 
 line, commencing just above the pubes. The various tissues are 
 divided down to the linea alba, which is cut through and the interspace 
 between the pyramidal muscles is sought for. If it be not found, 
 the muscular fibers should be separated, when the fatty layer on the 
 transversalis fascia and the fold of peritoneum will make their appear- 
 ance. Divide the fat, draw up the peritoneum with the finger, and, 
 after passing a strong ligature through each side of the bladder and 
 looping it, to provide a means to control the opening to be made into 
 it, open the bladder with a bistoury, in the median line. The hemor- 
 rhage, which may at first be severe, subsides as the bladder contracts 
 and empties itself. Introduce the finger into the bladder and locate 
 the stone. The forceps are now introduced into the bladder along the 
 finger, the stone seized and removed. If it is necessary, enlarge the 
 opening ; it should be extended downward. Examine* the bladder for 
 remaining calculi, and cleanse the wound. Some surgeons sew the 
 wound in the bladder with catgut, carried down to but not through 
 its mucous membrane. The abdominal wound is then closed with deep 
 and superficial sutures, and dressed antiseptically. The bladder should 
 be evacuated once in two or three hours during the first three days ; 
 after this it may be done less frequently and at the end of a week dis- 
 continued. It is strongly recommended and justly, too, it seems to 
 me to leave enough of the visceral and abdominal wounds open to 
 admit the introduction into the bladder of a long drainage-tube, and, 
 by keeping the patient on the side, thus avoid the use of the cathe- 
 ter. The use of the drainage-tube is open to the objection, however, 
 that a small amount of urine will escape beside it, in spite of the great- 
 est care. It is also advised to sew the lips of the visceral wound to 
 the borders of the abdominal wound, thus to surely prevent urinary 
 extravasation. Opposed to this last plan is the possible effect as yet 
 uncertain on the 
 functions of the 
 bladder of the 
 
 union of its walls j/ FIG. 711. Aponeurotome. 
 
 with those of the 
 abdomen. The wound should always be dressed with antiseptic care, 
 irrespective of the method employed. The opening through the linea
 
 '454 
 
 OPERATIVE SURGERY. 
 
 alba may be made with the aponeurotome (Fig. 711), or by the ordi- 
 nary scalpel. The sond$ a dart (Fig. 712) may be introduced into 
 the bladder and its trocar pushed through the anterior wall, thus serv- 
 ing as a good guide. The hooked gorget (Fig. 713) is useful to hold up 
 the bladder, and keep the wound open while the stone is being removed. 
 
 Results. The rate of mortality as reported by 
 some is about one in four. These estimates are, 
 however, deceptive, since they relate principally 
 to the results gained by this method when employed 
 under unfavorable circumstances. A rate of one 
 in eight or nine is now attained. 
 
 FIG. 712. Sonde & dart. FIG. 713. Hooked gorget. FIG. 714. Gross' dilator. 
 
 LITHOTOMY 
 
 THE FEMALE. 
 
 Aside from the method of crushing, a stone may be removed from 
 the bladder of the female by rapid dilatation of the urethra, or by 
 urethral and vesico-vaginal lithotomy. The method by dilatation is 
 performed with the aid of the finger or an instrument (Fig. 714) espe- 
 cially designed for the purpose. A calculus an inch or more in diam- 
 eter can be removed in this manner without unfavorable results. The 
 operation of lithotomy is not difficult of execution in the female.
 
 OPERATIONS ON THE PENIS AND SCROTUM. 4.55 
 
 Operation. Introduce a broad-grooved director into the bladder, 
 pass upon it a straight probe-pointed bistoury, and cut directly up- 
 ward toward the symphysis pubis. Follow the incision by dilatation, 
 and then remove the calculus with forceps. If greater space be re- 
 quired, the cut may be extended downward and outward toward the 
 tuber ischii. 
 
 This method is modified by combining the two preceding methods 
 as follows : first dilate the urethra, then divide either its anterior or 
 posterior wall as best suits the indications of the case, and remove 
 the stone. 
 
 The vesico-vaginal method consists in simply connecting the vagina 
 with the cavity of the bladder by a longitudinal incision made in the 
 median line of the vagina, the length varying according to the size of 
 the stone. A grooved staff is introduced into the bladder, the position 
 of the groove ascertained by the finger, and the tissues between the 
 finger and the groove are divided by a scalpel or scissors. The sequel 
 which contraindicates the vesico-vaginal method is the formation of a 
 chronic fistula. It is claimed that the wound can be made to heal 
 completely if the parts be frequently irrigated, so as to prevent phos- 
 phatic deposits. Tepid water acidulated with nitric or hydrochloric 
 acid will aid materially in the prevention of the deposit. A solution 
 of the acetate of lead one grain to the ounce of warm water is also 
 highly extolled for this purpose. 
 
 CHAPTER XVII. 
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 Hydrocele. This morbid condition may be treated by tapping 
 (which is palliative), and by incision, excision, and injection. 
 
 Tapping is a simple process, requiring for its performance a small 
 trocar and canula, or an aspirating needle, or an instrument of a simi- 
 lar nature. The patient is caused to sit upright on the edge of a chair 
 with the limbs separated, the enlargement is seized by the left hand, 
 and the tissues made tense on its anterior surface. The testicle is care- 
 fully located, and the course of the scrotal vessels as carefully avoided. 
 The instrument, guarded by the end of the finger (Fig. 715), is quickly 
 plunged into the scrotum at about th6 junction of its middle and 
 lower thirds. As the fluid escapes, the end of the canula is turned 
 away from the testicle, and the tumor is compressed carefully to expel 
 the entire fluid collection. After the fluid is removed the scrotum is 
 suspended, and the patient kept quiet, otherwise inflammation of the 
 sac may occur, which, while it may lead to a radical cure, will not be
 
 456 
 
 OPERATIVE SURGERY. 
 
 welcome, as it causes much pain and confines the patient to bed. It 
 will be necessary to repeat the operation in five or six months. 
 
 Fallacy. The testicle may be punctured by the trocar, unless the 
 exact location of the fluid has been determined by transmitted light. 
 
 Incision. In this operation the sac is laid freely open on the ante- 
 rior surface, and the wound dressed from the bottom. It heals in 
 
 from four to six weeks, and is seldom 
 followed by a return of the disease. 
 It is of especial efficacy when it is de- 
 sired to examine the pathological con- 
 dition of the testicles, with the view 
 of determining the relation of a sus- 
 pected morbid process to the fluid 
 collection. Volkmann incised the tis- 
 sues under antiseptic precautions, and 
 stitched the sac to the scrotal incis- 
 ion. This operation, like the preced- 
 ing one, has been followed, though 
 rarely, by a return of the disease. 
 
 Excision. In this method a por- 
 tion of the sac is cut away on either 
 side of the primary incision. As a 
 modification it allows a freer escape 
 of the discharges, and prevents the 
 protrusion of the rigid tunic, but 
 otherwise makes no practical difference. The external incisions in the 
 preceding methods may be made either long or short ; the former is 
 the better, as it affords more suitable drainage. 
 
 The wounds, after all of these operations, may be treated anti- 
 septically with most satisfactory results. 
 
 Incision with Excision. This method differs but little from the 
 one last mentioned, and is, in my opinion, the best operative proced- 
 ure for the radical cure of hydrocele. A long incision is made into 
 the tunica vaginalis, under the bichloride douche, and the condition 
 of the testis ascertained. The rigid protruding borders of the divided 
 tunic are then excised in the direction of the long axis of the external 
 incision, and the remaining portions stitched by catgut to the sub- 
 cutaneous scrotal tissues at the borders of the long incision. A drain- 
 age-tube is introduced, the scrotal wound closed, and the scrotal flaps 
 quilted together by catgut sutures to prevent the contractions of the 
 dartos from disturbing the union, the whole is then dusted with iodo- 
 form, and surrounded by antiseptic gauze. 
 
 Prognosis. The wound usually heals completely, in a week or ten 
 days, under the primary dressing, without any suppuration ; and the 
 probability of a return of the disease is very remote. 
 
 FIG. 715. Tapping hydrocele.
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 457 
 
 Injection. The fluids recommended are numerous, among which 
 iodine, sulphate of zinc, and carbolic acid are preferred at the present 
 time. The instrument required in the performance of the operation is 
 the rubber injection-bag, in addition to the ordinary trocar (Fig. 716). 
 The trocar is introduced and the fluid drawn off. The sac is then 
 seized, together with the scrotal tissues, to prevent the escape of the 
 extremity of the trocar from the 
 cavity of the sac, and the medicated 
 fluid is thrown in by means of the 
 gum bag. If the tincture of iodine 
 be used, it may be diluted with three 
 or four parts of water. Three or 
 four ounces of the mixture is quite 
 sufficient to come in contact with 
 the entire surface. It should be re- 
 tained for five or ten minutes, until 
 the patient complains of pain, and 
 then allowed to escape through the 
 canula. If the pure tincture be 
 used, a drachm or two injected in 
 the same manner, and allowed to re- 
 main and become absorbed, is quite 
 sufficient. If the sac be small, fifteen 
 or twenty drops may be thrown into 
 it by a hypodermic syringe, without 
 the previous removal of the fluid. 
 
 If the sulphate of zinc be used, 
 a solution composed of a drachm of 
 the salt to the pint of water is of 
 sufficient strength. 
 
 A drachm or two of a ten- to fif- 
 ty-per-cent solution of carbolic-acid 
 crystals in glycerine may be injected 
 and allowed to remain. This plan 
 is strongly advocated at the present 
 time by competent observers. 
 
 . The after-treatment in these cases consists in putting the patient in 
 bed, suspending the scrotum, and keeping lead and opium applied to 
 it, with anodynes to allay pain. For obvious reasons, the congenital 
 hydrocele should not be treated radically until its communication with 
 the abdominal cavity is closed. 
 
 Accidents. If care be not taken, the fluid may be thrown into 
 the connective tissue of the scrotum instead of the sac. If the canula 
 slip out after the fluid is withdrawn, a fresh puncture must be made, 
 since the previous opening will be closed by the contraction of the 
 
 FIG. 716. Rubber bag for injecting.
 
 4:58 
 
 OPERATIVE SURGERY. 
 
 dartos. Suppuration, sloughing, etc., which rarely follow, should be 
 treated upon general principles. The results following all of the 
 enumerated methods of operation are flattering ; yet failures are not 
 unknown in the best. 
 
 Castration. Castration is an operation simple of performance and 
 free from danger. Shave and disinfect the parts ; place the patient 
 upon the back and administer an anaesthetic. Make an incision in the 
 long axis of the tumor, beginning just below the external abdominal 
 ring and extend it to the lower extremity of the scrotum. The tis- 
 sues are carefully divided on a director down to the cord, which should 
 always be cut off short, if the operation be done for malignant dis- 
 ease. The three arteries accompanying it should be tied separately 
 with catgut ligatures. If any doubt exists as to their having been 
 properly secured, the cord should be isolated and transfixed by a 
 needle armed with a strong catgut ligature, each half tied separately, 
 and the cord divided. If it be divided low down, each vessel can then 
 be tied separately. In cases where it is divided high up, it must be 
 secured before its division, otherwise it may retract and seriously com- 
 plicate the final treatment. 
 
 After the division of the cord, the testicle can be easily removed 
 from the enveloping tissue by means of traction and an occasional 
 use of the scissors. All bleeding is then stopped, a small drainage- 
 tube is inserted into the lower edge of the wound, which is united by 
 fine catgut or carbolized silk, and the wound is dressed antiseptically. 
 If hemorrhage of the cord occurs afterward, the dressing must be 
 removed and the wound opened, and enlarged if it be necessary in 
 order to secure the bleeding vessels. 
 
 Circumcision. When phymosis or a simple redundancy of the 
 foreskin exists, circumcision, or some modification of this operation, 
 
 FIG. 717. Henry's phymosis forceps. 
 
 FIG. 718. Fisher's phymosis forceps. 
 
 should be performed. The instruments especially designed for the 
 purpose consist of the variously formed clamps (Figs. 717, 718), a 
 grooved director, and probe-pointed scissors (Fig. 719). The patient 
 is placed on the back and an anaesthetic administered, or a cocaine
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 459 
 
 solution injected into the prepuce, unless a determination is expressed 
 to endure the pain without it. The object of the operation is not to 
 remove the foreskin so as to leave the entire glans penis exposed after 
 
 FIG. 719. Taylor's phymosis scissore. 
 
 recovery, but to allow sufficient integument to remain so as to afford 
 the protection characteristic of the normal prepuce. The situation 
 of the base and apex of the glans should be determined, and with a 
 pen or pencil an oblique line drawn corresponding to the direction of 
 the base of the glans, about midway between it and the apex, upon the 
 integument. The foreskin 
 is then drawn downward, 
 placed between the blades 
 of the clamp, with the 
 line just made correspond- 
 ing to the lower border of 
 the blades, care being 
 taken to not include the 
 glans in its grasp (Fig. 
 720). The clamp is tight- 
 ened and the distal por- 
 tion severed by a sweep 
 of the scalpel. The clamp 
 
 is now removed, and the 
 
 % 
 integument retracts to or a little behind its previous location. The 
 
 mucous membrane which still covers the glans (Fig. 721, a) is slit up 
 on a grooved director, along the dorsum, J, and trimmed symmetrically 
 on either side, not even with the integument, c, but near enough to it 
 
 so that when it is turned over and 
 its free borders are stitched to 
 the skin, a vermilion border, d, 
 at least a third of an inch wide, 
 will be formed. Before the sew- 
 ing is done, the mucous mem- 
 brane should be stripped off the 
 glans to a point behind the coro- 
 na, after which it can be returned 
 . 721. Steps of circumcision. and its border joined to the integ- 
 
 FIG. 720. Clamping foreskin. 
 
 a
 
 460 
 
 OPERATIVE SURGERY. 
 
 ument by a continuous horse-hair suture. If the mucous membrane 
 grasps the glans too tightly, endangering the occurrence of paraphy- 
 mosis, it must be slit on the dorsal surface up to its point of reflection, 
 after which the borders are joined as before described. The complete 
 division along the dorsal surface will permit the prepuce to accommo- 
 date itself to the varying dimensions of the penis that not infrequent- 
 ly occur during the process of healing. 
 
 Another admirable method (Keyes), which is intended to meet the 
 same indications, is represented by Fig. 722. In this 
 the mucous membrane is not slit up, but both it and 
 the integument are shaped to correspond to the out- 
 lines 1, 2, 3, and 4, 5, 6, after which the former is re- 
 flected backward and joined to the integument, so that 
 1 shall correspond to 4, 2 to 5, and 3 to 6. This plan 
 does not, however, insure the same freedom as the long 
 dorsal slit just described. If the phymosis be not at- 
 tended by an elongation of the' foreskin, a cure may be 
 effected by slitting it upward on the dorsal surface to 
 the base of the glans. The ear-like projections on 
 either side are then trimmed off, and the mucous and 
 cutaneous borders stitched to each other (Fig. 723). 
 Cullerrier well accomplished the purpose in this con- 
 dition by subcutaneously dividing the mucous mem- 
 brane in three or four places by means of blunt-pointed 
 scissors, the blunt point resting upon the glans, while 
 the sharp one was passed between the membrane and the integument. 
 If the prepuce be short, and the case not an aggravated one, the mu- 
 cous lining can be stretched, and even torn asunder, 
 by introducing the blades of dressing-forceps be- 
 tween the glans and foreskin and expanding them, 
 after which the foreskin can be drawn backward 
 and retained until healing is completed. In all the 
 methods of operating, the after-treatment is di- 
 rected to modifying the inflammation and prevent- 
 ing the occurrence of an erection of the penis. 
 
 For this purpose, cold applications, large doses 
 of bromide of potassium, and anodynes are recom- 
 mended. It is now a favorite method to sew the 
 borders of the wound with a continuous suture of 
 fine catgut, dust it with iodoform, and surround the organ with 
 iodoform gauze. The catgut sutures are allowed to remain until ab- 
 sorbed. 
 
 In one case I now recall, local and general medication combined 
 were not sufficient to control or hardly mitigate the tendency to erec- 
 tion ; yet this tendency was effectually controlled by employing a 
 
 FIG. 722. 
 Keyes' modifi- 
 cation. 
 
 FIG. 723. Dorsal 
 slit.
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 461 
 
 nurse to watch the penis while the patient slept, with instructions to 
 awaken him at the first indication of an erection. 
 
 Paraphymosis (Fig. 724). In this condition the foreskin is im- 
 movably lodged behind the corona glandis, so as. to cause great con- 
 gestion and oedema of 
 the parts if not relieved 
 (Fig. 725), and the con- 
 dition may even termi- 
 nate in gangrene and ( i'/.^ 
 sloughing. The reduc- 
 tion may be accom- 
 plished as follows : 
 
 Oil the parts well, 
 and administer an an- 
 aesthetic, if necessary ; 
 grasp the penis behind 
 the constriction with 
 the thumb and fingers 
 of the left hand, and 
 the glans with the tips 
 
 of the thumb and fingers of the right ; press the glans with the latter 
 gradually to reduce the swelling, then draw the constriction forward 
 with the left, while the glans is gradually forced through it with the 
 thumb and fingers of the right (Fig. 726). If the constriction be not 
 
 F IG _ 704. Paraphymosis. 
 
 FIG. 725. Results of the 
 constriction. 
 
 FIG. 726. First method of reduction. 
 
 FIG. 727. Second method.
 
 462 
 
 OPERATIVE SURGERY. 
 
 X 
 
 FIG. 728. Third method. 
 
 great, and the oedema and congestion be slight, this manipulation will 
 soon effect the reduction. When the part is corrugated and much 
 swollen by long-standing severe constriction, followed by inflammation 
 and plastic oedema, it will be found necessary to sever the constriction 
 
 on the dorsal surface by a 
 sharp-pointed, curved bis- 
 toury. In all cases where 
 much oedema exists, acu- 
 puncture should be per- 
 formed, and the fluids 
 squeezed through the open- 
 ings before reduction is at- 
 tempted. Other methods of 
 grasping the penis are rec- 
 ommended to effect the re- 
 duction of the foreskin 
 (Figs. 727, 728). 
 
 After reduction, thor- 
 oughly cleanse and disinfect 
 the parts ; place the patient in bed, with the penis resting upon the 
 abdomen, and dress with cooling antiseptic lotions. 
 
 Amputation of the Penis Old Plan. Place the patient on his 
 back and give an anaesthetic, cause an assistant to retract the integu- 
 ment somewhat, transfix the corpora cavernosa transversely by an 
 acupressure-pin to prevent retraction of the stump, embrace the penis 
 behind the seat of the disease by a clamp (Fig. 729) inclined slight- 
 ly forward, and re- 
 move the projecting 
 portion with a large 
 scalpel, by cutting ob- 
 liquely downward and 
 forward ; secure all 
 the bleeding points, 
 draw out the mucous 
 membrane of the ure- 
 thra, divide it trans- 
 versely, and stitch it 
 to the integument at four different points, to prevent its contraction 
 into the canal. If the cavernous bodies bleed too freely, the hemor- 
 rhage can be checked by acupressure. If the amputation be made too 
 near the pubes to permit the application of the clamp, a tape or cord, 
 carried behind the pin, may be substituted. 
 
 Hilton's Modification consists in dividing the spongy body about a 
 fourth of an inch in front of the cavernous portion, splitting it longi- 
 tudinally, and uniting the lateral flaps to the integument as before. 
 
 FIG. 729. Bodcnhamer's clamp.
 
 OPERATIONS ON THE PENIS AND SCROTUM. 463 
 
 Humphrey's Modification consists in dissecting up the skin of the 
 penis, and turning back a circular flap about half an inch in length, 
 dividing the corpora cavernosa on a level with the attachment of the 
 flap, and cutting the spongy body at least half an inch longer than 
 the preceding, and attaching the integument to its extremity. 4 
 
 If the amputation is to be made close to the symphysis, two acci- 
 dents must be guarded against, viz., retraction of the stump and infil- 
 tration of the scrotum with urine. If a stout ligature be passed 
 through the fibrous sheath of the penis, a little above the point of 
 proposed section, the first accident will be obviated. The infiltration 
 can be prevented by dividing the scrotum entirely through, in the 
 line of the urinary canal, and uniting the borders of the integument 
 to those of the urethra, thus forming two scrotums, with the urinary 
 opening between them. 
 
 Extirpation of the Penis (Gouley). Anaesthetize the patient, make 
 a curvilinear incision on either side of the root of the penis, beginning 
 in the median line, about one inch and a half above the level of the 
 pubes, and ending a little below the peno-scrotal junction. The 
 cavernous bodies are exposed and transfixed with a large knitting- 
 needle, or with a suitable substitute ; the urethra is transfixed by a 
 smaller one on the same plane, and the penis is amputated an eighth 
 of an inch in front of them. After all the bleeding points are 
 secured, the urethra is found and a grooved staff introduced through 
 it into the bladder. A sharp-pointed scalpel is then carried through 
 the perineum and lodged in the grooved staff, and all the tissues, in- 
 cluding the scrotum, divided from behind forward. The urethra! 
 cut is about an inch and a half in length, and the cutaneous one 
 three inches. The urethra is now detached from the cavernous bod- 
 ies, and these bodies, together with their crura, are dissected away, 
 after which the borders of the urethra are united to those of the 
 perineal wound. 
 
 CONGENITAL MALFORMATION OF THE URETHRA. 
 
 The urethra may be absent or occluded ; it may be extremely small 
 or bifid ; the external opening may be higher or lower than normal, 
 and even double ; its walls may be deficient above or below, consti- 
 tuting epispadias and hypospadias. Epispadias is sometimes com- 
 plicated by separation of the symphysis pubis and exstrophy of the 
 bladder. 
 
 Hypospadias results from a deficiency in the floor of the urethra. 
 The opening may exist in the glans or in the penile or scrotal por- 
 tions. The first form is the most frequent and the least important. 
 The scrotal is the next in point of frequency, and the most important 
 of all. When the deficiency is in the anterior or balanic portion, the 
 following operation will give satisfaction :
 
 464 
 
 OPERATIVE SURGERY. 
 
 -7 
 
 FIG. 730. Gouley's method. 
 
 Gouley's Method (Fig. 730). Make two longitudinal cuts, 2-3 and 
 2-3, far enough apart to leave ample material for the new urethra ; 
 
 make 4-5 and 4-5 a fourth of an inch out- 
 side ; remove the integument of the spaces 
 bounded by these incisions ; leave undis- 
 turbed the skin and mucous membrane in- 
 cluded between the incisions 2, 3 at 1, 10 ; 
 slide the loose skin at the root of the penis 
 and of the scrotum forward, making it 
 double upon itself until 3, 3 is brought to 
 2, 2, and the denuded surfaces are brought 
 in accurate apposition, making the angle of 
 the fold at 7, 7. The first suture is taken 
 at 6, 6, passing through the upper flap from 
 within (beneath) outward, and the lower flap 
 or border, 2, 3, from without inward ; before 
 tying, pass the suture of the opposite side in 
 the same manner ; tie both, cut the ends 
 short, leaving the knots inside the new ure- 
 thra ; introduce sutures along the external 
 
 borders, uniting 3, 5, 9 to 2, 4, 8. The newly formed meatus is trans- 
 verse, its under lip being the fold of the skin from 10, formed by 
 the apposition of the points 3, 3 to 2, 2. If the opening be in the 
 penile portion, and the organ bent downward, the curve must first 
 be relieved by subcutaneous section of the tissues while the penis is 
 forcibly extended. 
 If transverse incis- 
 ions of the skin be 
 needed to aid in 
 overcoming the de- 
 formity, they will 
 be found to assume 
 a longitudinal as- 
 pect when the or- 
 gan is straight- 
 ened, and can then 
 be united by su- 
 tures. 
 
 When the defect 
 
 FIG. 731. Anger's method. 
 
 is in the penile portion, the following method is worthy of trial : 
 
 Anger's Method (Fig. 731). Make an incision on the left side of 
 the penis, from the glans to the scrotum, 1, 2, half an inch from the 
 median line, also incisions at 1, 3 and 2, 4 ; the flap thus formed, a, 
 is dissected up, its base being attached near to the median line, 3, 4. 
 A second longitudinal incision, 5, 6, is made at the right side of the
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 465 
 
 median line, near to it, and of the same length as 1, 2, with lateral 
 incisions an inch and a half long at each extremity, 5, 7 and 6, 8. 
 The flaps are raised, a sound introduced into the urethral groove, and 
 the first flap, a, turned over it, bringing the integumentary portion in 
 contact with the urethral sound. Independent sutures, each armed 
 with a needle, are passed through the free margin of the first flap, a, 
 and outward through the base of the second flap, 1), and fastened by 
 shot pressed around them. The remaining flap, b, is then placed upon 
 the raw surface of the first, a, and fastened to the margin of the first 
 incision, 1, 2. The sound or catheter is then removed, and only intro- 
 duced thereafter to evacuate the bladder. 
 
 Duplay's Method (Fig. 732). This operation can be divided into 
 three steps: 1, if the penis be incurved, it is straightened and a new 
 
 FIG. 732. Duplay's method. 
 
 meatus made ; 2, the missing wall of the urethra is restored ; 3, the 
 old and new portions are joined together. 
 
 The penis is straightened by making transverse subcutaneous in- 
 cisions through the restraining bands while the organ is being extend- 
 ed ; if the integument be too taut to admit of the proper rectification 
 of the organ, it, too, must be severed, the resulting cuts united in the 
 long axis of the penis, and the penis confined in the corrected posi- 
 tion a sufficient time to permit the healing of the wound before the 
 second step of the operation is attempted. 
 
 The first step is completed by freshening, and, if necessary, deep- 
 ening the urethral groove at the situation of the proposed meatus, 
 and uniting its raw surfaces by silver wire or carbolized silk around 
 a sound or gum catheter as in Thiersch's method (Fig. 736). 
 
 Second Step. Two longitudinal incisions are made, 3, 3, extend- 
 ing from the glans to near the abnormal opening, one on each side of 
 the urethral groove, at a distance from each other equal to half the 
 circumference of the proposed urethra, a dimension which can be 
 ascertained by measuring the gum catheter over which the flaps are 
 to be reflected. From the ends of these a transverse incision is made 
 toward, but not quite to, the median line. The flaps, 1 anel 2, are 
 30
 
 466 
 
 OPERATIVE SURGERY. 
 
 dissected up and turned inward over a gum catheter, 3 (transverse 
 sections), and their margins fastened together in the median line by 
 fine sutures. The outer flaps, 4 and 5, of the longitudinal incision 
 are dissected up sufficiently to permit them to be easily drawn over 
 the reflected ones, 1 and 2, when they, too, are united in the median 
 line by interrupted or continuous sutures. Unite the anterior ex- 
 tremities of all the flaps to the raw borders of the glans, thus com- 
 pleting the anterior portion. of the tube. 
 
 Third Step. Freshen the edges of the abnormal opening, 6, and 
 unite it to the posterior extremities of the flap by a double row of su- 
 tures. 
 
 SzymanoiusTd' 's Method (Fig. 733). Make an incision, 1, 1, near 
 the edge of the fistula, extending half an inch beyond it ; dissect 
 
 FIG. 733. Szymanowski's method. 
 
 up a flap bounded by the dotted line ; make a curved incision, 2, 2, 
 on the opposite side, its length being a trifle less than that marked on 
 the dotted line upon the other side, but otherwise of sufficient width 
 to cover the fistula and reach the dotted line when turned upon it- 
 self ; scrape the cuticle from the flap 2, 2, and dissect it up to the 
 edge of the fistula ; arm each end of a fine carbolized silk suture with 
 a small curved needle ; pass these two needles from the epidermic sur- 
 face, about a quarter to a sixth of an inch apart, through the edge of 
 the curled flap (Fig. 733, 5), introducing them from within outward 
 corresponding to the dotted line through the base of the flap 
 formed by the straight incision ; after passing a sufficient number of 
 these sutures one every quarter inch draw the curved flap beneath 
 the straight one into the space formed by the separation of the latter
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 467 
 
 FIG. 734. Nekton's method. 
 
 so that its edge will correspond to the dotted curved line (Fig. 733, 
 c), and secure them over a piece of quill or cork. The inner edge 
 of the straight flap is now united to the 
 outer edge of the curved one, and the opera- 
 tion is completed. 
 
 Epispadias. Epispadias results from a 
 deficiency in the roof of the urethra. The 
 ability to secure as satisfactory results in this 
 as in the preceding deformity has not yet 
 been attained. 
 
 Nelaton's Method. A ligature is passed 
 through the prepuce, which is drawn over 
 the end of the penis and held during the op- 
 eration. An incision, 1 and 2, is then made 
 along each side of the urethral gutter at the 
 junction of the skin and mucous membrane, 
 beginning at the prepuce and ending at the 
 abdominal wall (Fig. 734). The external 
 lip of each incision is dissected outward 
 
 about a sixth of an inch and allowed to remain continuous with the 
 skin ; the inner lip of each is likewise slightly detached. A third 
 flap, 3, is marked out upon the abdominal wall, its base being located 
 
 immediately above the abnormal 
 urethral orifice, between two ver- 
 tical incisions, which are connected 
 above by a transverse one ; this 
 flap should be as broad as and a 
 little longer than the penis, and be 
 dissected from above downward. 
 It is then turned downward upon 
 the dorsum of the penis, the raw 
 surface being uppermost (Fig. 
 735, 3), and the cuticle forms the 
 roof of the- new urethra. The 
 borders of the flap, h h, are now 
 united by sutures to the inner lips 
 of the incisions on the dorsum of 
 the penis (Fig. 734, g g), the con- 
 tact being made as broad as pos- 
 sible. The abdominal flap is now 
 re-enforced by a scrotal one , (Fig. 735, //), which is limited above 
 by a curved incision circumscribing the under half of the penis at the 
 peno-scrotal junction, and below by a curved incision located the 
 length of the penis below the upper one, each extremity remaining 
 continuous with the integument on the outer surface (Fig. 735, e). 
 
 e - 
 
 IT-/ 
 
 FIG. 735. Nekton's method.
 
 468 
 
 OPERATIVE SURGERY. 
 
 This flap is dissected up, the penis slipped under it, and its raw sur- 
 face apposed to the abdominal one already in position. 
 
 The outer borders of the scrotal flap are now united to the borders 
 of the external flaps, 1, 2, found by the primary incisions made along 
 the urethral gutter. 
 
 TJiiersch's Method. This method comprises four distinct steps, 
 and requires several months for its completion. 
 
 A fistulous opening should be established in the perineum to per- 
 mit the escape of the urine before any of the steps are taken. 
 
 First Step. Formation of a meatus and that portion of the canal 
 occupying the glans. 
 
 A deep incision (Fig. 736, 1) is made along each side of the 
 urethral groove, in the glans, and the surface of the outer lips of each 
 
 FIG. 736. Thiersch's method : forming the meatus. 
 
 incision is pared, a a, 2, and they are drawn around a sound or cath- 
 eter, brought in contact with each other, and united by sutures or 
 hare-lip pins, a (Fig. 73G, 3). 
 
 Second Step. Formation of the urethra. 
 
 Make an incision through the skin and subcutaneous tissue at the 
 edge of the urethral gutter at the right side, 3, 3 (Fig. 737) ; also a 
 
 34 
 
 FIG. 737. Thiersch's method. 
 
 short transverse cut outward from each end, 3, 4. Make a second in- 
 cision on the left side parallel with the preceding one half an inch ex- 
 ternal to the edge of the gutter, 1, 1, and a transverse one at each ex- 
 tremity, 1, 2, extending inward to the border of the groove. The flap, 
 a, is dissected up, making it as thick as possible. The flap on the right
 
 OPERATIONS ON THE PENIS AND SCROTUM. 469 
 
 side, b, is also raised. The flap, a, is now turned over to form the roof 
 of the new channel, its raw surface being uppermost. Several sutures 
 should be passed through it near to its free margin, in the manner 
 previously shown (Fig. 731), thence through the base of the flap b, 
 and fastened by a quill or shot attachment. The flap 5 is then drawn 
 across the former so that their raw surfaces are in contact throughout, 
 and its free margin, 3, 3, joined to the outer side of the incision, 1, 1, 
 by sutures. 
 
 Fourth Step. To close the posterior portion of the canal. 
 
 This opening is closed by two flaps, one taken from each groin. 
 The left flap is shaped like an isosceles triangle. Its base is located 
 at the left half of the opening, and when turned downward forms the 
 roof of the new urethra. The right flap is quadrilateral, its base 
 being located at the right external abdominal ring ; its raw surface is 
 placed in contact with the raw surface of the fellow, and its borders 
 are united by sutures to all contiguous borders. After the healing is 
 completed, the perfection of the canal can be tested by temporarily 
 closing the perinea! fistula by the finger during micturition. If sat- 
 isfactory, the perineal fistula should be permanently closed. 
 
 ACQUIRED URETHRAL DEFECTS. 
 
 The walls of the urethra may suffer loss of substance, producing a 
 fistula. The caliber of the canal may be diminished, causing strict- 
 ure, either of which usually depends upon acquired causes. 
 
 Before attempting an operation for the closure of a urethral fis- 
 tula, the caliber of the canal should be made as near to its normal size 
 as possible by appropriate treatment of the strictures and such other 
 obstructions as may exist. 
 
 Urethroraphy. This operation is employed to close a small ure- 
 thral fistula, not exceeding a fifth of an inch in diameter if it be cir- 
 cular, and one fourth if longitudinal. If reasonable success is to 
 be attained, it is necessary that careful attention be paid to every 
 detail. 
 
 Before beginning the operation empty the bladder, and if necessary 
 administer an anaesthetic. 
 
 Operation. A sound is introduced into the urethra and the handle 
 given in charge of an assistant. The edges of the opening are care- 
 fully pared obliquely, and when completed should present a funnel- 
 shape appearance, the apex corresponding to the mucous opening of 
 the canal. The wound is then closed longitudinally by means of a 
 fine wire, horse-hair, or antiseptic silk, carried down to, but not 
 through, the mucous lining ; the intervals between them being 
 short. 
 
 The patient should be kept quiet and given alkaline and demul- 
 cent drinks, and the urine drawn with a catheter. It is a wise pre-
 
 470 
 
 OPERATIVE SURGERY. 
 
 caution to inject oil into the urethra before the introduction of the 
 catheter, to protect the cut as much as possible from any urine that 
 might come in contact with it. 
 
 Urethroplasty. Urethroplasty is employed to close larger open- 
 ings than those within the domain of urethroraphy. 
 
 If flaps be dissected upon either side of the opening, and drawn 
 together and joined in the median line, imperfect union is very apt to 
 result on account of their thinness and median contact. To over- 
 come this, it has been proposed to pass a sheet of thin rubber above 
 the flaps to protect them from the urine during the healing process 
 (Fig. 738). If, for this sheet-rubber, thin rubber-skin, separated from 
 the cut surfaces by a strip of Lister gauze, 
 be substituted, the irritation will be lessened 
 and the prospect of success correspondingly 
 increased. 
 
 Mlaton's Method (Fig. 739). The edges 
 of the opening are first pared, and then the 
 integument is detached subcutaneously for 
 about an inch around it by entering a long, 
 thin knife-blade through a transverse cut just 
 below the opening (Fig. 739). The liberated 
 integument is then joined in a longitudinal 
 fold along the median line by means of 
 quilted sutures. 
 
 Dieffenbach, instead of dissecting subcuta- 
 neously, raised two parallel longitudinal flaps 
 and fastened the middle of their raw under 
 
 surfaces together by sutures passed through leather supports at each 
 side. Two or three rows of sutures can be 
 used instead of this. 
 
 Delpech dissected up a single flap, drew 
 it across the fistula, and fastened it to a raw 
 surface prepared on the opposite side. Ar- 
 laud made two transverse flaps, one in front 
 and the other behind the fistula, about an 
 inch and a half in width. The anterior one 
 was dissected up toward the glans about 
 three fourths of an inch, and the posterior 
 one back over the scrotum, until it could 
 be easily drawn forward, so as to cover the 
 fistula. The cutaneous surface of the an- 
 terior portion of the scrotal flap was fresh- 
 ened and the flap drawn forward so as to cover the fistula, and the an- 
 terior flap drawn backward over it and united by sutures. 
 
 Rigaud (Fig. 740) closed a large fistula at the peno-scrotal junc- 
 
 FIG. 738. Urethroplasty. 
 
 FIG. 739. Nekton's method.
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 471 
 
 tion by the method employed by Nekton in the treatment of epispa- 
 dias. A quadrilateral median flap, with its base adjoining the open- 
 ing, was taken from the scrotum, turned 
 forward over the fistula, and its raw sur- 
 face covered by two flaps taken from the 
 sides and drawn together so as to meet 
 in the median line. 
 
 SzymanowsTci suggested that the cuta- 
 neous surface of the reversed flap be blis- 
 tered instead of scraped. This meth- 
 od is not as reliable, however, as the 
 former. 
 
 External Perineal Urethrotomy, some- 
 times called perineal section, is employed 
 in the treatment of intractable strictures, especially when accompanied 
 by a urethral fistula located in the perineum. It may be performed 
 
 FIG. 740. Rigaud's method. 
 
 FIG. 741. Gouley's beaked bistoury. 
 
 either with or without a guide. The former is not a difficult opera- 
 tion, while the latter is frequently an extremely perplexing one. The 
 instruments essential for the operation are an ordinary scalpel, also 
 
 FIG. 742. Gouley's grooved and tunneled catheter staffs. 
 
 one with a sharp point and a long, thin blade, the beaked bistoury of 
 Gouley (Fig. 741), whalebone guides, a grooved and tunneled catheter 
 staff (Fig. 742, a, b), ordinary sounds, a gum catheter, small probe, 
 grooved director, c, spatula, tenacula, two strong ligatures, each armed
 
 472 OPERATIVE SURGERY. 
 
 with a curved needle, and the usual instruments for controlling hem- 
 orrhage. Syme's grooved staff (Fig. 743) is objectionable, in that its 
 point may get into a false passage and the stricture 
 be missed. Moreover, its introduction through the 
 stricture is more difficult than that of the whale- 
 bone guide, and attended by greater danger to the 
 soft parts. If the ordinary small-sized grooved staff 
 employed in lithotomy can be introduced, nothing 
 better need be asked for. 
 
 Operation with a Guide. Evacuate the bowel, 
 shave and cleanse the perineum, administer an an- 
 aesthetic, fill the urethra with olive -oil, and intro- 
 duce a whalebone guide into the bladder in the 
 manner before described (page 420) ; over this pass 
 the grooved and tunneled catheter staff down to 
 and through the stricture, if it can be done readi- 
 ly ; if not, allow its beak to rest against the ob- 
 struction, carefully supported by an assistant, who 
 at the same time raises and holds the scrotum. 
 The patient is now placed in a lithotomy position, 
 and the limbs supported by an assistant upon either 
 side. The surgeon, sitting upon a low stool facing 
 the perineum of the patient, introduces the left in- 
 dex-finger into the rectum to ascertain the condi- 
 tion of the membranous and prostatic portions of 
 the canal. A free incision, from an inch to an 
 inch and a half long, is then made in the median 
 line of the perineum, extending from the base of 
 the scrotum to within half an inch of the anus, 
 through the integument and fascia. The grooved 
 instrument is carefully located by the finger, and 
 the urethra brought into view by repeated cuts in 
 the same line. The nail of the index-finger assures 
 the surgeon of the location of the groove, and the 
 urethra is divided upon it. Two silk ligatures are 
 now passed, one through each border of the divided 
 urethra, and are then looped and given in charge of the assistants, 
 who are instructed to carefully draw the lips of the wound apart 
 (Fig. 744). This important step exposes the mucous wall of the 
 urethra completely, enabling the operator to follow its course by 
 carefully observing the continuity of its structures. The staff is 
 now withdrawn sufficiently to show the black guide, then the beaked 
 bistoury is introduced in its course, and the stricture, together 
 with about half an inch of the canal immediately behind it, is di- 
 vided in the median line.
 
 OPERATIONS OX THE PENIS AND SCROTUM. 
 
 473 
 
 The admission of a grooved director or a small gum catheter 
 through the opening into the bladder, followed by the flow of urine, 
 assures the surgeon that he has located the proper channel ; or, after 
 
 FIG. 744. Borders of incision drawn apart 
 
 the division of the stricture, the tunneled catheter staff may be 
 passed along the whalebone guide into the bladder and the stylet 
 withdrawn, when the diagnostic urinary stream will appear. The 
 instruments are now withdrawn from the urethra, and the ordi- 
 nary sound of suitable size is introduced into the neck of the blad- 
 der, through the urethra, to determine the complete freedom of the 
 passage. 
 
 Operation without a Guide. After all efforts to introduce a whale- 
 bone guide into the bladder have failed, pass the tunneled catheter 
 staff over a whalebone guide along the urethra as far as it will go 
 without using violence ; then place the staff and guide in charge of 
 an assistant, as before. Make an incision of the usual length directly 
 in the median line down to and through the urethra into the groove 
 at the end of the staff ; pass the silken loops through the borders of 
 the incised urethra as before; check all hemorrhage, withdraw the 
 staff slightly, and examine to see if it be located in the urethral tube. 
 The lips of the urethral incision are now drawn well apart, and the
 
 474: OPERATIVE SURGERY. 
 
 operator, whose patience, care, and knowledge must now be well 
 tested, endeavors to introduce a whalebone guide or a fine probe or 
 grooved director through the stricture into the bladder by way of the 
 perineal incision. If the effort be successful, the remainder of the 
 operation is simple, and consists only in dividing the stricture with 
 the probe-pointed bistoury from above downward as before ; usually, 
 however, no anterior opening can be found, or one may be detected 
 which leads away from the median line, showing the existence of a 
 false passage. 
 
 In either case the plan of the operator must be the same. Keep in 
 the median line. If, after a patient search, no direct orifice be found, 
 it is often possible to detect it, by making moderate pressure above 
 the pubes on the bladder, which will frequently cause a few drops of 
 urine to escape from the obscure opening in the perineal cut, into 
 which a whalebone guide or a fine director can be inserted, and usu- 
 ally passed into the bladder. If the pressure accomplishes nothing, 
 then the surgeon feels for the opening in the triangular ligament, 
 through which the urethra normally passes, and cuts toward and even 
 through it if the urethra can not be found before. As he cuts he re- 
 peatedly seeks for the orifice, and closely examines for a continuation 
 of the fibrous mass in the line of his incision with the tissues compos- 
 ing the Walls of the urethra. In the obscure division of the amalga- 
 mated perineal tissues, the surgeon is also guided by the established 
 relations of the normal urethra to the arch and rami of the pubes, to 
 the tuberosities and rami of the ischium, and, still more important, 
 the relations to the rectum. The careful cutting and searching are 
 continued until an opening is found which leads into the bladder. 
 The tissue barring the passage is cut, and a small gum catheter is 
 passed along the probe or director into the organ. This is followed 
 by the welcome flow of urine. The catheter is then withdrawn, the 
 canal dilated with the little finger, and all constricting bands at the 
 roof and floor of the urethra are severed. A steel sound the size of 
 the canal is then introduced into the bladder through the urethra 
 several times until its uninterrupted entrance is assured. Increase 
 the size of the meatus and divide by internal urethrotomy all obstinate 
 strictures in front of the perineal opening. Examine the bladder for 
 stone, and, if found, remove it ; stop all bleeding ; place the patient 
 in bed with hot fomentations to the abdomen ; elevate the scrotum to 
 prevent infiltration ; administer anodynes and demulcents, and keep 
 the patient quiet. The major portion of the perineal wound may be 
 closed by antiseptic sutures carried deeply, leaving, however, sufficient 
 room for the introduction of a large flexible catheter, through the 
 neck of the bladder. The wound should be dressed antiseptically. 
 The catheter should be allowed to remain in position for four or five 
 days, unless its presence causes some degree of vesical irritation. Suit-
 
 OPERATIONS ON THE PENIS AND SCROTUM. 
 
 475 
 
 able-sized sounds should be passed every two or three days for a con- 
 siderable time at a later period. 
 
 Results. In eight thousand cases of external urethrotomy a little 
 ovej 1 five per cent died. 
 
 Internal Urethrotomy. The division of strictures by cutting in- 
 struments introduced into the urethra is called "internal urethroto- 
 my." 
 
 It is usually limited to strictures of the penile portion, although 
 sub-pubic and even those of the membranous portions may be divided. 
 The number, size, location, and extent of the obstructions should be 
 determined before their division is attempted. 
 
 For this purpose, bulbous bougies and 
 urethrometers have been devised. The me- 
 tallic bougie of Otis (Fig. 745), and also the 
 non-metallic forms (Fig. 746), meet the indica- 
 tions admirably. If it be the intention of the 
 operator to distend the canal to its fullest 
 capacity, and if the meatus be undersized, it 
 should be slit up before the stricture is divided. 
 
 FIG. 746. Non-metallic bougies. 
 
 FIG. 747. Civiale's bistouri cache. 
 
 The slitting can be easily done by means of the 
 bistouri cache of Civiale (Fig. 747). After prop- 
 erly distending the meatus, it is introduced with 
 the cutting surface downward, and quickly with- 
 drawn. The ordinary probe-pointed bistoury, 
 or a straight-edged one, with the end guarded, 
 will accomplish the purpose perfectly. The lips 
 of the cut will unite unless they be kept sepa- 
 rated by lint or cotton, or by the occasional in- 
 troduction of a large-sized sound. The location, 
 number, and size of strictures can be determined 
 by the introduction of bulbous bougies. One of 
 large size that will slip through the meatus is 
 selected, oiled, and passed down the canal until 
 arrested. The distance in the canal is noted on the handle. It is then 
 withdrawn, and the size of the bulb measured by the familiar scale. 
 
 FIG. 745. Otis' bougies 
 a boule.
 
 476 
 
 OPERATIVE SURGERY. 
 
 The surgeon next ascertains the size of the one that will pass the 
 obstruction, and so on, recording the location and size of each obstruc- 
 tion in its turn until the bladder is entered. The urethrometer of 
 Otis (Fig. 748) is constructed on a principle calculated to 
 give practically accurate measurements. The unexpanded 
 blades of the extremity of the instrument, B, are covered 
 by a small rubber cap or closed tube, C ; the instrument 
 is oiled and carried, closed, through the last obstruction, 
 if possible, when the extremity is expanded by a screw at 
 the outer end until it fills the urethra, the capacity of 
 which is noted upon the dial ; it is slowly withdrawn while 
 the expanded extremity is regulated to accommodate the 
 varied dimensions of the canal, the caliber and location of 
 which should always be noted. By this simple though- 
 ingenious method the surgeon is enabled to locate quite 
 correctly the seat of the obstacle he is to treat. The re- 
 maining instruments required are the urethrotome, and a 
 double-barreled catheter, to apply an iced-water current 
 to the canal. 
 
 Urethrotomes, like other instruments designed for spe- 
 cial purposes, vary in many important particulars. Those, 
 however, of greatest practical utility were devised by Otis 
 and Peet (Figs. 749, 750, and 751). Each bears upon its 
 handle a scale which enables the operator to ascertain not 
 only the size but the distensibility of an obstruction. 
 Either of these instruments, when taken in connection 
 with the urethrometer, enables the surgeon to divide the 
 strictured portions until the scale on the dial or handle of 
 the cutting instrument indicates that the strictured por- 
 tions of the urethra correspond in size to the dimensions 
 of the normal portions, as indicated by the dial of the 
 urethrometer. 
 
 Operation. An anaesthetic or cocaine solution is em- 
 ployed, and the patient is placed upon the back. Then a 
 well-oiled instrument is introduced, and the extremity 
 concealing the blade is carried beyond the obstruction, 
 which is dilated by turning or depressing the screw at 
 the end until the strictured tissues are made tense, when 
 the knife is withdrawn sufficiently to divide the stricture freely. The 
 action of the instrument is then reversed and the knife pushed back 
 into its hiding-place, and the instrument again dilated to note the 
 effect of the incision upon the caliber of the stricture. If it still be 
 below the standard, as indicated by the urethrometer, the blade is 
 again applied to it. In this manner each constriction can be divided 
 and the tube made of a uniform diameter throughout. If two or 
 
 FIG. 748. 
 Otis' ure- 
 thrometer.
 
 OPERATIONS OX THE PENIS AND SCROTUM. 
 
 477 
 
 more strictures hare a common, or an almost common, diameter, they 
 can be cut simultaneously by drawing the knife along the course of 
 
 the shaft. There is little danger of 
 cutting the healthy mucous mem- 
 brane, so long as the dial on the 
 urethrotome indicates a smaller di- 
 mension than that of the normal 
 urethra, as shown by the nrethrom- 
 eter. If severe hemorrhage fol- 
 
 FIGS. 749, 750. Otis' urethrotomes. 
 
 FIG. 751. Poet's urethrotome 
 
 low, a large-sized sound can be introduced, and the penis bandaged 
 to it. Cold may be applied by means of a stream of iced-water con- 
 ducted through a double-barreled catheter. It is sometimes necessary
 
 478 
 
 OPERATIVE SURGERY. 
 
 to make pressure on the perineum, in conjunction with other expedi- 
 ents. The necessity for this is extremely rare. Following urethrot- 
 
 omy the patient must 
 be kept quiet in bed 
 for three or four 
 days, with a light 
 diet and open bow- 
 els ; demulcent and 
 alkaline drinks are 
 often advisable. A 
 sound may be passed 
 every third day un- 
 til the wound is 
 healed. Very few 
 patients perish as the 
 direct result of in- 
 ternal urethrotomy, 
 
 and when carefully done upon proper cases, an unfavorable result need 
 not be anticipated. 
 
 Tapping the Urethra (Cock). In a distended bladder from impass- 
 able stricture this is a feasible operation. The patient is placed in the 
 lithotomy position, and the left index-finger introduced into the rec- 
 tum, and its tip pressed against the apex of the prostate (Fig. 752). A 
 double-edged knife is then plunged into the perineum, in the median 
 line, the point being directed to the tip of the finger, and caused to open 
 the urethra in front of the prostate, behind the stricture, by a slight lat- 
 eral motion. As the knife is withdrawn, the dimension of the wound 
 may be increased anteriorly. A grooved director is then carried into 
 the bladder through the opening, and a catheter passed upon it to re- 
 lieve the distended viscus. The opening may be made through the an- 
 terior wall of the rectum when objections exist to the perineal puncture. 
 
 FIG. 752. Tapping the urethra. 
 
 CHAPTER XVIII. 
 
 MISCELLANEOUS OPERATIONS. 
 
 Tapping the Pericardium. If the pericardium be hyper-distended 
 by fluid, or contain pus, and the attending symptoms denote danger- 
 ous heart failure from pressure, the accumulated fluid may be removed 
 by tapping or by aspiration through the trocar of Fitch. 
 
 The instrument devised by Dr. Roberts, of Philadelphia, who has
 
 MISCELLANEOUS OPERATIONS. 
 
 479 
 
 given much attention to the subject, is well adapted to the purpose 
 mentioned. The principal operation should be preceded by an explor- 
 atory puncture with a hypodermic syringe. The arteries to be avoided 
 are the mammary and intercostal ; the former rests upon the costal 
 cartilages, about a half inch from the outer border of the sternum, the 
 latter run along the lower border of the ribs. The point of the instru- 
 ment should be directed away from the apex of the heart, since the 
 latter moves from left to right and from behind forward at each pul- 
 sation. 
 
 Operation. Place the patient diagonally upon the left side, with 
 the shoulder and chest raised. Insert the instrument through the 
 fifth intercostal space, an inch or an inch and a half from the left 
 border of the sternum, close to the upper border of the sixth rib, using 
 great care to prevent the entrance of air. 
 
 Results. Nearly forty per cent of the patients have recovered 
 after the operation. 
 
 Extirpation of the Breast. The breast is removed to eradicate 
 growths of a malignant and non-malignant character. If malignant, 
 the entire gland must be 
 extirpated. If non-ma- 
 lignant, only such tissues 
 as are involved in the 
 growth need be removed. 
 If the growth be malig- 
 nant or of a doubtful 
 character, all of the en- 
 larged lymphatics in its 
 vicinity should be taken 
 away. Indeed, it is wise 
 under these conditions to remove the entire axillary system of lymphatic 
 glands, even though but one or two have become slightly enlarged. 
 The shape and extent of the growth will modify the outlines of the 
 incisions. If it be irregular, some other form rather than the estab- 
 lished elliptical cut may be employed (Figs. 753 and 754). 
 
 Operation. Wash and asepticize the part and its immediate sur- 
 roundings ; shave the axilla if the examination of the contents be con- 
 templated ; place the patient on the back and administer an anaes- 
 thetic. Eaise the arm to make tense the fibers of the pectoralis major ; 
 assume a position relative to the patient which will be most convenient 
 for making the inferior incision first (Fig. 755). A scalpel of large 
 size is now selected ; the breast pressed upward and supported by the 
 left hand, and the inferior incision made in the direction, if possible, 
 of the fibers of the pectoralis major. It should extend down to the 
 pectoral fibers, and the breast should be reflected upward from them 
 by traction with the hand, aided by the scalpel when necessary. As 
 
 FIGS. 753, 754. Incisions for removal of the breast.
 
 480 
 
 OPERATIVE SURGERY. 
 
 soon as the under surface of the tumor is raised, the upper incision is 
 made and the growth removed. The amount of hemorrhage is some- 
 times quite ex- 
 tensive ; still, it 
 can be easily kept 
 under control if 
 an assistant fol- 
 lows the course 
 of the knife with 
 an antiseptic tow- 
 el, making firm 
 pressure on the 
 bleeding points. 
 Two towels are 
 required, one for 
 each incision. 
 
 FIG. 755. Removal of the breast. 
 
 After the removal of the growth, the towels are cautiously raised from 
 below upward, and the bleeding points secured by serresfines as soon 
 as seen. Any remaining portions of the morbid growth which may 
 be attached to the pectoral fascia, muscle, etc., should be removed, 
 even at the complete sacrifice of the parts with which they are con- 
 nected. The vessels should be ligated with catgut. If any enlarged 
 glands exist in the axilla, or along the border of the great pectoral 
 muscle, they should be removed at once, together with all of their 
 associates, irrespective of their size. The wound must be properly 
 drained at its most dependent part, united with silver wire or carbol- 
 ized silk, and otherwise treated antiseptically. 
 
 Results. The rate of mortality from removal of mammary growths 
 and their axillary complications is about seventeen per cent. How- 
 ever, this mortality is offset by the fact that the operation adds twelve 
 months to the life of the patient, and when thoroughly performed 
 cures about nine per cent (Prof. S. W. Gross). 
 
 The mortuary results from limited extirpation alone are practically 
 the same as those following complete removal. It often happens that 
 the skin is too extensively diseased to admit of the formation of a suit- 
 able flap. The wound should then be allowed to heal by granulation. 
 
 Extirpation of the Axillary Glands. This operation is often neces- 
 sary when the lymphatic glands located therein become enlarged, 
 either primarily or secondarily, from malignant growths. In fact, it 
 is wise to " clean out " the space whenever one or more of these glands 
 is enlarged from this cause, even though the enlargement be slight and 
 of recent date. Whenever an axillary gland is found to be enlarged, 
 not only should this be removed, but likewise the entire series should 
 be removed^ together with the connective tissue supporting them, 
 simultaneously with the removal of the contiguous malignant growth.
 
 MISCELLANEOUS OPERATIONS. 481 
 
 Location of the Glands. These glands are normally of compara- 
 tively large size, are from ten to twelve in number, and are surrounded 
 by loose areolar tissue. There are three chains of them : one, surround- 
 ing the axillary vessels, which receive the lymphatics from the arm ; 
 another, but smaller one, runs along the lower border of the pectoralis 
 major muscle, and receives the lymphatics from the mammary gland 
 and the front of the chest ; the last chain is located along the poste- 
 rior border of the axilla and receives the lymphatics from the back. 
 There are, in addition also, two or three larger so-called subclavian 
 lymphatic glands, that are located beneath the clavicle, through which 
 the axillary and deep cervical glands communicate with each other. 
 
 Location of the Vessels. If a line be drawn through the center of 
 the long axis of the axilla, the important vessels and nerves will be 
 located within the anterior half of the space. It, therefore, follows 
 that all deep incisions should be made within the posterior half, the 
 nearer to the posterior border of the axilla the safer. 
 
 Operation. The parts should be always shaven and scrubbed be- 
 fore the operation. The operation may then be performed either by 
 extending into the axilla the incision for the removal of the primary 
 growth, or by means of an independent one. If the latter plan be 
 adopted, make an incision in the long axis of the axilla just in front 
 of the axillary border of the scapula through the integument and fas-" 
 cia, then with the fingers and the handle of the scalpel cautiously dis- 
 connect and remove the areolar tissue and glands. The large veins 
 must be carefully avoided, not so much on account of the hemorrhage 
 that may result if they be injured, as from the danger of the entrance 
 of air, due to the respiratory action. "When the removal is completed, 
 wash the space thoroughly with an antiseptic solution, introduce 
 drainage-tubes, bring the arm to the side of the chest, and dress anti- 
 septically. Keep the patient quiet, so that union by first intention 
 may be secured if possible ; for, if the wound heals by granulation, 
 there is danger of obstruction of the circulation, and crippling of the 
 movements of the arm from cicatricial contraction. 
 
 If it be found to be impossible to remove the malignant growths 
 from around the vessels, the question of amputation at the shoulder- 
 joint is to be taken into consideration. 
 
 Extirpation of the Parotid Gland. The complete removal of this 
 gland is one of the most difficult operations in surgery, especially 
 when its relations are changed by a morbid malignant growth, impli- 
 cating its structure. 
 
 Contiguous Anatomy. The space in which this gland is located is 
 deep, narrow above, broader below, and modified by the movement of 
 the lower jaw. It is bounded above by the zygoma ; below, by a line 
 extending from the angle of the inferior maxilla backward to the 
 sterno-mastoid muscle ; in front, by the posterior border of the ramus 
 31
 
 482 OPERATIVE SURGERY. 
 
 of the jaw ; behind, by the external auditory meatus and mastoid pro- 
 cess. The gland is separated from the submaxillary region by the 
 stylo-maxillary ligament, and from the deeper tissues by the styloid 
 process, and the ligaments and muscles connected with it. Prolonga- 
 tions of considerable size extend from its deep surface inward, one in 
 front and the other behind the styloid process, the former passing be- 
 hind the mastoid process and sterno-mastoid muscle, the latter to the 
 back part of the glenoid fossa. The external carotid artery passes 
 through the gland from below upward, dividing into its terminal 
 branches before its escape. Superficial to this artery there is a venous 
 trunk formed by the union of the temporal and internal maxillary 
 veins ; to this trunk the internal jugular is connected by a small 
 branch that passes through the gland structure. The facial nerve and 
 its branches traverse the gland from behind forward and receive a 
 communicating branch from the great auricular in its substance. Im- 
 mediately beneath the floor of the space lie the internal carotid artery 
 and internal jugular vein, along with the spinal accessory, glosso-pha- 
 ryngeal, and pneumogastric nerves. Lymphatic glands lie over the 
 parotid, and their enlargement may be mistaken for that of the gland 
 itself. 
 
 Contraindications to Extirpation: immobility of the tumor, and 
 a malignant growth implicating the structure of the gland. 
 
 Operation. Place the patient upon a suitable table, in a good 
 light, with the shoulders elevated and the head turned to the opposite 
 side. Make an incision from the zygoma along the central line of the 
 tumor to its lower border. If necessary, this one can be supplemented 
 by one or more extending from it at right angles. The integument- 
 ary flaps are freely reflected to expose the growth. The tumor should 
 be raised from below upward, and held by a volsella. This will raise 
 the external carotid from its bed, when it must be isolated and tied 
 between two ligatures. The vessels that enter or escape from the tu- 
 mor at this point should be treated in the same manner. The tumor 
 can now be raised upward, and its separation from the deeper tissues 
 continued by means of the fingers or handle of the scalpel ; the former 
 are the better. 
 
 The separation of the growth from the floor of the space must be 
 done gently and with great caution, on account of the contiguity of 
 the internal jugular vein and the other important vessels, and the 
 nerves located there, which, if the growth be a large one, will be 
 pressed upon by it, and may become adherent to it. It is scarcely 
 possible to avoid division of the facial nerves'if the growth be com- 
 pact. If it be soft and spongy, the integrity of the nerve may be pre- 
 served by a careful use of the fingers or director. The upper extrem- 
 ity of the gland is last removed. This step of the operation is neces- 
 sarily attended with considerable hemorrhage, which is, however, easily
 
 MISCELLANEOUS OPERATIONS. 483 
 
 controlled. After the removal, unite the flaps, establish drainage, and 
 dress antiseptically. 
 
 Results. This operation has been done upwai'd of one hundred 
 and ten times. When done for malignant growths, the disease has 
 almost invariably returned within six months. The dangers to life 
 from the operation itself, when carefully performed, are not imminent. 
 
 Paracentesis Thoracis. This operation is done to remove a fluid 
 accumulation from the chest cavity. 
 
 The instruments employed for the purpose should be one of the 
 many forms of aspirators (Figs. 580, 581). If one of these be not 
 available, the ordinary trocar and canula can be used, due heed being 
 given to the danger of the admission of air into the pleural cavity. 
 The intercostal space through which the trocar should be introduced 
 will depend upon the amount of fluid in the cavity. As a rule it may 
 be stated that the intercostal space selected should be three or four 
 inches above the lowest limit of abnormal dullness. The instrument is 
 introduced nearest to the upper border of the rib, midway between its 
 sternal and vertebral extremities, or on a line with the inferior angle 
 of the scapula. It is often very difficult, on account of obesity, to 
 determine the numerical relations of the ribs. The elevation between 
 the first and second bones of the sternum corresponds exactly to the 
 articulation of the second costal cartilages. The nipple in the male 
 is located usually between the fourth and fifth ribs. If the nipple be 
 normally located, a line carried horizontally from it around the chest 
 will pass over the sixth intercostal space in the line of the axilla ; if 
 the arm be raised, the first visible digitation of the serratus magnus 
 is attached to the sixth rib. The inferior angle of the scapula covers 
 the seventh rib, therefore the first intercostal space below it is the 
 seventh. The eleventh and twelfth ribs can be felt in corpulent per- 
 sons outside the erector spines, sloping downward. If any one of the 
 intercostal spaces below the seventh be selected, the diaphragm may 
 be punctured if the trocar be inserted incautiously. 
 
 Operation. Prop up the patient in bed, or, if able, allow him to 
 sit astride a chair with his arms resting on its back, and his head sup- 
 ported by them. The thickness of the walls of the chest and the 
 presence of fluid must first be determined by the introduction of the 
 needle of a hypodermic syringe. All the instruments and the surface 
 at the point of proposed puncture should be well carbolized. The 
 integument over the intercostal space through which the puncture is 
 to be made must be drawn upward, since, as the fluid escapes from 
 the chest, the space will descend : if this be not done, the puncture 
 through the skin will soon be above the intercostal space. A knowl- 
 edge of this fact is of immense importance if a permanent opening 
 is to be established, as in empyema. If the puncture be made in the 
 vicinity of the diaphragm, the point of the instrument must be di-
 
 OPERATIVE SURGERY. 
 
 rected upward and inward. Locate the seat of the proposed puncture 
 and make a small incision through the skin with a lance, with or with- 
 out the use of cocaine, insert the end of the instrument, and as soon 
 as the point is fully engaged in the tissues, extract the air if it be 
 connected with an aspirator, and push it quickly in, guarded by the 
 index-finger laid along its side. If the instrument become closed by 
 false membrane or floating fibrin, the obstruction must be removed by 
 a small wire passed through its lumen. The pulse and the sensations 
 of the patient must be consulted during the evacuation to avoid, if 
 possible, sudden syncope. Death is rarely directly due to this oper- 
 ation. 
 
 Perforation of the Antrum. When fluid accumulations occur in 
 this cavity, they can be removed by the trephine, or by the ordinary 
 bone-drill passed into it through its anterior wall, or into its floor 
 through the socket of the first permanent molar tooth, being careful 
 that the drill does not perforate the floor of the orbit. The cavity is 
 then washed out and the opening maintained by the introduction of 
 a gold tube, if practicable, until the function of the mucous membrane 
 is restored. 
 
 OPEEATIONS UPON THE NOSE. 
 
 Plugging the Posterior Nares (Fig. 756). This is done to arrest 
 obstinate epistaxis. The tampon or plug can be made of sponge, lint, 
 
 FIG. 756. Plugging posterior nares. 
 
 iffyk 
 
 FIG. 757. Bellocq's canula. 
 
 or of suitable cloth, and should be of a proper size to closely fit the 
 posterior naris, which in the adult is about three fourths of an inch 
 long and half an inch wide. The plug is made by tying a strong 
 ligature around the middle of the material selected for the purpose 
 and suitably arranged, cutting the ends of the ligature short, and pass- 
 ing beneath it on opposite sides of the plug two equally strong liga-
 
 MISCELLANEOUS OPERATIONS. 
 
 485 
 
 tures, which are looped around and firmly tied to the first one. The 
 canula of Bellocq (Fig. 757), with the spring withdrawn, is then car- 
 ried along the floor of the nostril to the posterior wall of the pharynx, 
 when the movable rod is projected and curves forward into the mouth. 
 The extremities of the loop at one side of the tampon are passed 
 through the instrument and down through the meatus by returning 
 the central rod and withdrawing the instrument. The tampon is 
 now carried into position by pulling upon the strings aided by the 
 finger carried behind the soft palate. Sufficient traction is made 
 upon it to forcibly close the naris, and the strings in front are tied 
 around a plug of a similar material, which closes the anterior open- 
 ing. The plug should be well carbolized before its introduction, 
 and, if need be, can be wet with astringent solutions. It should be 
 removed at the end of forty-eight hours, which can be easily done by 
 pulling on the strings remaining in the mouth while it is forced back- 
 ward by an instrument introduced through the floor of the nostril. 
 If the canula of Bellocq be not available, 
 a long, flexible probe, an ordinary gum 
 catheter, and even common wire, may be 
 utilized. Sometimes a string is carried 
 through the nostril by means of the can- 
 ula and attached to the plug, instead of 
 being tied to it before the canula is in- 
 troduced. 
 
 Removal of Nasal Polypi. If the 
 growths or pedicles be small, they can be 
 quite readily removed by forceps (Figs. 
 758 and 759) or the snare. If the forceps 
 are to be employed, the patient should sit 
 in a chair, exposed to a strong light, with 
 the head supported by an assistant, and, 
 after spraying the nares with a strong 
 solution of cocaine, the attachment of the 
 growth is seized, and it is twisted off by 
 turning the instrument several times on 
 its long axis. If the growth be attached 
 to a turbinated bone, it may be necessary 
 
 to pull away some of the bone structure before the tumor can be re- 
 moved. If the growth be situated far back or hang down into the 
 
 FIG. 158. Curved FIG. 759. 
 nasal polypus for- Straight na- 
 ceps. Bal polypus 
 
 forceps. 
 
 FIG. 760. Nasal polypus canula.
 
 486 
 
 OPERATIVE SURGERY. 
 
 fauces, it may be detached by the finger passed behind the soft palate. 
 If this fail, it may be snared (Figs. 761, 762, 763). The wire, either 
 
 o 
 
 FIG. 761. Sexton's 
 snare. 
 
 FIG. 762. Codman & 9burt- 
 Icff's snare. 
 
 FIG. 763. Jarvis' 
 polypus snare. 
 
 with or without the canula, is passed along the floor of the nose, 
 and the loop passed over the tumor (Fig. 764), by aid of the finger 
 
 FIG. 764. Removing polypus. 
 
 if necessary ; the loop is tightened and the growth severed (Fig. 765). 
 If the growth be fibrous and not accessible by the previously men- 
 tioned methods, it can then be exposed by opening the nasal cavity.
 
 MISCELLANEOUS OPERATIONS. 
 
 487 
 
 FIG. 765. Double canula in position. 
 
 The cavity of the nose may be exposed if the nose be turned upward 
 after detaching it on both sides through the also and at the junction of 
 the nasal bones with the , 
 
 nasal processes of the supe- 
 rior maxillae, and in the 
 median line to the septum. 
 After the removal of the 
 growth the parts are re- 
 stored to their normal po- 
 sition, and the edges of the 
 wound united. If this 
 method be not deemed ad- 
 visable, the nose can be 
 turned downward by mak- 
 ing a U-shaped incision 
 
 down to the bone, the convex portion of which shall cross the root of 
 the nose between the eyes and extend downward at each side of the 
 
 nose to the outer borders of the 
 alee (Fig. 766, a). The bones are 
 then sawn through in the line of 
 the incision, the septum liberated 
 at their under surface, and the 
 nose turned downward, so as to 
 expose the interior surfaces to ob- 
 servation and manipulation. If 
 the growth be a large one and 
 greater space be necessary, the 
 incision can be modified, as shown 
 by the dotted line &, and the 
 bones lying in their course sawn 
 through as before described, care 
 being taken to avoid the roots of 
 the teeth. After the removal of 
 the growth the parts are replaced 
 and confined in position by su- 
 tures, dressings, etc. Naso-pha- 
 ryngeal polypi can sometimes be 
 removed by this method (Oilier). 
 
 Langeribeck's Method. Make an incision from the junction of the 
 nasal with the frontal bone vertically downward in the median line of 
 the nose to the upper border of the cartilages of the alae, thence 
 outward upon the cheek (Fig. 767, a). Dissect off the triangular 
 flap, leaving the periosteum ; sever the alar cartilage from the nasal 
 bone, and with bone nippers sever the nasal bone from its fellow. 
 Also in the same manner separate the nasal process of the superior 
 
 FIG. 766. Lines of incision.
 
 488 
 
 OPERATIVE SURGERY. 
 
 FIG. 767. Lanerenbeck's lines of incision. 
 
 maxilla from its body, then the entire upper part of the nasal cavity 
 can be exposed by raising upward the quadrilateral plate of bone. 
 
 After the tumor is re- 
 moved, the bone can 
 be returned and fast- 
 ened in its proper 
 position. If the tu- 
 mor be still larger, it 
 may be attacked by 
 an opening through 
 the hard palate (Ne- 
 laton, Fig. 768). 
 
 Nelatorfs Method 
 (Fig. 768). Make an 
 incision in the medi- 
 an line, through the 
 soft palate down to 
 the bone ; continue 
 it forward, along the 
 posterior half of the 
 hard palate ; two oth- 
 ers are now carried obliquely outward on either side from the anterior 
 extremity of the incision along the hard palate, to the alveolar pro- 
 cess ; these flaps, including the periosteum, are reflected outward, the 
 hard palate perforated and cut away, the periosteum and mucous 
 membrane of the floor of the nose turned aside, the septum removed 
 if necessary, and the tumor will be exposed 
 to view and can be removed. The periosteal 
 flap of the hard palate should be returned to 
 the normal position, and stitched after the 
 growth is removed. The cut through the 
 soft palate can be joined subsequently. If 
 the growth be a small one, but one side of 
 the hard palate, need be attacked. Naso- 
 pharyngeal polypi may be advantageously 
 reached by this method. 
 
 Removal of Naso-Pharyngeal Polypi. 
 LangenbecTc's Method. Make a slightly 
 curved incision with the convexity down- 
 ward, extending from the ala of the nose to 
 the malar bone and as far backward as the 
 middle of the zygoma. A second incision is 
 
 made, beginning near to the center of the root of the nose, and, pass- 
 ing along the inferior margin of the orbit, it joins the former near the 
 middle of the malar bone (Fig. 767, b). These incisions should extend 
 
 FIG. 768. Nekton's method.
 
 MISCELLANEOUS OPERATIONS. 489 
 
 through the periosteum down to the bone ; the soft parts, however, are 
 not to be raised. Separate the masseter muscle from the malar bone, 
 divide the buccal fascia, depress the inferior maxilla, and pass the fin- 
 ger, if possible, into the posterior nares by carrying it through the ptery- 
 go-maxillary fissure into the spheno-maxillary fossa, thence through 
 the spheno-palatine foramen, all of which passages may have been dis- 
 tended by the morbid growth. A small key-hole saw is passed by the 
 same route, and the superior maxilla divided from behind forward ; 
 the extremity of the saw is covered by the end of the index-finger, car- 
 ried into the pharynx through the mouth, to protect the tissues from 
 being injured by it. The zygomatic process of the temporal, frontal 
 process of the malar, and orbital process of the superior maxilla are 
 sawn through to the lachrymal bone. The superior maxilla can be 
 divided in the line of the superior incision of the soft parts, thus leav- 
 ing the orbital process intact. The osteo-cutaneous flap is now raised 
 by an elevator carried beneath the malar bone and slowly lifted upward 
 and inward toward the nose, the bones and soft parts of which form 
 a hinge to the flap at that side. If the saw can not be passed into 
 the posterior nasal cavity even by the aid of a grooved director, 
 the lips of the incision of the soft parts may be drawn asunder 
 and the bone sawn from without inward and before backward. 
 Either incision exposes polypoid growths of the pharynx admirably 
 for manipulation! The operation is usually attended by quite se- 
 vere hemorrhage, which, however, can be controlled readily by press- 
 ure and an occasional ligature. After the removal of the growth, 
 the parts are adjusted and confined in position by sutures, etc. If the 
 growth to be removed be a large and vascular one, a preliminary tra- 
 cheotomy should be done. If it be malignant and very vascular, and 
 have a large attachment, I deem it a wise precaution to tie both exter- 
 nal carotids prior to removal. The dangers from hemorrhage will be 
 lessened by this measure, and, moreover, the diminished vascularity 
 of the parts will hinder the redevelopment of the growth. 
 
 Results. The rate of mortality from this method is less than 
 twenty-five per cent, and depends more on the removal of the growth 
 than upon the steps necessary to reach it. The mortality is greater 
 when the operation is done through the hard palate than when per- 
 formed by means of the displacement of the upper jaw. 
 
 Cheever's Method. In this both superior maxilla? were removed, 
 owing to the large size and central situation of the growth. He made 
 an incision from near the inner canthus on each side of the nose down- 
 ward along the natural furrow, around the ala3 to the median line of 
 the lip, which he divided. These flaps were reflected upward and 
 outward as far as the malar prominence, and the body of each supe- 
 rior maxilla was sawn from behind forward to the middle meatus of 
 the nose ; the septum and vomer were cut with scissors ; the jaws were
 
 490 OPERATIVE SURGERY. 
 
 then depressed and the tumor removed ; after which the bones were 
 replaced and wired in position. The loss of blood was not great, but 
 the patient died on the fifth day from exhaustion. 
 
 The excision of the entire upper jaw may be practiced for the re- 
 moval of these growths, or only the portion below the line of the 
 orbital floor may be removed. The superior maxilla can be raised 
 and turned outward on a hinge formed by the zygomatic process of 
 the malar bone and the contiguous soft parts, by dividing the bone 
 in the line of Ferguson's incision (Fig. 243, J), the upper portion 
 of which, for this purpose, should be extended to the malar bone. 
 The maxillse are separated by sawing through the hard palate and 
 alveolar process, and the nasal bone is disconnected from the superior 
 maxilla by severing its connections with bone-forceps. The osteo- 
 cutaneous flap can then be raised and swung outward. If necessary, 
 the soft palate may be divided. After the removal of the growths 
 the parts, including the soft palate, are adjusted and joined by su- 
 tures. 
 
 With the view of avoiding as far as possible the division of the ter- 
 minal filaments of the superior dental nerve, and obviating the loss of 
 function incident thereto, Langeubeck recommended that a curved 
 incision be made, crossing the cheek about midway between the angle 
 of the mouth and the lower border of the orbit, beginning near the 
 lower end of the nasal bone and extending downward, outward, and 
 upward so as to avoid the Stenon duct. The flaps are dissected from 
 the superior maxilla and it is removed through the opening made 
 in the soft parts. If the whole bone is to be removed, the integ- 
 rity of the superior maxillary nerve can be still further preserved by 
 removing it from the infra-orbital groove by the aid of a fine, sharp 
 chisel. 
 
 The removal of a growth of any great size from the posterior nares 
 or pharynx, especially the latter, will be attended, if its attachment 
 be extensive, by the entrance of a large amount of blood into the 
 pharynx and trachea ; it is, therefore, wise to do a preliminary trache- 
 otomy so that the lower extremity of the pharynx may be closed by 
 sponges, or otherwise tamponed. If the shoulders be elevated and 
 the head allowed to fall far backward, the blood can be removed from 
 the dependent portion of the pharynx as fast as it collects ; this posi- 
 tion, however, impedes respiration by over-extending the muscles that 
 act on the os hyoides. If a preliminary tracheotomy be done, the 
 anaesthetic must be administered through the tube. The apparatus 
 devised for this purpose by Trendelenburg (Fig. 769) may be used 
 entire, or only the inhaling portion attached to the ordinary trache- 
 otomy-tube can be employed ; the latter plan is generally to be pre- 
 ferred, since the rubber tampon attached to this tube often causes 
 bronchial irritation when inflated ; moreover, if it become ruptured
 
 MISCELLANEOUS OPERATIONS. 
 
 491 
 
 during the course of an operation, or be imperfectly distended, blood 
 may enter the trachea unawares. 
 
 .ct 
 
 FIG. 769. Trendelenburg's trachea tampon. 
 
 Deviation of the Septum Nasi. It not unfrequently occurs that both 
 the bony and cartilaginous portions of the septum are deflected to 
 such an extent as to seriously interfere with breathing through the nose 
 during attacks of coryza, and likewise impart a distinct nasal twang 
 to the voice. This deformity may or may not be associated with ex- 
 ternal modifications of the nasal symmetry. In either case the indi- 
 cation remains the same to overcome the deformity and to maintain 
 the corrected relations of the parts until recovery takes place. 
 
 Operation. The deformity can be overcome by grasping the ab- 
 normal septum between the blades of forceps especially designed for 
 the purpose (Fig. 770), which are thrust into the anterior nares and 
 closed upon the de- 
 formed septum, and 
 held for a few mo- 
 ments with suffi- 
 cient firmness to 
 press its irregulari- 
 ties into a normal 
 position. The re- 
 sistance is still fur- 
 ther overcome by cautiously turning the forceps from side to side on 
 their long axis. The pressure exerts a crushing and compressing in- 
 fluence on the septum, causing it to assume or admit of its being 
 pressed into a normal position. The retentive -apparatus is a specially 
 constructed clamp (Fig. 771), which is screwed into position while 
 grasping the septum. The instrument retains the parts thus rectified 
 until the reparative processes necessary to their permanency shall 
 take place. The clamp can be permitted to remain in position 
 two or three days, not tightly screwed for this would cause ulcera- 
 tion but closely enough to exert a gradual controlling influence. 
 This indication can likewise be well met by introducing rubber 
 
 FIG. 770. Adams' rhinoplastos forceps.
 
 492 
 
 OPERATIVE SURGERY. 
 
 FIG. 771. Adams 
 clamps. 
 
 FIG. 772. Ivory 
 plugs. 
 
 tubes of proper size and length, surrounded by oiled lint, into 
 each nostril ; these tubes by their elastic pressure answer the pur- 
 poses of the clamp, and at the same time permit air to pass unob- 
 structed through the nostrils. 
 After three or four days either 
 of the preceding appliances 
 should be replaced by ivory 
 plugs (Fig. 772), which are 
 pushed into each nostril and 
 worn at night only. It is true 
 that this treatment is annoying 
 and even attended by positive 
 discomfort, yet the almost as- 
 sured good result will amply re- 
 pay the patient for the affliction 
 incurred. In addition to this, 
 other operations are recom- 
 mended, such as the removal of 
 the inferior turbinated bone on 
 the side of the deflection ; punching the septum, to establish a com- 
 munication between the closed and the unclosed nostril. Neither 
 of these rectify the deformity, and both are open to objections, the 
 former of a physiological, the latter of a pathological nature. The 
 removal of the projecting cartilage and its mucous membrane is like- 
 wise commended. The removal of the deformed septum together 
 with a portion of the superior maxilla (Post), accomplished by sepa- 
 rating the side of the nose from the cheek, turning the nose over, 
 and thus gaining access to the obstruction, constitutes an opera- 
 tion having a severity out of proportion to that of the primary diffi- 
 culty ; and, moreover, it may be followed by an unsightly scar. It 
 is recommended that the meatus be burred out (Wagner) by means of 
 the dental engine. The results which he reports certainly give strong 
 testimony in favor of the suggestion. The deformed portion of the 
 septum may be sawn off on a plane conforming to that of the remain- 
 ing portion by first applying a strong solution of cocaine to it, then 
 removing the deformity with a narrow fine saw constructed especially 
 for the purpose. This plan is followed by Professor Bosworth, and 
 it appears to me preferable to burring or punching the septum. 
 
 BROKCHOTOMY. 
 
 This expression includes three distinct operations laryngotomy, 
 tracheotomy, and laryngo-traclieotomy, the first two of which are still 
 further- classified. These operations are comparatively easy in the 
 adult, especially if the neck be long and the landmarks well devel- 
 oped. In the infant and the child, and before puberty the periods
 
 MISCELLANEOUS OPERATIONS. 
 
 493 
 
 of life when they are most demanded the performance is most diffi- 
 cult, owing to the shortness of the neck, obesity of the patient, and 
 the rudimentary condition of the land- 
 marks. The thyroid cartilage, which 
 is well marked in the adult, constitut- 
 ing a prominent point of reckoning, is 
 scarcely discernible in the child, and 
 in the infant it is impracticable to de- 
 termine its location by physical exami- 
 nation. The cricoid cartilage is a far 
 better guide by which to determine the 
 comparative relations of the parts. It 
 is the distinctive cartilage of the laryn- 
 geal group, and, irrespective of age, it 
 can be felt as a firm, round ring, much 
 more prominent than the cartilaginous 
 rings of the trachea, which lie imme- 
 diately below it. The crico-thyroid 
 space, through which in laryngotomy 
 the deep incision is made, is located 
 immediately above the cricoid carti- 
 lage, between it and the thyroid (Fig. 
 773). It is situated at the bottom of 
 the first groove-like depression above 
 the cricoid cartilage. The crico-thy- 
 roid membrane is composed of yellow 
 elastic tissue, and is, therefore, of a yellowish appearance, and is often 
 dotted by openings for small vessels. "When incised it will retract, 
 owing to its resilient nature ; hence all hemorrhage should be 
 stopped before it is opened if the urgency of the case will per- 
 mit. It is not difficult to locate the guides in the dead subject 
 under ordinary circumstances ; but, in the living, when they are be- 
 ing jerked upward and downward by the efforts at respiration, it is 
 a matter of great difficulty, and may be impossible. The only artery 
 normally in the line of the operation of laryngotomy that need be re- 
 spected is the crico-thyroid, which runs along the upper border of the 
 space, resting on the membrane of the same name. It is troublesome, 
 not from the amount of blood it contains, but from its relation to the 
 opening in the membrane, through which a small amount of blood 
 may pass into the tube. The vessels causing the greater annoyance 
 especially if the patient be much cyanosed are the small venous 
 trunks which run across the trachea! and laryngeal region, without any 
 definitely established relationship, and which return their blood chiefly 
 into the superior thyroid veins (Fig. 774). The anterior jugular veins 
 will be troublesome, unless the median line be adhered to closely. It 
 
 FIG. 7*73. External cartilages of the 
 larynx, a. Body of hyoid bone. 6. 
 Thyroid-hyoid membrane. c. Thy- 
 roid cartilage. , d. Crico-thyroid 
 membrane, e. Cricoid cartilage, f. 
 First tracheal ring. g. Isthmus of 
 thyroid body.
 
 494 
 
 OPERATIVE SURGERY. 
 
 is unnecessary, I trust, to allude to the well-known relation between 
 the larynx and the large vessels of the neck. The thymus gland in 
 
 FIG. 774. Surgical anatomy of larynx and trachea, a. Thyroid cartilage, b. Crico-thyroid 
 membrane and artery, c. Cricoid cartilage, d. Superior thyroid vein. e. Inferior thy- 
 roid vein. /. Artcria innominata. 7t. Thyroid body. 
 
 the very young deserves respectful consideration, as will hereafter 
 appear. The choice of anaesthetics to be given in operations where 
 the respiratory function of the larynx is involved is a matter entitled 
 to some consideration. For instance, if ether be given to one who 
 has no laryngeal irritation or obstruction, the frequent spasm of those 
 parts is familiar to all. If to this be now added the deficient aeration 
 of the blood, due to a laryngeal obstruction, together with the in- 
 creased tendency to spasm, dependent on laryngeal disease, then is 
 the danger of asphyxia greatly augmented. Chloroform may be given 
 with but little danger of causing spasm ; if ether be administered, it 
 must be commenced very gradually, to avoid as much as possible the 
 occurrence of laryngeal spasms. In many instances the pressing na- 
 ture of the case will not permit the expenditure of the time necessary 
 to produce anaesthesia. In those cases presenting marked cyanosis 
 the sense of pain is much blunted, and the operation should be done 
 without anaesthesia. The instruments suitable for these operations 
 are quite numerous, yet the absence of any one or more of them is 
 not to be considered a reason for its non-performance when demanded. 
 When necessary, a pocket-knife, a hair-pin, or a toothpick, can be 
 extemporized to advantage, thus preventing the death of the patient 
 unaided because a tracheotomy-tube is not obtainable.
 
 MISCELLANEOUS OPERATIONS. 
 
 495 
 
 Tracheotomy Instruments. Two scalpels should be at hand, one 
 sharp and the other probe-pointed (Fig. 775) ; also an ordinary grooved 
 director, retractors (Figs. 776 and 777), and small spatulas, to draw 
 aside the tissues, and tracheotomy-hooks, to fix the trachea during its 
 
 FIG. 775. 
 
 Probe-pointed 
 
 scalpel. 
 
 FIG. 776. FIG. 777. FIG. 778. Lan- 
 Retractor. Tenaculum- genbeck's dou- 
 retractor. ble hook. 
 
 FIG. 779. Trousseau's 
 trachea dilator. 
 
 incision (Fig. 778). The hook illustrated is the best in use, because the 
 line of the cut can be made between its blades, and the center line of 
 
 FIG. 780. Chassaignac's trachea dilator.
 
 496 
 
 OPERATIVE SURGERY. 
 
 the trachea is therefore better assured. There are various forms of 
 tracheotomes, which should not, in my opinion, be substituted for the 
 sharp-pointed bistoury, because they are much less surgical in their 
 
 FIG. 781. Silver trachea tube. 
 
 FIG. 782. Hard rubber trachea tube. 
 
 inception and far more dangerous in their use. Dilators, too, are quite 
 numerous and varied in pattern. Trousseau's (Fig. 779) and Chas- 
 saignac's (Fig. 780) are fair representatives of them, and will answer 
 the purpose admirably. The borders of the tracheal opening can 
 always be easily drawn apart by the common tenacula or by two of the 
 ordinary grooved directors with aneurism-needle attachments. Trache- 
 otomy-tubes of various forms are employed. Figs. 781 and 782 repre- 
 sent those in every-day use, the 
 latter being of hard rubber. 
 The bivalve trachea tube (Fig. 
 783) is an admirable instru- 
 ment, since it can be introduced 
 through the opening in the 
 trachea much more readily than 
 the ordinary blunt-ended pat- 
 tern, and can be afterward 
 quickly opened by the introduc- 
 tion into it of the companion 
 tube (Fig. 784). Fig. 785 repre- 
 sents forceps for the removal of 
 foreign bodies. A long feather, 
 
 with the tip of the brush remaining, should be at hand to insert into 
 the trachea through the tube, to create the irritation sometimes neces- 
 sary to cause the expulsion of the tracheal mucus. A so-called trachea 
 aspirator has been devised to remove mucus and blood from the trachea 
 (Fig. 786). It is used as follows : After the insertion of the trachea 
 tube, place the thumb on the air-hole of the barrel ; apply the soft 
 rubber cup over the tube, and withdraw the piston, when the mucus 
 and blood will enter the barrel. It has not infrequently happened that 
 a patient is unable to expel the blood and mucus on account of stupor or 
 weakness, and the lips of the operator were used to clear the trachea. 
 
 FIGS. 783, 784. Bivalve trachea tubes.
 
 MISCELLANEOUS OPERATIONS. 497 
 
 This is obviously a hazardous procedure, if the patient have syphilis 
 or diphtheria. * The possession of the tracheal aspirator will be wel- 
 comed as prefera- 
 ble under all cir- 
 cumstances. 
 
 A serviceable 
 instrument for 
 the purpose of re- 
 moving blood, 
 etc., from the 
 
 trachea-tube, and FIG. 785. Trachea forceps, 
 
 even from the 
 
 trachea itself, can be quickly extemporized by attaching to the nozzle 
 of an ordinary two-ounce rubber syringe a soft piece of rubber tubing 
 
 FIG. 786. Trachea aspirator. 
 
 five or six inches in length. The unattached end of the rubber tubing 
 is inserted into the trachea-tube or into the trachea itself ; the piston 
 of the syringe is withdrawn somewhat quickly, and the fluid sucked 
 up. If the suction be made too quickly, the tube will be collapsed 
 and inoperative. Large portions of membrane have been drawn from 
 the bronchial tubes in this manner. 
 
 Laryngotomy. Place the patient on a table with the shoulders 
 elevated, head thrown back, and neck exposed to a strong light. At 
 least three assistants are required, especially if an anaesthetic be given. 
 Locate the cricoid cartilage, support the larynx firmly between the 
 thumb and finger of the left hand, then make an incision through the 
 integument an inch and a half in length in the adult, terminating at 
 the lower border of the cricoid cartilage, and divide the fascia on a 
 director ; divide the connections between, and separate the borders of 
 the sterno-hyoid muscles with retractors, push aside the veins and con- 
 nective tissue, and the crico-thyroid membrane will be seen. If the 
 case be not urgent, check all haemorrhge before opening the larynx. 
 If otherwise, open it at once, when the entrance of air and the resump- 
 tion of the respiratory functions will dispel the cyanosis and check the 
 bleeding. The larynx is seized and held firmly by a tenaculum while 
 the opening is made through the crico-thyroid membrane transversely 
 along the upper border of the cricoid cartilage to avoid the crico-thyroid 
 artery, that runs along the upper border of the membrane, near the thy- 
 32
 
 498 
 
 OPERATIVE SURGERY. 
 
 roid cartilage, and also to remove the tube as far as possible from the 
 vocal cords. The whistling of the ingoing air, succeeded by an expul- 
 sive cough which ejects the mucus, blood, and other matters follow 
 
 FIG. 787. Opening the trachea. 
 
 quickly after the incision. If the operation be performed for the re- 
 moval of a foreign body, it may at this time be expelled, or become 
 lodged near the opening, when it can be removed by forceps. If the 
 
 operation be performed for 
 laryngeal diphtheria, the tube 
 should not be inserted until all 
 loose membrane has been ex- 
 pelled, and such as may be 
 within reach of the forceps has 
 been pulled away. If blood 
 escape into the opening from 
 the oozing vessels, the pressure 
 of the tube upon the lips of the 
 wound will serve to check it, 
 and for this reason it may be 
 introduced early. The tube is 
 
 carried carefully in while the 
 borders of the opening are held 
 apart with the orthodox retract- 
 FIG. 788. Tube in position. or, or by means of two blunt 
 
 artery-needles or tenacula, after 
 
 which it is fastened in position by means of tapes carried around the 
 neck and tied behind (Fig. 788). If the opening be too small, it may
 
 MISCELLANEOUS OPERATIONS. 
 
 499 
 
 be increased by division of the cricoid cartilage (crico-laryngotomy). 
 The size of the tube is a matter of great importance, since if it be too 
 large it will be difficult to introduce and be followed by ulceration. 
 For patients four years and under, a tube with a caliber of a fourth of 
 an inch is sufficient, in those four to eight years of age, one third of 
 an inch, and about one half an inch for an adult. The soft parts 
 above and below the tube are closed by antiseptic sutures, the patient 
 is then placed in bed and caused to breathe air saturated with warm 
 vapor from which all floating particles of dirt should be excluded. 
 The tube is carefully watched to prevent it from becoming closed, and 
 occasionally removed and cleansed. Too great emphasis can not be 
 laid upon the necessity of instantly relieving the sudden occlusion of 
 the tube due to false membrane. For this reason, a momentary in- 
 attention, as leaving the room, etc., may prove fatal to the patient. 
 After three or four days the tube may be removed and the patient 
 allowed to breathe through the opening for a few hours, when the tube 
 must be again inserted ; later in the case it may be inserted only during 
 the night. As soon as the patient can breathe well, the tube should be 
 entirely removed, the opening closed and cleansed, and the soft parts 
 joined by a suture. If antiseptic gauze (not bichloride) or adhesive 
 plaster be placed between the surface of the neck and the flanges of the 
 tube, the danger of irritation of the soft parts by these portions of the 
 tube will be obviated (Fig. 788). 
 
 Tracheotomy is the operation usually performed upon children, 
 owing to the small size of the crico-thyroid 
 space. It is the preferable operation in all 
 instances when the incision should be made 
 as far as possible from a contagious local 
 disease. It may be done in three situations 
 above, below, and behind the isthmus of 
 the thyroid gland ; the one below the isth- 
 mus is to be preferred. The upper portion 
 of the trachea is quite superficial, while the 
 lower is from half an inch to an inch in 
 depth, depending upon the shortness of 
 the neck and the obesity of the patient. 
 The lower portion recedes, following the 
 curve of the spinal column. The vascu- 
 lar structures in this portion are far more 
 important and numerous than in other parts 
 of its course ; the inferior thyroid veins 
 
 (Fig. 789), and their communications, pass in the course of the incis- 
 ion ; the arteria thyroidea ima when present runs along the center of 
 the trachea ; the arteria innominata, especially in the child, runs ob- 
 liquely across it, at the root of the neck from left to right. The isth- 
 
 FIG. 789. Vascular relations 
 of throat.
 
 500 OPERATIVE SURGERY. 
 
 mus of the thyroid covers the second, third, and often the fourth rings 
 of the trachea ; above it is seen the communicating branch between the 
 superior thyroid veins (Fig. 774, d) ; the thymus gland, which attains 
 its full size at two years, encroaches upon the space from below up- 
 ward with each labored respiratory act, and may be incised. It is 
 sometimes difficult for the beginner, when surrounded by the turmoil 
 incident to the operation, to be certain of the location of the trachea. 
 If the index-finger be inserted into the wound, the trachea will roll un- 
 der it, and be felt ascending and descending beneath its extremity, and, 
 when sufficiently isolated, the rings can be seen and felt. The inex- 
 perienced operator is also likely to make the opening at one side of the 
 median cut, which makes it difficult to introduce the tube, causes it 
 to bind after introduction, and not infrequently, if the tissues overlap 
 the cut before its introduction, causes air to be forced between their 
 planes, creating local emphysema. If the knife be inserted too far, 
 the posterior wall of the trachea will be divided. 
 
 Operation below the Isthmus. Place the patient as for laryn- 
 gotomy, and, if practicable, administer an aneesthetic. Finally, sup- 
 port the trachea in the median line of the neck and make an incision 
 in the median line, extending from the cricoid cartilage to within 
 half an inch of the top of the sternum ; divide the fascia on a director ; 
 cautiously separate and pull aside the sterno-thyroid and sterno-hyoid 
 muscles, thus exposing the deeper cervical fascia, beneath which are 
 located the inferior thyroid veins (Fig. 789, 13) supported by connectiye 
 tissue. This fascia should be torn asunder by a blunt instrument, and 
 pushed aside along with the veins and connective tissue beneath, which 
 will expose the trachea. The blunt ends of two ordinary directors can 
 be utilized for separating the fascia, or instruments especially devised 
 for dry dissections can be employed. Throughout the entire opera- 
 tion the tissues must be drawn asunder as fast as separated, by means 
 of blunt hooks or other form of retractors, to afford ample exposure 
 of each succeeding part. As soon as the trachea is reached and all 
 hemorrhage checked, it is -seized by a hook the double one of Lan- 
 genbeck being the best drawn forward to near the surface of the 
 wound, firmly held, and three or four rings of the trachea divided ex- 
 actly in the median line from below upward, by a sharp-pointed knife 
 (Fig. 787). Then the dilator is introduced, and the tube inserted 
 and confined in position after the tracheal mucus and blood have 
 been expelled. All incisions, except the primary one, must be di- 
 rected upward to avoid the great vessels at the root of the neck. The 
 opening in the trachea should be long enough to admit the easy ex- 
 pulsion of all false membranes and foreign bodies (even an inch in 
 length is not too much for this purpose), and must likewise readily 
 admit the trachea tube. 
 
 Operation above the Isthmus. Make an incision of the usual
 
 MISCELLANEOUS OPERATIONS. 501 
 
 length, its center corresponding to the lower border of the cricoid car- 
 tilage ; divide and carefully separate the tissues as before ; the loop of 
 communication between the superior thyroid veins must be carefully 
 drawn upward ; the fascial attachment between the isthmus and the 
 cricoid cartilage divided, the isthmus pulled downward and drawn for- 
 ward by a blunt hook, when the trachea can be opened beneath it 
 from below upward, and the tube inserted with the same precautions 
 as before. 
 
 Operation through the Isthmus. This is hardly of enough prac- 
 tical importance to be entitled to a detailed consideration, since the 
 opportunities afforded above and below it will be sufficient. If, how- 
 ever, this position be selected, the isthmus should be divided between 
 two ligatures to avoid the probability of troublesome hemorrhage. It 
 sometimes happens that the isthmus is small or too illy developed to 
 be troublesome after its division. 
 
 Laryngo-tracheotomy. In this operation the larynx and trachea 
 are both opened by a continuous incision, which is usually made to 
 increase the space, that foreign bodies and false membrane may be re- 
 moved. The incision through the cricoid cartilage and upper rings 
 of the trachea is then secondary to the opening of the larynx. Before 
 the primary incision is extended, the communicating branches of the 
 superior thyroid veins should be pulled downward, the lower border 
 of the cricoid exposed, its fascial connection to the isthmus severed, 
 and the isthmus drawn downward and forward as before. 
 
 Rapid Laryngo-tracheotomy (Saint-Germain). It is sometimes 
 necessary to open the larynx very quickly ; therefore it is quite 
 proper to mention some of the points connected therewith, that the 
 surgeon may be prepared to act with dispatch combined with great 
 caution. 
 
 Operation. With the patient placed in the usual position for tra- 
 cheal operations, the surgeon locates the thyroid and cricoid cartilages 
 and the space between them. Then, standing on the right side of the 
 patient, he seizes and pushes forward the larynx by pressing the 
 thumb and index-finger between it and the vertebral column, thereby 
 making the integument tense. At the same time the index-finger 
 locates the lower border of the thyroid cartilage. A straight, sharp- 
 pointed bistoury is then seized between the thumb, index, and middle 
 fingers, its back upward, with the middle finger so placed that the 
 knife can not penetrate to exceed half an inch in depth. While thus 
 held, its point is quickly entered at the nail of the index-finger and 
 the blade is carried downward with a sawing motion, dividing the 
 crico-thyroid membrane, cricoid cartilage, and one or two rings of the 
 trachea. The opening through the integument should equal in length 
 the one made in the larynx and trachea. The dilator is introduced, 
 all bleeding checked, and the tracheal tube placed in position. Saint-
 
 502 OPERATIVE SURGERY. 
 
 Germain up to 1877 had operated by this method ninety-seven times, 
 with but three cases of hemorrhage, and one in which the posterior 
 wall of the trachea was cut. 
 
 If the tube be too large, too loose, or too angular, it is liable to 
 cause erosions and ulcerations of the trachea, which may extend 
 through it and implicate the vessels at the root of the neck, causing 
 fatal hemorrhage. The method of opening into the trachea by a sin- 
 gle incision is fraught with danger, and should not be attempted ex- 
 cept the neck of the patient be long and thin, and not even then unless 
 the exigencies of the case call for it. The division of the tissues down 
 to the trachea by means of thermo- or galvano-cautery has many advo- 
 cates ; it is not, however, the adopted practice of this country. The 
 searing of the tissues is said to prevent or lessen hemorrhage, and 
 likewise to obviate the inoculation of the incision by contagious germs. 
 This is not altogether true, since the large veins which might be oth- 
 erwise avoided are burned asunder and too often cause severe hemor- 
 rhage, which is not easily controlled because of the difficulty of prop- 
 erly securing the charred extremities of the vessels. The resulting 
 cicatrix is more disfiguring than that following other methods. It is 
 advised in bronchotomy for diphtheria and acute affections of the air- 
 passages that the tube be dispensed with, since it can only prove a 
 source of local irritation, and obstructs the exit of false membranes 
 and the secretions. As a substitute, the borders of the tracheal open- 
 ing can be kept drawn asunder by passing looped ligatures through 
 them (Martin), which are united to each other behind the neck. The 
 patient must be carefully watched with this appliance, since if the 
 head be turned the opening may become closed. If this prove trouble- 
 some, an elliptical piece can be removed from the anterior surface of 
 the tube. If the piece removed exceed a third of the diameter of the 
 tube, fatal stenosis may follow its closure. 
 
 Results. But few perish from the direct results of the preced- 
 ing operations. Bronchitis, pneumonia, hemorrhage from liberation 
 through the trachea caused by the tube, and primary hemorrhage 
 from wounds of the vessels at the root of the neck, or from any ab- 
 normally large crico-thyroid artery, constitute the leading causes of 
 death directly due to the operation. A deeply cyanosed patient, in 
 the tonic stage of angesthesia, may die, especially if blood be allowed 
 to enter the tracheal opening. In this contingency the blood must be 
 removed at once, and artificial respiration be resorted to. Tracheoto- 
 my in diphtheria is undoubtedly a most feasible operation, and should 
 be performed early, before cyanosis is well established. Dr. Monti, 
 of Vienna, in his recent work on "Croup and Diphtheria," records 
 12,736 tracheotomies for diphtheria, alone, with 3,409 recoveries, or 
 nearly twenty-eight per cent. It is estimated that twenty-five per 
 cent of these cases have been saved which otherwise would have died.
 
 MISCELLANEOUS OPERATIONS. 
 
 503 
 
 About twenty-seven and a half per cent perish after bronchotomy for 
 the removal of foreign bodies. 
 
 Intubation of the Larynx. It appears to be proper in this place to 
 consider a plan of treatment of laryngeal obstruction which has of 
 late attracted more than usual attention, especially in connection with 
 the apparatus devised for the purpose by Dr. O'Dwyer, of this city 
 (Fig. 790). "The numbers on the scale (Fig. 790, d) indicate the 
 
 8 -12 
 
 r> 7 
 
 3-4 - 
 2 
 
 1 -- 
 
 FIG. 790. O'Dwyer's instruments for intubation of the larynx, a. Mouth-gag. 
 b. Introducer, with larynx tubes, c. Extractor, d. Scale. 
 
 years for which the corresponding tubes are suitable. For instance, 
 the smallest tube when applied to the scale will reach to the first line, 
 marked 1, and is intended to be used up to the age of twelve or fifteen 
 months ; the size marked 2 is suitable for the next year, 3 and 4 for 
 these years, and so on. When the proper tube is selected for the case
 
 504 OPERATIVE SURGERY. 
 
 to be operated on, a fine thread is passed through, the small hole near 
 its anterior angle, and left long enough to hang out of the mouth 
 after the introduction of the tube, its object being to withdraw the 
 tube should it be found to have passed into the oesophagus instead of 
 the larynx. 
 
 " The obturator is then fastened tightly to the introductor, to pre- 
 vent the possibility of its rotating while being inserted and passed into 
 the tube. 
 
 " The following is the method of introducing the tube, which is 
 done without the use of an anaesthetic : The child is held upright in 
 the arms of a nurse, and the gag (Fig. 790, a) inserted in the left angle 
 of the mouth, well back between the teeth, and opened widely ; an 
 assistant holds the head, thrown somewhat backward, while the op- 
 erator inserts the index-finger of the left hand into the mouth to ele- 
 vate the epiglottis and draw the bone of the tongue forward, and at 
 the same time direct the tube into the larynx. 
 
 " The handle of the introductor (Fig. 790, b) is held close to the 
 patient's chest in the beginning of the operation, and rapidly elevated 
 as the canula approaches the glottis. The tube is then pushed down- 
 ward, without using much force. The tube is then detached. The 
 joint in the shank of the obturator is for the purpose of facilitating 
 this part of the operation. As soon as the obturator is removed, and 
 it is ascertained that the tube is in the larynx, the thread is with- 
 drawn, but at the same time the finger is kept in contact with the 
 tube to prevent its being also withdrawn. 
 
 " It is important that the attempt at introduction be made quickly, 
 as respiration is practically suspended from the time that the finger 
 enters the larynx until the obturator is removed. It is, therefore, 
 under the circumstances, much safer to make several abortive attempts 
 than one prolonged effort, even if successful. 
 
 "For the purpose of removal, the patient is held in a similar posi- 
 tion, except that the head is not inclined backward, or very slightly 
 so, and the extractor (Fig. 790, c) passed into the tube guided by the 
 index-finger of the left hand, which also fixes the epiglottis, and is 
 brought in contact with the head of the canula. Firm pressure with 
 the thumb is then made on the lever above the handle while the tube 
 is being withdrawn. If secondary dyspnoaa supervenes at any time, 
 the tube should be removed and a larger one substituted. These 
 tubes will also prove valuable as dilators in chronic stenosis of the 
 larynx or trachea." 
 
 It is recommended by Dr. O'Dwyer that preliminary practice in 
 the introduction and removal of the tube be had upon the cadaver 
 when this means of gaining experience is feasible. The removal of 
 the tube is more difficult than the introduction, on account of the 
 trouble of inserting the blades of the extractor into the open upper
 
 MISCELLANEOUS OPERATIOXS. 505 
 
 end of the tube while more or less completely hidden from view by the 
 natural position of the surrounding soft parts. This part of the 
 operation becomes especially troublesome when the patient offers any 
 opposition to the attempt, and it may become necessary under these 
 circumstances to administer an anaesthetic- before the tube can be 
 safely removed. 
 
 Prognosis. The rate of mortality in laryngeal obstruction when 
 treated by this method is not as yet well established, although it ap- 
 pears thus far to compare favorably with that following either of the 
 varieties of bronchotomy. This plan certainly offers especial advan- 
 tages for the treatment of stenosis of the larynx from other causes, 
 and for the relief of those cases of acute stenosis for which the 
 friends of the patient refuse tracheotomy as a means of relief. 
 
 Foreign Bodies in the Bronchi. It is advisable to endeavor to ex- 
 tract a foreign body located in either bronchus rather than to trust to 
 nature to expel it. Its site should be carefully determined by auscul- 
 tation it is more frequently located on the left side before the open- 
 ing is made in the trachea. After this, if a flexible probe be passed 
 through the opening in the line of the suspected bronchus, it may be 
 easily detected. The foreign body may be grasped . by forceps of a 
 proper shape and size, or a wire with a hooked extremity may be 
 passed beyond it, and withdrawn, thus displacing or removing the 
 obstruction. A loop of surgical silver wire, as suggested by Dr. J. 
 L. Little, can be pushed past it, turned somewhat and withdrawn 
 with the best of results. In any instance no harm can be done by 
 this simple agent. Half an hour is quite sufficient time to continue 
 the manipulation. 
 
 Thyrotomy. This operation consists in dividing the thyroid car- 
 tilage exactly in the median line, together with the crico-thyroid and 
 thyro-hyoid membranes when additional room is desired. Morbid 
 growths and foreign bodies in the larynx, below the false vocal cords, 
 which threaten death from asphyxia and can not be removed through 
 the mouth, demand its performance. It is wise to anticipate the dan- 
 ger that may arise from the passage of blood into the trachea, by pre- 
 liminary tracheotomy, especially if the tumor be a large or a very vas- 
 cular one. 
 
 Operation. Place the patient as for tracheotomy ; administer 
 an anaesthetic ; make an incision an inch and a half in length in the 
 median line, extending from the hyoid bone downward ; divide the 
 fascia on a director ; separate the sterno-hyoid muscles, and with a 
 grooved director press aside the tissues beneath, and expose the angle 
 of the thyroid cartilage. If the patient be a child, this will be some- 
 what difficult to discern, 6ven after the exposure ; still, the center of 
 the notch at the upper and lower borders of the cartilage marks the 
 extremities of the line of the incision to be made. The cartilage is
 
 506 OPERATIVE SURGERY. 
 
 held firmly by a tenaculum, and the division made exactly in the me- 
 dian line, with a sharp-pointed knife, down to the mucous lining 
 within. If it be divided at either side of the median line, the origin 
 of the corresponding vocal cord will be cut. After all hemorrhage is 
 checked, the mucous lining is divided and the lips of the cartilage 
 wound separated by hooked retractors, and, if need be, the incision 
 extended through the membranes above and below. The obstruction 
 is then removed and the cartilage accurately apposed and united by 
 fine catgut. The soft parts are then united and treated antiseptically. 
 If the cartilage be not accurately joined, the functions of the vocal 
 cords will be impaired, owing to their abnormal relations to each 
 other. If the cartilaginous ridge be nicked transversely before its 
 division, it can be accurately apposed thereafter by joining the carti- 
 laginous borders on the line of the nicks. 
 
 Results. Nearly eight and one half per cent die from the opera- 
 tion. 
 
 Sub-hyoid Laryngotomy, or Pharyngotomy. This operation is ad- 
 missible for the removal of foreign bodies and morbid growths situ- 
 ated high up in the air-passage, and for the relief of abscesses at the 
 base of the epiglottis. 
 
 Operation. Place the patient as for laryngotomy ; administer an 
 anaesthetic, and make an incision an inch and a half or two inches in 
 length transversely along the lower border of the hyoid bone, with its 
 center in the median line. The integument, fascia, platysma, and the 
 inner portions of each sterno-hyoid muscle, and finally the thyro- 
 hyoid, are divided on a director. The only vessel contiguous to the 
 incision is the superior thyroid artery, which runs along the upper bor- 
 der of the thyroid cartilage, parallel with the incision. As soon as 
 the thyro-hyoid membrane is cut, the epiglottis will project through 
 the opening, and must be drawn aside, when the tumor will be ex- 
 posed to view. After the removal of the growth, the wound is closed 
 and dressed antiseptically. The majority of the conditions calling for 
 this operation can be satisfactorily treated through the mouth. 
 
 Prognosis. The operation itself implies no unusual danger to the 
 patient. 
 
 Laryngectomy. The removal of the entire larynx is not a difficult 
 operation if the surrounding tissues be not involved by the disease. 
 
 Operation. Make a vertical incision in the median line from the 
 hyoid bone to the second ring of the trachea ; free the sides of the 
 larynx from its muscular attachments without opening into it ; draw 
 the trachea forward with a hook and separate it transversely from the 
 larynx ; a siphon-tube of vulcanite is then introduced, or the Tren- 
 delenburg tampon, to prevent the entrance of blood, and at the same 
 time afford a proper channel for the use of the anaesthetic. If there 
 be much oozing of blood, the head may be lowered to cause it to flow
 
 MISCELLANEOUS OPERATIONS. 507 
 
 from the trachea, when the posterior and upper connections of the 
 larynx are severed. The oesophagus must be carefully located, or it 
 may be cut. The tissues should be separated by the fingers when pos- 
 sible, aided by blunt-pointed scissors. The amount of hemorrhage 
 is trifling and easily controlled ; the branches of the superior and in- 
 ferior thyroid vessels furnish the principal bleeding points, and these 
 should be tied and divided between two ligatures before the growth is 
 separated from its connections. The after-treatment consists in keep- 
 ing the parts thoroughly cleansed, and regulating the temperature of 
 the room, together with careful attention to the tracheal tube. It 
 often happens that in addition to the larynx the hyoid bone, base of the 
 tongue, pharynx, and oesophagus, are involved in a malignant growth. 
 The first step under these circumstances is to introduce the tampon 
 canula of Trendelenburg, or a substitute, through which the anaes- 
 thetic is administered. Make a transverse incision through the skin 
 from the inner edge of one sterno-mastoid muscle to the other, pass- 
 ing half an inch above the hyoid bone ; from this carry a second one 
 vertically downward along the median line of the trachea to the in- 
 cision made to open the trachea ; turn the flaps outward ; remove all 
 large glands'in the vicinity ; divide the muscular attachments to the 
 hyoid bone ; tie the lingual and superior thyroid arteries ; excise the 
 tongue below the disease, along with the palato-pharyngeal arches if 
 necessary, carefully avoiding the external carotid arteries, when it is 
 possible ; if not, draw them forward along with the pharynx and 
 divide them between two ligatures ; cut the lingual and hypoglossal 
 nerves. The larynx is now separated from the trachea by cutting 
 the latter just below the cricoid cartilage ; a cauula is introduced 
 into it ; the parts are thoroughly washed with a carbolized solution ; 
 the flaps placed in contact with the raw surfaces without sutures, and 
 the wound sprinkled with iodoform. If the oesophagus be divided, 
 its lower extremity must be kept open and so placed that it can be 
 protected from the entrance of discharges, and become an available 
 channel through which to nourish the patient. 
 
 Results. The prognosis of complete extirpation is better than the 
 partial. In speaking of the results, Prof. S. D. Gross says : " Of 
 thirty-seven complete excisions, nineteen recovered and eighteen died, 
 at periods varying from ten to sixteen days, the cause of death in 
 twelve having been pneumonia. Of the entire number thirty were for 
 carcinoma, of which sixteen perished from the effects of the operation ; 
 seven died of the recurrence of the disease in from four to nine 
 months ; one died from an accident, and six were still living." After 
 the extirpation of the larynx, its place may be supplied by an artificial 
 appliance which, although ingenious, serves as a poor substitute for 
 the normal parts. 
 
 Cohen, of Philadelphia, in a paper on "Does Excision of the Lar-
 
 508 OPERATIVE SURGERY. 
 
 ynx tend to the Prolongation of Life ? " gives the results of sixty-five 
 complete operations, over forty of which were done for carcinoma. 
 "Without entering into the details of the cases, it is sufficient to add 
 that Dr. Cohen is of the opinion that tracheotomy and simpler means 
 give a much better chance of prolonging life. 
 
 Removal of a Goitre (Watson). When the patient is in danger of 
 suffocation, it is admissible to attempt the removal of the growth, 
 which is done in the following manner : 
 
 Operation. The patient is placed in the dorsal position with the 
 head situated so as to afford the best opportunity for breathing ; care- 
 fully administer an ansesthetic ; make a free incision in the median 
 line from the upper part of the growth to the sternal notch ; divide 
 all the tissues on a director in the line of the incision down to the 
 capsule ; draw aside the muscles covering the growth if its size will 
 permit ; if not, cut them transversely on a director ; secure all bleed- 
 ing points as fast as seen ; separate the cervical fascia from the capsule 
 of the tumor with the fingers, down to the thyroid arteries, which 
 must be ligatured. All fibrous connections between the capsule and 
 the fascia should be tied before they are cut. The capsule can now 
 be opened and its attachments to the growth severed by the scissors. 
 If the capsule be opened before the arteries are ligatured, the hemor- 
 rhage will be profuse and the ability to control it limited. After all 
 hemorrhage has ceased, the wound is closed with catgut sutures, 
 drained, and dressed antiseptically. 
 
 Results. The chance for the life of the patient is flattering. Since 
 the plan of operation just described has been practiced, less than seven 
 per cent have perished from it. The operation has been performed 
 about three hundred and forty-five times since 1877. Recently, when 
 done with antiseptic precautions, a large proportion have proved suc- 
 cessful. Total extirpation is no more fatal than incomplete. Kocher 
 has pointed out the fact that, if the thyroid body be removed before 
 adolescence, cachexia followed by idiocy of the patient are common 
 sequels. 
 
 Arthrectomy. The performance of this operation is limited sub- 
 stantially to the knee-joint, and consists in forming a flap by a semi- 
 lunar incision, similar in its outline to the one employed in excision of 
 the knee.' The flap is reflected upward, and the capsule opened at 
 each side of the patella and its ligament, or the patella may be sawn 
 across and the fragments turned upward and downward. The re- 
 mainder of the operation consists in the careful removal of all the 
 diseased portions of bone, cartilage, synovial metobrane, and liga- 
 ment, with scissors, scoops, etc. 
 
 The most difficult part of the operation is the removal of the pos- 
 terior portions of the semilunar cartilages and the synovial membrane 
 at the posterior part of the joint. Much time and patience are neces-
 
 MISCELLANEOUS OPERATIONS. 
 
 509 
 
 sary to faithfully meet the indications of this operation. - After all 
 hemorrhage has ceased, the entire cavity, including the upper syno- 
 vial pouch, must be thoroughly cleansed and drained, and an anti- 
 septic dressing applied to the limb. 
 
 Prognosis. The results thus far do not warrant the belief that this 
 operation can be employed as a suitable substitute for excision, except, 
 perhaps, in those cases where suppuration is slight, disease of the 
 bone superficial and circumscribed, and when no constitutional vice is 
 present. 
 
 Wiring the Patella. The generally 
 accepted opinion that this operation is 
 a justifiable measure in selected cases, 
 and under suitable conditions, requires 
 that its modus operandi be given some 
 attention. 
 
 Operation. An incision is made 
 transversely across the joint from one 
 condyle to the other, passing between 
 the fragments of the bone and freely ex- 
 posing the joint-cavity. All blood-clots 
 and bony asperities are removed from 
 the broken borders of the fragments. 
 The lacerated tissues about the joint are 
 trimmed away and the blood-clots turned 
 out. The fibrous tissues at the broken 
 borders of the bone are trimmed off 
 closely. Every form of blood and for- 
 eign substance must be removed from 
 the joint-cavity, especial care being tak- 
 en to cleanse the upper synovial pouch 
 and the posterior aspect of the joint. 
 Drainage should be made through the 
 posterior wall at each condyloid depres- 
 sion, carefully avoiding the nerves and 
 vessels in the popliteal space. The frag- 
 ments are then drilled (Fig. 791), and 
 one or more wire sutures introduced 
 (Fig. 792). The joint-cavity is again 
 thoroughly cleansed, all hemorrhage 
 checked, and the fragments placed in 
 contact with each other, the sutures 
 tightened, their ends twisted together, 
 cut short and turned inward from the 
 surface (Fig. 793). The cut borders of the capsule of the joint are 
 united independently by a continuous suture of fine catgut, after 
 
 FIG. 791. French bone-drill.
 
 510 
 
 OPERATIVE SURGERY. 
 
 which the superficial tissues are joined by catgut of a larger size. 
 Horse-hair drainage may be made at the sides between the tissues 
 
 FIG. 792. Wire introduced. 
 
 FIG. 793. Fragments united. 
 
 joined by the two rows of sutures. The antiseptic douching should 
 be continuous during the entire operation. The external dressings 
 are applied, and the limb is immovably fixed in an extended position. 
 After a week or ten days fresh dressings are applied, and the drainage 
 agents removed ; if suppuration has not occurred, one redressing may 
 suffice. Yet it is better to again redress the limb after a week or so, 
 when, if the wounds be healed, the limb can be confined in a plaster- 
 of- Paris splint and the patient permitted to move around. The op- 
 eration may be performed at any time during the first week or ten 
 days after the injury. If the fracture be compound, it should be 
 wired at once. In an old case, when the quadriceps extensor tissues 
 have become contracted and atrophied, a V-shaped incision through its 
 structure may be necessary in order to bring the freshened edges of 
 the fragments in contact. The olecranon process, when fractured, 
 may likewise be wired. The wire sutures need not be removed at all 
 unless they cause trouble. Silk- worm gut is sometimes employed for 
 this purpose, instead of the silver wire. 
 
 Results. Prior to 1883 the patella had been wired forty-nine 
 times, of which two of the patients died, one of pyaemia and one of 
 exhaustion. Besides these, six cases resulted in suppuration and an- 
 chylosis. During the last two years upward of a hundred and forty 
 cases have been reported, in a few of which suppuration has occurred, 
 and in two or three death has followed. In my opinion, this measure 
 should not be employed except for other reasons than that of the 
 existence of a simple fracture of the bone, because I do not believe 
 that it is good surgery to expose a patient to the contingencies of 
 suppuration, amputation, anchylosis, and even death, for the better 
 rectification of an injury, which at its worst has no tendency to ter- 
 minate fatally, and almost invariably results in a serviceable limb 
 when treated by the ordinary methods. 
 
 Movable Bodies in Joints. Movable bodies in joints not infre- 
 quently become a source of so much annoyance that the comfort of
 
 MISCELLANEOUS OPERATIONS. 511 
 
 the patient, as well as the usefulness of the limb, demand their re- 
 moval. Ordinarily these bodies appear at intervals at some point cor- 
 responding to the external line of the articulation, where they can be 
 easily felt, and where they will remain until displaced into the articu- 
 lation again by movements of the joint or by manual manipulation. 
 
 Operation. An attempt to remove these bodies should not be 
 made except under strict antiseptic precautions. The patient is given 
 an anaesthetic, or, if the object be a small one, an injection of cocaine 
 may be employed instead. After the movable body is fixed firmly in 
 position by passing into it through the superficial tissues a sharp- 
 pointed awl-like instrument, an incision is made directly down upon 
 it, all bleeding checked, and the synovial lining of the joint is carefully 
 opened sufficiently to permit the introduction of a strong pair of 
 sharp-toothed forceps, by which the movable body is grasped and care- 
 fully drawn through the incision in the soft parts. If it be adherent 
 to the deeper joint-structure, it may be either pulled or cut away. 
 The wound is closed by two rows of sutures, one of fine catgut, that 
 unites the borders of the synovial membrane and its subjacent tissue, 
 the second completely unites the remaining tissues. A few strands of 
 horse-hair or catgut introduced between the tissues united by the two 
 rows of sutures are sufficient for suitable drainage. The limb is now 
 dressed antiseptically and immovably fixed in the extended position. 
 At the end of four or five days the dressing is removed, drainage 
 agents withdrawn, and the limb redressed as in the first instance. If 
 the drainage agents are composed of a material that can be absorbed, 
 one dressing may suffice for the entire treatment of the case. If the 
 foreign bodies be not accessible during their wanderings, it may 
 become necessary to open the joint in front by a free incision to re- 
 lieve the suffering of the patient. Flexion and extension of a joint 
 often aid in the removal of these bodies. 
 
 Prognosis. The danger to life or limb is trivial when the opera- 
 tion is performed antiseptically. Belief from the suffering is certain 
 if all the offending agents be removed. 
 
 Ganglion is a name applied to a limited though abnormal collec- 
 tion of fluid found in connection with the sheaths of tendons, and 
 situated most commonly at the back of the wrist, although found not 
 infrequently at the anterior surface and in the palm. It is also de- 
 pendent on the protrusion of the synovial lining of the carpal articular 
 surfaces, through a rupture of the fibrous sheath by which they are 
 connected with each other. 
 
 Two methods of treatment are commonly employed : 1. The simple 
 or palliative method. 2. The radical or curative method. 
 
 The palliative method comprises simple measures, such as rest to 
 the part, pressure, counter-irritation, tapping, etc. These measures 
 are sometimes followed by permanent recovery.
 
 512 OPERATIVE SURGERY. 
 
 The radical method has two distinct plans of procedure : 1. The 
 rupture of the ganglion by pressure with the thumbs or by a sharp, 
 quick blow with the back of a book, while the hand is placed on the 
 knee. After this the simple measures may be employed. 2. The sac 
 may be divided subcutaneously, under antiseptic precautions, or a free 
 incision may be made through the soft parts down to the sac. It is then 
 opened, the contents evacuated, and the borders trimmed sufficiently 
 to permit their union, which is accomplished by sewing them with a 
 continuous suture of fine catgut. Antiseptic precautions should be 
 rigidly enforced during and subsequent to this plan of operation. It 
 sometimes becomes necessary to scoop or dissect out the diseased 
 membrane, especially when the disease is in the course of the tendi- 
 nous sheaths of the digits, before a cure can be effected. 
 
 The injection of irritating fluids, such as tincture of iodine, etc., 
 is recommended with much reserve. 
 
 Prognosis. The radical method of treatment is" the only one that 
 offers a fair prospect of cure, and this is not usually successful unless 
 the diseased membrane be treated by means of direct incision. If it 
 become necessary to dissect or scrape away the synovial sheaths, the 
 prognosis of usefulness of these digits is somewhat dubious. How- 
 ever, so far as the preservation of life and limb is- concerned, neither 
 is exposed to unusual danger if the surgical principles of antisepsis be 
 strictly observed. 
 
 Wiring of Bones for Compound Fractures. This operation is con- 
 sidered now to be an entirely proper one, when it can be done with 
 strict antiseptic precautions. It is indicated especially if "the tendency 
 to displacement of the fragments be great, due to either involuntaryor 
 voluntary muscular movements. 
 
 Operation. Administer an anaesthetic, and employ all antiseptic 
 precautions. Enlarge the wound of the soft parts in the direction best 
 intended to expose to view the injuries of the deeper tissues and to 
 avoid injury of the blood-vessels and nerves. Trim off the bruised 
 portions of the soft parts, both deep and superficial, with scissors. 
 The periosteum should be carefully preserved, and be replaced in the 
 normal position, when possible, even if it have been detached from the 
 bone. The disconnected fragments of bone, and other loose portions 
 of bone that can not be preserved, should be taken away. Eemove the 
 blood-clots, check the haemorrhage, and make counter-openings for 
 drainage. The fracture is now reduced, and the remaining fragments 
 are drilled and united together firmly with fine silver wire or silk-worm 
 gut. The drainage-tubes are then introduced, the openings of the 
 soft parts are closed by catgut sutures, the limb dressed antiseptically, 
 and immovably fixed by being incased in a plaster-of-Paris splint, or 
 with strips of tin or iron placed longitudinally. The general princi- 
 ples relating to antiseptic dressings should be observed in the further
 
 MISCELLANEOUS OPERATIONS. 513 
 
 treatment of the case. The wire sutures need not be remoyed unless 
 they cause trouble. 
 
 Prognosis. The prognosis is excellent. Many useful limbs have 
 been gained by this method, combined with strict antisepsis, perfect 
 immobility, and suspension, that would otherwise have been amputated 
 or have recovered with great loss of function. 
 
 33
 
 INDEX. 
 
 ABDOMINAL aorta, ligature of. 60. 
 
 linear guide to, 60. 
 Abdominal section, 362. 
 
 explorative, 362. 
 Abdominal tourniquet, Brandis', 287. 
 
 Esmarch's, 287. 
 
 Lister's, 287. 
 
 Lloyd's, 289. 
 
 Pancoast's, 287. 
 Abscess in the right iliac fossa, 373. 
 
 perityphlitic, 373. 
 Actual cautery, 35. 
 Acupressure, 31. * 
 
 pins, 32. 
 Adams' operation for subcutaneous division 
 
 of the neck of the femur, 216. 
 Adductor magnus, tenotomy of, 158. 
 Agents for controlling hemorrhage, 23. 
 Agnew's operation for radical cure of in- 
 guinal hernia, 383. 
 Air in the veins, 65. 
 
 symptoms, 55. 
 
 treatment of, 55. 
 
 preventive treatment of, 55. 
 Allis' ether-inhaler, 8. 
 Amputating knife, manner of grasping the, 
 230. 
 
 knives, 230. 
 
 knives, the catlin, 231. 
 
 saw, proper method of using an, 233. 
 
 saws, 232. 
 Amputation, agents required for, 230. 
 
 circular method, 224. 
 
 circular method, modified, 226. 
 
 classification of flaps, 224. 
 
 comparative merits of different forms of 
 flaps, 230. 
 
 double-flap method, 227. 
 
 equilateral flaps, 229. 
 
 hood flap, 229. 
 
 how to operate, 235. 
 
 Langenbeck's method, 228. 
 
 mixed double-flap method, 228. 
 
 oval method, 227. 
 
 periosteal flap, 229. 
 
 rectangular-flap method, 228. 
 
 single-flap method, 227. 
 
 Teale's method, 228. 
 
 the retractor in, 236. 
 
 Amputation at the ankle-joint, Pirogoff, 270. 
 
 Bruns' modification of Pirogoff's, 272. 
 
 Esmarch's modification of Le Fort's, 273. 
 
 Fergusson's modification of Pirogoff's, 
 271. 
 
 Le Fort's modification of Pirogoff's, 272. 
 
 Roux's, 269. 
 
 Syme's, 267. 
 
 modification of Syme's, 268. 
 Amputation of the arm, 248. 
 
 circular-flap method, 248. 
 
 large anterior and small posterior flaps, 
 250. 
 
 musculo-cutaneous flaps, Langenbeck, 249. 
 
 unequal double-flap method, 249. 
 Amputation at the elbow- joint, 247. 
 
 circular method, 247. 
 
 single-flap method, 248. 
 Amputation of the forearm, 246. 
 
 circular method, 246. 
 
 equilateral skin-flaps, 246. 
 
 musculo-cutaneous flaps, 247. 
 Amputation at the hip-joint, 287. 
 
 anterior oval method, Verneuil, 296. 
 
 circular method, Dieffenbach, 292. 
 
 lateral-flap method, 296. 
 
 long anterior and short posterior flap, 
 Maenec, 290. 
 
 single-flap method, Malgaigne, 293. 
 Amputation at the knee-joint, 278. 
 
 bilateral method, 279. 
 
 circular method, 280. 
 
 long anterior, with a short posterior flap, 
 281. 
 
 through the condyles, 281. 
 
 through the condyles, Carden, 282. 
 
 through the condyles, Gritti, 283. 
 
 Stokes' modification of Gritti's, 283. 
 Amputation of the leg, lower third, 274. 
 
 lower third, bilateral method, 276. 
 
 lower third, circular, with periosteal re- 
 flection, 274. 
 
 lower third, hood or oval flap, 277. 
 
 middle third, 277. 
 
 middle third, unilateral-flap method, 278. 
 
 supra-malleolar, 274. 
 
 upper third, 278. , 
 
 Amputation, lower extremity, 255. 
 
 through medio-tarsal joint, Chopart, 262.
 
 516 
 
 INDEX. 
 
 Amputation through medio-tarsal joint, 
 Forbes' modification of Chopart's, 264. 
 of the last four metacarpal bones, 243. 
 through the metacarpal bones, 242. 
 Amputation at the metacarpo-phalangeal ar- 
 ticulation, 239. 
 
 through all the metatarsal bones, 258. 
 Amputation, osteoplastic, of heel and ankle, 
 
 Mikulicz, 273. 
 
 Amputation of the penis, old plan, 462. 
 Hilton's modification, 462. 
 Humphrey's modification, 463. 
 Amputation at phalangeal articulations of 
 
 the hand, 237. 
 
 Amputation above the shoulder-joint, 255. 
 Amputation at the shoulder-joint, 250. 
 by circular incision, 252. 
 by internal and external flaps, Dupuytren, 
 
 250. 
 
 by oval method, Larrey, 252. 
 Spence's method, 253. 
 Amputation, subastragaloid, De Lignerolles, 
 
 264. 
 
 subastragaloid, Hancock, 266. 
 subastragaloid, Tripier's method, 266. 
 Amputation, tarsal, irregular, Moliere, 266. 
 Amputation at the tarso-metatarsal joint, 
 
 Lisfranc, 260. 
 
 Bauden's modification of Lisfranc's, 262. 
 Hey's modification of Lisfranc's, 262. 
 Skey's modification of Lisfranc's, 262. 
 Amputation of the thigh, 283. 
 
 antero-posterior musculo - integumentary 
 
 flaps, 285. 
 
 bilateral method, 284. 
 circular integumentary flap, 285. 
 long anterior-flap method, Sedillot, 286. 
 single circular incision method, Celsus, 
 
 285. 
 
 Amputation of the thumb, at the carpo-meta- 
 carpal articulation, lateral-flap method, 
 241. 
 at the carpo-metacarpal articulation, oval 
 
 method, 240. 
 
 Amputation of the toe, fifth, with its meta- 
 tarsal bone, lateral-flap method, 259. 
 fifth, with its metatarsal bone, 259. 
 great, by large square internal flap, 257. 
 great, with its metatarsal bone, 259. 
 Amputation of the toes, all, at the metatarso- 
 
 phalangeal joint, 258. 
 of toes, in their continuity, 255. 
 of toes, two adjoining, 257. 
 of single toes, 256. 
 of single toes, by lateral flap, 256. 
 Amputation of upper extremities, 236. 
 Amputation at the wrist-joint, 244. 
 circular method, 244. 
 double-flap method, Ruysch, 244. 
 radial flap, Dubrueil, 245. 
 single palmar-flap method, 245. 
 Amputations, 223. 
 Amussat's operation of left lumbar coloto- 
 
 my, 368. 
 Anaesthesia, how to prepare a patient for, 12. 
 
 Anaesthesia, local, 16. 
 Anaesthetic, purity of, 11. 
 Anaesthetics, 6. 
 
 inhalers for, 7. 
 Anchylosis, 297. 
 
 bony, of knee-joint, supra-condyloid, oste- 
 otomy for, 217. 
 
 of inferior maxilla, 178. 
 
 of inferior maxilla, removal of a wedge- 
 shaped piece, Esmarch, 179. 
 Aneurism-needle, 59. 
 
 Fletcher's, 60. 
 
 Mott's, 59. 
 
 students', 60. 
 
 Syme's, 59. 
 
 Anger's operation for hypospadias, 464. 
 Ankle and heel, osteoplastic amputation at, 
 
 Mikulicz, 273. 
 Ankle-joint, amputation at, Bruns, 272. 
 
 Fergusson's modification of Pirogoff's, 
 271. 
 
 Le Fort's modification of Pirogoff's, 272. 
 
 Le Fort's modification of Esmarch's, 273. 
 
 Pirogoff's, 270. 
 
 Roux's, 269. 
 
 Syme's, 267. 
 
 Syme's, modification of, 268. 
 Ankle-joint, excision of, 199. 
 
 excision of, subperiosteal, Langenbeck, 
 199. 
 
 disarticulation at the, 267. 
 Annandale's operation for webbed fingers, 
 
 301. 
 Antiseptic fluid, Thiersch's, 61. 
 
 protective, 48. 
 
 receptacle for instruments, 21. 
 
 solutions, 22. 
 
 spray apparatus, 48. 
 Antrum, perforation of the, 484. 
 Anus, absence of, 403. 
 
 artificial, 373. 
 
 examination of, 401. 
 
 imperforate, 402. 
 Aorta, abdominal, ligature of, 60. 
 Aorta, abdominal, linear guide to, 60. 
 Apparatus, antiseptic spray, 48. 
 
 douching, 49. 
 
 for enterectomy, Treves', 365. 
 Arch, palmar, superficial, ligature of, 106. 
 Arch, palmar, superficial, linear guide to, 
 
 106. 
 Arm, amputation of the, 248. 
 
 by large anterior and small posterior flaps, 
 250. 
 
 by musculo-cutaneous flaps, Langenbeck, 
 249. 
 
 circular-flap method, 248. 
 
 unequal double-flap method, 249. 
 Arteries, ligature of, 56. 
 
 general considerations, 56. 
 
 guides to, 56. 
 
 iliac, 62. 
 
 instruments required for, 59. 
 
 operations on special, 60. 
 Artery, abdominal aorta, ligature of, 60.
 
 INDEX. 
 
 517 
 
 Artery, abdominal aorta, linear guide to, 60. 
 
 axillary, first portion, ligature of, 95. 
 
 axillary, first portion, linear guide to, 95. 
 
 axillary, ligature of, 95. 
 
 axillary, third portion, ligature of, 97. 
 
 axillary, third portion, linear guide to, 97. 
 
 brachial, ligature of, 98. 
 
 brachial, linear guide to, 99. 
 Artery, carotid, common, ligature of, 106. 
 
 common, linear guide to, 107. 
 
 common, ligature of both, 110. 
 
 external, ligature of, 110. 
 
 external, linear guide to, 110. 
 
 internal, ligature of, 111. 
 Artery, dorsalis pedis, ligature of, 82. 
 
 dorsalis pedis, linear guide to, 82. 
 
 dorsalis penis, ligature of, 69. 
 
 epigastric, ligature of, 71. 
 
 epigastric, linear guide to, 71. 
 
 facial, ligature of, 115. 
 
 femoral, deep, ligature of, 77. 
 
 femoral, ligature of, 72. 
 
 femoral, linear guide to, 72. 
 
 gluteal, ligature of, 66. 
 
 gluteal, linear guide to, 66. 
 Artery, iliac, circumflex, deep, ligature of, 71. 
 
 iliac, common, ligature of, 62. 
 
 iliac, external, ligature of, 69. 
 
 iliac, internal, ligature of, 65. 
 Artery, innominate, ligature of, 86. 
 
 lingual, ligature of, 113. 
 
 lingual, linear guide to, 113. 
 
 mammary, internal, ligature of, 94. 
 
 mammary, internal, linear guide to, 95. 
 
 occipital, ligature of, 116. 
 
 peroneal, ligature of, 85. 
 
 peroneal, linear guide to, 85. 
 
 popliteal, ligature of, 77. 
 
 popliteal, linear guide to, 77. 
 
 profunda femoris, ligature of, 77. 
 
 pudic, internal, ligature of, 68. 
 
 pudic, internal, linear guide to, 68. 
 
 radial, ligature of, 101. 
 
 radial, linear guide to, 101. 
 
 sciatic, ligature of, 67. < 
 
 sciatic, linear guide to, 67. 
 
 subclavian, ligature of first portion, left 
 side, 87. 
 
 subclavian, ligature of first portion, right 
 side, 89. 
 
 subclavian, ligature of second portion, 92. 
 
 subclavian, ligature of third portion, 90. 
 
 subclavian, second portion, linear guide 
 to, 89. 
 
 subclavian, third portion, linear guide to, 
 89. 
 
 temporal, ligature of, 116. 
 
 thyroid, inferior, ligature of, 95. 
 
 thyroid, inferior, linear guide to, 95. 
 
 thyroid, superior, ligature of, 113. 
 
 tibial, anterior, ligature of, 79. 
 
 tibial, anterior, linear guide to, 79. 
 
 tibial, posterior, ligature of, 82. 
 
 tibial, posterior, linear guide to, 83. 
 
 ulnar, ligature cf, 104. 
 
 Artery, ulnar, linear guide to, 104. 
 vertebral, ligature of, 92. 
 vertebral, linear guide to, 93. 
 Arthrectomy, 508. 
 Artificial anus, 373. 
 Artificial hemostatics, 24. 
 Artificial respiration, 14, 54. 
 Aspiration of the bladder, 421. 
 Assistants at operations, 40. 
 Astragaloid osteotomy, Stokes', 303. 
 Astragalus, excision of, 199. 
 Auricularis magnus nerve, operations on, 
 
 146. 
 Axillary artery, first portion, ligature of, 
 
 95. 
 Axillary artery, first portion, linear guide 
 
 to, 95. 
 
 Axillary artery, ligature of, 95. 
 Axillary artery, third portion, ligature of, 
 
 97. 
 Axillary artery, third portion, linear guide 
 
 to, 97. 
 Axillary glands, extirpation of the, 481. 
 
 Bandages, 24. 
 
 elastic, 24, 54. 
 Battery, electric, 53. 
 Bauden's amputation at tarso-metatarsal 
 
 joint, 262. 
 
 Bichloride-of -mercury dressing, 51. 
 Bilateral lithotomy, 450. 
 
 Nelaton's modification of, 451. 
 Billroth's operation for excision of the 
 
 tongue, 342. 
 Birth-mark, 132. 
 Bladder, aspiration of the, 421. 
 
 digital exploration of the, 422. 
 
 extroversion of the, 423. 
 
 extroversion of the, F. F. Maury's opera- 
 tion, 423. 
 
 extroversion of the, Pancoast's operation, 
 424. 
 
 extroversion of the, Wood's operation, 
 424. 
 
 stone in the, 427. 
 
 operations on the, 416. 
 
 puncturing the, 425. 
 
 puncturing the, through the rectum, 426. 
 
 puncturing the, under the pubes, 426. 
 
 rupture of the, 421. 
 Bloodless stretching of sciatic nerve, great, 
 
 148. 
 
 Bone-forceps, 136, 163. 
 Bones, operations on, 162. 
 
 excision, 165. 
 
 gouging, 162. 
 
 osteotomy, 212 
 
 sequestrotomy, 163. 
 
 sequestrotomy, direct method, 164. 
 
 sequestrotomy, indirect method, 165. 
 
 wiring of, in compound fractures, 512. 
 Bourgary's excision of bones of forearm, 
 
 lower extremities of, 192. 
 Bow-legs, 221. 
 Brachial artery, ligature of, 98.
 
 518 
 
 INDEX. 
 
 Brachial artery, linear guide to, 99. 
 
 Brachial plexus, operations on,146. 
 
 Brandis' tourniquet, abdominal, 287. 
 
 Breast, extirpation of the, 480. 
 
 Brisement force, 297. 
 
 Bronchi, foreign bodies in the, 505. 
 
 Bronchotomy, 492. 
 
 Bruns' amputation at ankle-joint, 272. 
 
 Buchanan's medio-lateral operation of lithot- 
 omy, 451. 
 
 Buck's operation of cheiloplasty, for lower 
 
 lip, 322. 
 
 interne - lateral flap method of cheilo- 
 plasty of upper lip, 325. 
 semicircular flap method of cheiloplasty 
 of .uppper lip, 325. 
 
 Bull's (W. T.) transfusion, of saline solu- 
 tions. 130. 
 
 Bunion, 302. 
 
 Calcaneum, excision of, 198. 
 Canalization, Neuber, 47. 
 Cancer of the rectum, 412. 
 Capillaries, operations on, 131. 
 division and ligaturing, 134. 
 subcutaneous ligaturing, 132. 
 Garden's amputation at the knee-joint, 282. 
 Carotid artery, common, ligature of, 106. 
 common, linear guide to, 107. 
 external, ligature of, 110. 
 external, linear guide to, 110. 
 internal, ligature of, 111. 
 Carotid arteries, common, ligature of both, 
 
 110. 
 
 Carpo-metacarpal articulation, amputation 
 of the thumb at, by lateral-flap method, 
 241. 
 
 by oval method, 240. 
 Castration, 458. 
 Catgut ligatures, 39. 
 how prepared, 40. 
 
 Catheter, introduction of a, into the blad- 
 der, 417. 
 
 Catheterization, 417. 
 Cautery, actual, 35. 
 galvano-, 37. 
 thermo-, 36. 
 
 Celsus' circular amputation of thigh, 285. 
 method of cheiloplasty for lower lip, 
 
 321. 
 Cheever's operation for removal of naso- 
 
 pharyngeal polypi, 489. 
 Chiene's osteo-arthrotomy, 220. 
 Cheiloplasty, 320. 
 
 Buck's method of, for lower lip, 322. 
 Buck's interno-lateral flap method of, for 
 
 upper lip, 325. 
 Buck's semicircular flap method of, for 
 
 upper lip, 325. 
 
 Celsus' method of, for lower lip, 321. 
 deformity of lower lip, V-shaped incision, 
 
 320. 
 Dieffenbach's operation of, for upper lip, 
 
 326. 
 horizontal incision for lower lip, 321. 
 
 Cheiloplasty, Malgaigne's operation of, for 
 lower lip, 324. 
 
 Sedillot's operation of, for lower lip, 324. 
 
 Sedillot's vertical-flap method of, for up- 
 per lip, 326. 
 
 Syme's operation of, for lower lip, 322. 
 Chloroform, 6. 
 
 inhaler, Esmarch's, 6. 
 
 poisoning by, or overdose of, treatment 
 
 for, 14. 
 
 Cholecystectomy, 361. 
 Cholecystotomy, 360. 
 Chopart's amputation through' medio-tarsal 
 
 joint, 262. 
 Circumclusion, 32. 
 Circumcision, 458. 
 Cirsoid growths, 134. 
 Clavicle, excision of, 180. 
 Clean towels and old linen, 22. 
 Clover's ether inhaler, 9. 
 Cocaine, 17. 
 Cock's operation of tapping the urethra, 
 
 478. 
 
 Colotomy, left inguinal, linear guide to, 
 372. 
 
 left inguinal, Littre, 372. 
 
 left lumbar, Amussat, 368. 
 
 left lumbar, linear guide to, 368. 
 
 right lumbar, 372. 
 Compresses, 26. 
 Compress, graduated, 26. 
 Cone, ether, simplest form of, 7. 
 Continuous suture, 44, 349. 
 Contraction of palmar fascia, 160. 
 Cotton-batting dressing, 49. 
 Cripp's operation of excision of the rectum, 
 
 413. 
 
 Crural nerve, anterior, operations on, 149. 
 Curvature of the spine, 298. 
 Czerny's operation for radical cure of in- 
 guinal hernia, 387. 
 Czerny-Lambert intestinal suture, 351. 
 
 Davy's lever, 29, 288. 
 Decalcified drainage-tubes of Neuber, 47. 
 Deep circumflex iliac artery, ligature of, 71. 
 Deformities, 297. 
 
 of upper lip, 325. 
 Deformity of lower lip, V-shaped incision, 
 
 320. 
 De Lignerolle's amputation, subastragaloid, 
 
 264. 
 
 Delpech's operation of urethroplasty, 470. 
 De Morgan's incision for spinal accessory 
 
 nerve, 146. 
 
 Dental nerve, inferior, operations on, 144. 
 Deviation of the septum nasi, 491. 
 Dieffenbach's amputation at the hip-joint, 
 
 292. 
 operation of cheiloplasty for the upper lip, 
 
 326. 
 
 operation of rhinoplasty, 310. 
 operation of urethroplasty, 470. 
 Digital pressure, 27. 
 Disarticulation at the ankle-joint, 267.
 
 INDEX. 
 
 519 
 
 Disarticulation, at the elbow-joint, 247. 
 
 at the hip-joint, 287. 
 
 at the knee-joint, 278. 
 
 at medio-tarsal joint, 264. 
 
 at the metacarpo-phalangeal articulation, 
 239. 
 
 at the metatarso-phalangeal joint, 258. 
 
 at the phalangeal articulations of the foot, 
 256. 
 
 at the phalangeal articulations of the hand, 
 237. 
 
 at the shoulder-joint, 250. 
 
 at the tarso-metatarsal joints, 260. 
 
 at the wrist-joint, 244. 
 
 of the fingers, 237. 
 
 of the last four metacarpal bones, 243. 
 
 of the toes, 256. 
 
 sub-astragaloid, 264. 
 Dorsalis-pedis artery, ligature of, 69. 
 
 linear guide to, 82. 
 Dorsalis-penis arteiy, ligature of, 82. 
 Douching apparatus, 49. 
 Dowell's operation for radical cure of in- 
 guinal hernia, 388. 
 
 Dubrueil's amputation at the wrist-joint, 245. 
 Duodenostomy, 356. 
 
 Duplay's operation for hypospadias, 465. 
 Dupuytren's amputation at shoulder-joint, 
 250. 
 
 contraction, 160. 
 
 contraction, operation for, 160. 
 Drainage of wounds, 46. 
 Drainage, spiral, Ellis', 46. 
 Drainage-tube, decalcified, of Xeuber, 47. 
 
 rubber, 46. 
 Dressing, open, 53. 
 Dressings, bichloride of mercury, 51. 
 
 combined, 49. 
 
 cotton batting, 49. 
 
 iodoform, 49. 
 
 peat, 50. 
 
 protective, 48. 
 
 Elastic bandages, 24, 54. 
 Elbow-joint, amputation at, 247. 
 
 amputation at, circular method, 247. 
 
 amputation at, single-flap method, 248. 
 
 disarticulation at the, 247. 
 
 excision of, Huter, 189. 
 Electric battery, 53. 
 Ellis' drainage spiral, 46. 
 Elongated uvula, 335. 
 Emergencies, special, 54. 
 Empty vessels, 21. 
 Engine, surgical, 169. 
 Enterectomy, 364. 
 
 Troves' apparatus for, 365. 
 Enterotomy, 363. 
 
 right inguinal, Nelaton's operation of, 363. 
 Epigastric artery, ligature of, 71. 
 
 linear guide to, 71. 
 Epispadias, 467. 
 
 Nelaton's operation for, 467. 
 
 Thiersch's operation for, 468. 
 Erector spins, tenotomy of, 159. 
 
 Esmarch's chloroform inhaler, 6. 
 Esmarch's modification of Le Fort's ampu- 
 tation at ankle-joint, 273. 
 Esmarch's operation for anchylosis of infe- 
 rior maxilla, 179. 
 
 Esmarch's tourniquet, abdominal, 287. 
 Ether, 5. 
 
 amount required to produce anaesthesia, 10. 
 
 cone or inhaler, simplest form, 7. 
 
 dangers from use of, 11. 
 
 method of administering, 13. 
 
 treatment for poisoning by, or overdose 
 
 of, 14. 
 Ether inhaler, Allis', 8. 
 
 Clover's, 9. 
 
 Lente's modified, 9. 
 
 Noyes', 10. 
 
 simplest form of cone, 7. 
 
 Squibbs', 10.^ 
 Etherization, intestinal, 15. 
 Excision of the ankle-joint, 199. 
 
 of ankle-joint, subperiosteal, Langenbeck, 
 
 199. 
 
 Excision of the astragalus, 199. 
 Excision of bones of forearm, lower ex- 
 tremities of, Bourgary, 192. 
 Excision of the bones of the leg, 202. 
 Excision of the calcaneum, 198. 
 Excision of clavicle, 180. 
 Excision of elbow- joint, Hiiter, 189. 
 
 of the elbow-joint, Listen, 190. 
 
 of elbow- joint, subperiosteal, Langenbeck, 
 
 190. 
 
 Excision of the fibula, 202. 
 Excision of great trochanter of femur, 207. 
 Excision of hip-joint, 208. 
 
 subperiosteal, Langenbeck, 209. 
 
 Sayre, 211. 
 
 White, 208. 
 Excision of humerus, 185. 
 
 head of, subperiosteal, Langenbeck, 186. 
 
 lower extremity of, 188. 
 
 shaft of, 187. 
 
 upper end of, Langenbeck, 185. 
 Excision of the knee-joint, 202. 
 
 by transverse incision, 207. 
 
 non-subperiosteal, Mackenzie, 204. 
 
 subperiosteal, Langenbeck, 205. 
 
 subperiosteal, Oilier, 206. 
 Excision of joints of lower extremities, 197. 
 Excision of maxillae, both, 174. 
 Excision of maxilla, inferior, 175. 
 
 alveolar process, 178. 
 
 central portion, 176. 
 
 half of, 177. 
 
 lateral portion of body, 1 76. 
 
 whole of, 178. 
 Excision of maxilla, superior, 170. 
 
 below floor of orbit, 1 73. 
 
 by median incision, with removal of the 
 whole bone, 172. 
 
 subperiosteal, 173. 
 Excision of metacarpo-phalangeal joints, 
 
 197. 
 Excision of nerves, 141.
 
 520 
 
 INDEX. 
 
 Excision of the patella, 207. 
 
 Excision of phalangeal joints of hand, 197. 
 
 Excision of the radius, 192. 
 
 Excision of the rectum, 412. 
 
 Cripp's operation, 413. 
 
 Maisonneuve's operation, 414. 
 
 Volkmann's operations, 413. 
 Excision of rib, portion of, 180. 
 Excision of scapula, 182. 
 
 body of, 183. 
 
 for malignant growths, 184. 
 
 glenoid angle of, 187. 
 
 subperiosteal, Oilier, 184. 
 Excision of scrotum, 122. 
 Excision of the sternum, 179. 
 Excision of the tibia, 202. 
 Excision of the tongue, 339. 
 
 Billroth's operation, 342. 
 
 Heart's operation, 342. 
 
 Knox's operation, 342. 
 
 Kocher's operation, 343. 
 
 Regnoli's operation, 342. 
 
 Sedillot's operation, 342. 
 Excision of the tonsils, 337. 
 Excision of the ulna, 192. 
 Excision of wrist-joint, 193. 
 
 of the wrist-joint, complete, Langenbeck, 
 
 194. 
 
 Exploration, digital, of the bladder, 422. 
 Extensor communis digitorum, tenotomy of, 
 153. 
 
 longus digitorum, tenotomy of, 156. 
 
 ossis metacarpi pollicis, tenotomy of, 153. 
 
 primi internodii pollicis, tenotomy of, 153. 
 
 proprius pollicis, tenotomy of, 156. 
 
 secundi internodii pollicis, tenotomy of, 
 153. 
 
 quadriceps cruris, tenotomy of, 157. 
 Extirpation of the axillary glands, 480. 
 
 of the breast, 480. 
 
 of the parotid gland, 481. 
 
 of the penis, Gouley, 463. 
 Extroversion of the bladder, F. F. Maury's 
 operation, 423. 
 
 Pancoast's operation, 424. 
 
 Wood's operation, 424. 
 Extremities, lower, excision of joints of, 197. 
 
 Facial artery, ligature of, 115. 
 Facial nerve, operations on, 145. 
 Fasciotomy, 151. 
 Fascia, palmar, 159. 
 
 Dupuytren's contraction of, 160. 
 
 Dupuytren's operation for contraction of, 
 
 160. 
 
 Fascia, plantar, 159. 
 Fecal fistula, 373. 
 Femoral artery, ligature of, 72. 
 
 linear guide to, 72. 
 
 deep, ligature of, 77. 
 Femur, great trochanter of, excision of, 207. 
 
 neck of, subcutaneous division of, Adams, 
 
 216. 
 
 Fergusson's amputation at the ankle-joint, 
 271. 
 
 Ferguson's operation of uranoplasty, 334. 
 Fibula, excision of the, 202. 
 Fingers, disarticulation of the, 237. 
 Fingers, webbed, 300. 
 
 Annandale's operation, 301. 
 
 Nelaton's operation, 301. 
 Fistula in ano, 404. 
 
 incision with closure, 407. 
 
 operation by direct incision, 406. 
 
 treatment by ligaturing, 407. 
 Fistula, fecal, 373. 
 Fistula, salivary, 335. 
 
 Homer's operation, 336. 
 
 operation by a seton, 336. 
 Flat foot, Ogsten's operation, 302. 
 Fletcher's aneurism needle, 60. 
 Flexor, biceps cruris, tenotomy of, 157. 
 
 biceps cubiti, tenotomy of, 154. 
 
 carpi radialis, tenotomy of, 153. 
 
 carpi ulnaris, tenotomy of, 154. 
 
 longus digitorum, tenotomy of, 154. 
 
 longus pollicis, tenotomy of, 155. 
 
 profundus digitorum, tenotomy of, 153. 
 
 sublimis digitorum, tenotomy of, 153. 
 Fluid, antiseptic, Thiersch's, 51. 
 Foot, flat, Ogsten's operation, 302. 
 Forceps, artery, 33. 
 
 bone, 136, 163. 
 
 bone-holding, 167, 235. 
 
 needle, 42, 332. 
 
 throat, 348. 
 
 thumb, 18. 
 
 wire-twisting, 329. 
 Fore-arm, amputation of, 246. 
 
 circular method, 246. 
 
 equilateral skin-flaps, 246. 
 
 musculo- cutaneous flaps, 247. 
 Foreign bodies in the bronchi, 505. 
 Forbes' amputation through the medio- 
 
 tarsal joint, 264. 
 Fractures, compound, wiring of bones in, 
 
 512. 
 French operation of rhinoplasty, 307. 
 
 Gall-bladder, operations on the, 860. 
 Galvano-cautery, 37. 
 Ganglion, 511. 
 Gastro-enterostomy, 355. 
 Gastrostomy, 353. 
 Gauze, iodoform, 50. 
 Gely's intestinal suture, 350. 
 General considerations of operative sur- 
 gery, 1. 
 
 nursing, 3. 
 
 place for operation, 3. 
 
 season of year, 2. 
 
 temperature of room, 3. 
 
 time of day, 3. 
 Genu valgum, 218. 
 
 osteotomy for, 218. 
 Genu varum, osteotomy for, 220. 
 Giraldes' operation for hare-lip, 318. 
 Gland, parotid, extirpation of the, 482. 
 Glands, axillary, extirpation of the, 480. 
 Glover's suture, 44.
 
 INDEX. 
 
 Gluteal artery, ligature of, 66. 
 Goitre, removal of a, Watson, 508. 
 Gouley's operation for extirpation of the 
 
 penis, 463. 
 
 Gouley's operation for hypospadias, 464. 
 Gracilis, tenotomy of, 157. 
 Graduated compress, 26. 
 Grafting, skin, 307. 
 
 Gritti's amputation at the knee-joint, 283. 
 Grooved director, 18. 
 Guide, linear, to abdominal aorta, 60. 
 
 to axillary artery, first portion, 95. 
 
 to axillary artery, third portion, 97. 
 
 to brachial artery, 99. 
 
 to carotid artery, common, 107. 
 
 to carotid artery, external, 110. 
 
 to dorsalis pedis artery, 82. 
 
 to epigastric artery, 71. 
 
 to femoral artery, 72. 
 
 to gluteal artery, 66. 
 
 to iliac arteries, common, 62. 
 
 to iliac artery, external, 69. 
 
 to left inguinal colotomy, 372. 
 
 to left lumbar colotomy, 368. 
 
 to lingual artery, 113. 
 
 to mammary artery, internal, 95. 
 
 to palmar arch, superficial, 106. 
 
 to peroneal artery, 85. 
 
 to popliteal artery, 77. 
 
 to pudic, internal, artery, 68. 
 
 to radial artery, 101. 
 
 to sciatic artery, 67. 
 
 to subclavian artery, second portion, 89. 
 
 to subclavian artery, third portion, 89. 
 
 to thyroid artery, inferior, 95. 
 
 to tibial artery, anterior, 79. 
 
 to tibial artery, posterior, 83. 
 
 to ulnar artery, 104. 
 
 to vertebral artery, 93. 
 Guides, whalebone, introduction of, 420. 
 Gussenbauer's intestinal suture, 351. 
 
 Hallux ralgus, 222. 
 
 Hancock's subastragaloid disarticulation, 
 
 266. 
 Hare-lip, 315. 
 
 complicated, 319. 
 
 double (simple), 319. 
 
 simple, 317. 
 
 simple double-flap operation, 318. 
 
 Giraldes' operation, 318. 
 
 simple single-flap operation, 317. 
 
 sutures, 45. 
 Heart's operation for excision of the tongue, 
 
 342. 
 
 Beaton's operation for radical cure of in- 
 guinal hernia, 381. 
 
 Hemorrhage, agents for controlling, 23. 
 Hemorrhoids, 119. 
 Hemorrhoids, internal, operations for, 119. 
 
 crushing, 120. 
 
 excision, 119. 
 
 injection, 121. 
 
 ligaturing, 120. 
 
 ligaturing with incision, 120. 
 
 Hemostatics, artificial, 24. 
 Hernia, 380. 
 
 femoral, radical cure for, Wood's opera- 
 tion, 388. 
 
 femoral, strangulated, 397. 
 Hernia, inguinal, radical cure for, Agnew'a 
 operation, 383. 
 
 Czerny's operation, 387. 
 
 Dowell's operation, 388. 
 
 Beaton's operation, 381. 
 
 Wood's operation, 384. 
 
 Wood's operation with pins, 386. 
 
 Wiitzer's operation, 382. 
 Hernia, inguinal, strangulated, 395. 
 Hernia, obturator, strangulated, 401. 
 Hernia, strangulated, 390. 
 Hernia, umbilical, 389. 
 Hernia, umbilical, strangulated, 400. 
 Hey's amputation at tarso-metatarsal joint, 
 
 262. 
 
 Hilton's amputation of the penis, 462. 
 Hip-joint, amputation at, 287. 
 
 anterior oval method, Verneuil, 296. 
 
 circular method, Dieffenbach, 292. 
 
 lateral-flap method, 296. 
 
 long anterior and short posterior flap, 
 Maenec, 290. 
 
 single-flap method, Malgaigne,.293. 
 Hip-joint, excision of, 208. 
 
 Sayre, 211. 
 
 subperiosteal, Langenbeck, 209. 
 
 White, 208. 
 
 Hip-joint, disarticulation at the, 28Y. 
 Holder, needle, 42. 
 
 Homer's operation for salivary fistula, 336. 
 Horse-hair sutures, 43. 
 Humerus, excision of, 1 85. 
 
 of lower extremity of, 188. 
 
 of shaft of, 187. 
 
 subperiosteal of head of, Langenbeck, 185. 
 
 of upper end of, Langenbeck, 186. 
 Humphrey's amputation of the penis, 463. 
 Hiitcr's excision of elbow-joint, 189. 
 Bydrocele, 455. 
 
 incision of sac of, 456. 
 
 incision with excision of part of sac, 456. 
 
 injection of sac, 457. 
 
 injection of sac, accidents after, 457. 
 
 tapping of sac of, 455. 
 Hydrocephalus, 134. 
 Hydro-rachis, 135. 
 Hypertrophy of the tongue, 340. 
 Hypospadias, 463. 
 
 Anger's operation, 464. 
 
 Duplay's operation, 465. 
 
 Gouley's operation, 464. 
 
 Szymanowski's operation, 466. 
 
 Iliac artery, circumflex, deep, ligature of, 71. 
 Iliac arteries, common, ligature of, 62. 
 
 linear guide to, 62. 
 Iliac artery, external, ligature of, 69. 
 
 linear guide to, 69. 
 Iliac artery, internal, ligature of, 65. 
 
 linear guide to, 66.
 
 522 
 
 INDEX. 
 
 Imperforate anus, 402. 
 
 Imperf orate rectum, 414. 
 
 Incisions, 20. 
 
 Indian method of rhinoplasty, 311. 
 
 Infra-orbital nerve, operations on, 142. 
 
 Ingrowing toe-nail, 302. 
 
 Inhaler, chloroform, Esmarch's, 6. 
 
 Inhaler, ether, Allis', 8. 
 
 Clover's, 9. 
 
 Lente's modified, 9. 
 
 Koyes', 10. 
 
 simplest form of cone, 7. 
 
 Squibb's, 10. 
 
 Inhalers for anaesthetics, 7. 
 Innominate artery, ligature of, 86. 
 Inorganic or metallic sutures, 43. 
 Instrumental pressure for controlling hemor- 
 rhage, 28. 
 Instruments necessary for the performance 
 
 of an operation, 18. 
 Instruments, receptacle for, 21. 
 Instruments should be plain, 21. 
 Internal oasophagotomy for stricture, 346. 
 Interrupted suture, 44. 
 Intestinal etherization, 15. 
 Intestinal suture, Czerny-Lambert, 351. 
 
 Gely's, 350. 
 
 Gussenbauer's, 351. 
 
 Jobert's, 350. 
 
 Lembert's, 350. 
 
 Intubation of the larynx, O'Dwyer, 503. 
 lodoform dressing, 49. 
 lodoform gauze, 50. 
 Italian method of rhinoplasty, 312. 
 
 Jaw, lower, anchylosis of, 178. 
 
 Esmarch's operation for, 179. 
 Jaw, lower, excision of, 175. 
 
 of alveolar process of, 178. 
 
 of central portion of, 176. 
 
 of half of, 177. 
 
 of lateral portion of body of, 176. 
 
 of whole of, 178. 
 
 Jaws, upper, excision of both, 174. 
 Jaw, upper, excision of, 170. 
 
 below floor of orbit, 173. 
 
 by median incision, with removal of whole 
 bone, 172. 
 
 subperiosteal, 173. 
 Jejuuostomy, 356. 
 Jobcrt's intestinal suture, 350. 
 Joint, ankle, amputation at, Esmarch's modi- 
 fication of Le Fort's, 273. 
 
 Pirogoff, 270. 
 
 Pirogoff s, Bruns' modification of, 272. 
 
 Pirogoffs, Fergusson's modification of , 2 7 1 . 
 
 Pirogoff' s, Le Fort's modification of, 272. 
 Joint, ankle, amputation at, removal of en- 
 tire foot, Syme, 267. 
 
 removal of entire foot, modification of 
 Syme's, 268. 
 
 removal of entire foot, Roux's modifica- 
 tion of Syrae's, 269. 
 
 Joint, ankle, disarticulation at the, 267. 
 Joint, ankle, excision of, 199. 
 
 Joint, ankle, subperiosteal, Langenbeck, 199. 
 Joint, carpo-metacarpal, amputation at, 240. 
 Joint, elbow, amputation at, 247. 
 
 circular, 247. 
 
 single flap, 248. 
 
 Joint, elbow, disarticulation at the, 247. 
 Joint, elbow, excision of, Hiiter, 189. 
 
 Listen, 190. 
 
 subperiosteal, Langenbeck, 190. 
 Joint, hip, amputation at, 287. 
 
 anterior oval method, Verneuil, 296. 
 
 circular method, Dieffenbach, 292. 
 
 lateral-flap method, 296. 
 
 long anterior and short posterior flap, 
 Maenec, 290. 
 
 single-flap method, Malgaigne, 293. 
 Joint, hip, disarticulation at the, 287. 
 Joint hip, excision of, 208., 
 
 Sayre, 211. 
 
 subperiosteal, Langenbeck, 209. 
 
 White, 208. 
 Joint, knee, amputation at, 278. 
 
 bilateral method, 279. 
 
 circular method, 280. 
 
 long anterior, with a short posterior flap, 
 281. 
 
 through the condyles, Garden, 282. 
 
 through the condyles, Gritti, 283. 
 
 through the condyles, Stokes' modifica- 
 tion of Gritti's, 283. 
 Joint, knee, disarticulation at the, 278. 
 Joint, knee, excision of, 202. 
 
 by transverse incision, 207. 
 
 non-subperiosteal, Mackenzie, 204. 
 
 subperiosteal, Langenbeck, 205. 
 
 subperiosteal, Oilier, 206. 
 Joint, knee, osteotomy for bony anchylosis 
 
 of, 217. 
 
 Joint, medio-tarsal, amputation through, 
 Chopart, 262. 
 
 Forbes' modification of Chopart's, 264. 
 Joint, metacarpo-phalangeal, amputation at, 
 239. 
 
 disarticulation at, 239. 
 
 excision of, 197. 
 
 Joint, metatarso-phalangeal, amputation of 
 all the toes at, 258. 
 
 disarticulation at the, 258. 
 Joint, shoulder, amputation above the, 255. 
 Joint, shoulder, amputation at the, 250. 
 
 by circular incision, 252. 
 
 by internal and external flaps, Dupuytren, 
 250. 
 
 oval method, Larrey, 252. 
 
 Spence's method, 253. 
 Joint, shoulder, disarticulation at the, 250. 
 Joint, subastragaloid, amputation at, De 
 Lignerolle's, 264. 
 
 subastragaloid, Hancock's, 266. 
 
 subastragaloid, Tripier's, 266. 
 Joint, tarso-metatarsal, amputation, Lis- 
 franc, 260. 
 
 Bauden's modification of, 262. 
 
 Hey's modification of, 262. 
 
 Skey's modification of, 262.
 
 IXDEX. 
 
 523 
 
 Joint, wrist, amputation at, 244. 
 
 circular method, 244 
 
 double-flap method, Ruysch, 244. 
 
 radial flap, Dubrueil, 245. 
 
 single palmar flap, 245. 
 Joint, wrist, disarticulation at the, 244. 
 Joint, wrist, excision of, 193. 
 
 complete, Langenbeck, 194. 
 Joints, movable bodies in, 510. 
 Joints of lower extremities, excision of, 
 
 197. ^ 
 
 Joints, phalangeal, of foot, amputation at, 
 256. 
 
 disarticulation of the, 256. 
 
 excision of the, 197. 
 
 Joints, phalangeal, of hand, amputation at, 
 237. 
 
 disarticulation of the, 237. 
 
 excision of the, 197. 
 
 Joints, tarso-metatarsal, disarticulation at 
 the, 260. 
 
 Kelotomy, 392. 
 
 Keyes' operation for varicocele, 124. 
 
 Knee-joint, amputation at, 278. 
 
 bilateral method, 279. 
 
 circular method, 280. 
 
 long anterior, with a short posterior flap, 
 281. 
 
 through the condylcs, Garden, 282. 
 
 through the condyles, Gritti, 283. 
 
 Stokes' modification of Gritti's, 283. 
 Knee-joint, disarticulation at the, 278. 
 Knee-joint, excision of, 202. 
 
 by transverse incision, 207. 
 
 non-subperiosteal, Mackenzie, 204. 
 
 subperiosteal, Langenbeck, 205. 
 
 subperiosteal, Oilier, 206. 
 Knee-joint, osteotomy for bony anchylosis 
 
 of, 217. 
 Knife, amputating, manner of grasping the, 
 
 230. 
 
 Knife, amputating, the catlin, 231. 
 Knives, amputating, 230. 
 Knot, reef or square, 38. 
 Knots, 38. 
 Knox's operation for excision of the tongue, 
 
 342. 
 
 Kocher's operation for excision of the 
 tongue, 343. 
 
 Langenbeck's amputation of the arm, 
 
 249. 
 Langenbeck's excision of the ankle-joint, 
 
 subperiosteal, 199. 
 
 of the elbow-joint, subperiosteal, 190. 
 of the hip-joint, subperiosteal, 209. 
 of the humerus, head of, subperiosteal, 
 
 186. 
 
 of humerus, upper end of, 185. 
 of knee-joint, subperiosteal, 205. 
 of wrist- joint, complete, 194. 
 Langenbeck's method of amputation, 228. 
 Langenbeck's operation for removal of nasal 
 polypi, 487. 
 
 Langenbeck's operation for removal of naso- 
 pharyngeal polypi, 488. 
 
 of rhinoplasty, 308. 
 Lannelongue's operation of uranoplasty, 
 
 334. 
 Laparotomy or abdominal section, 362. 
 
 explorative, 362. 
 Larrey's amputation at the shoulder-joint, 
 
 252. 
 
 Laryngectomy, 506. 
 Laryngotomy, 497. 
 
 sub-hyoid, 506. 
 Laryngo-tracheotomy, 501. 
 
 rapid, St. Germain, 501. 
 Larynx, intubation of the, O'Dwyer, 503. 
 Larynx, surgical anatomy of the, 493. 
 Lateral lithotomy, 441. 
 Latissimus dorsi, tenotomy of, 158. 
 Le Fort's amputation at the ankle-joint, 272. 
 Left lumbar colotomy, Amussat, 368. 
 Leg, amputation of the, at the lower third, 
 274. 
 
 at the lower third, bilateral method, 276. 
 
 at the lower third, circular, with periosteal 
 reflection, 274. 
 
 at the lower third, hood or oval flap, 277. 
 
 supra-malleolar, 274. 
 
 through the middle third, 277. 
 
 through middle third, unilateral-flap meth- 
 od, 278. 
 
 at the upper third, 279. 
 Leg, excision of the bones of the, 202. 
 Lembert's suture, intestinal, 350. 
 Lente's ether inhaler, modified, 9. 
 Lever, Davy's, 29, 228. 
 Ligature of abdominal aorta, 60. 
 ftgaturc of arteries, 56. 
 
 general considerations of, 56. 
 
 guides to, 56. 
 
 instruments required to, 59. 
 Ligature of axillary artery, 95. 
 
 first portion, 95. 
 
 third portion, 97. 
 Ligature of brachial artery, 98. 
 Ligature of carotid arteries, common, both, 
 
 . 110. 
 Ligature of carotid artery, common, 106. 
 
 external, 110. 
 
 internal, 111. 
 Ligature of dorsalis pedis artery, 82. 
 
 of dorsalis penis artery, 69. 
 
 of epigastric artery, 71. 
 
 of facial artery, 115. 
 
 of femoral artery, 72. 
 
 of femoral artery, deep, 77. 
 
 of gluteal artery, 66. 
 Ligature of iliac artery, common, 62. 
 
 circumflex, deep, 71. 
 
 external, 69. 
 
 internal, 65. 
 Ligature of innominate artery, 86. 
 
 of lingual artery, 113. 
 
 of mammary artery, internal, 94. 
 
 of occipital artery, 116. 
 
 of palmar arch, superficial, 106.
 
 524 
 
 INDEX. 
 
 Ligature of peroneal artery, 85. 
 
 of popliteal artery, 77. 
 
 of pudic artery, internal, 68. 
 
 of radial artery, 101. 
 
 of sciatic artery, 67. 
 
 Ligature of subclavian artery, first portion, 
 left side, 87. 
 
 of first portion, right side, 89. 
 
 of second portion, 92. 
 
 of third portion, 90. 
 Ligature of temporal artery, 116. 
 
 of thyroid artery, inferior, 95. 
 
 superior, 113. 
 Ligature of tibial artery, anterior, 79. 
 
 posterior, 82. 
 Ligature of ulnar artery, 104. 
 
 of veins, 117. 
 
 of vertebral artery, 92. 
 Ligatures, 37. 
 
 catgut, how prepared antiseptically, 40. 
 
 hemp and silk, how prepared antisepti- 
 cally, 39. 
 Linear guide to abdominal aorta, 60. 
 
 to axillary artery, first portion, 95. 
 
 to axillary artery, third portion, 97. 
 
 to brachial artery, 99. 
 
 to carotid artery, common, 107. 
 
 to carotid artery, external, 110. 
 
 to dorsalis pedis artery, 82. 
 
 to epigastric artery, 71. 
 
 to femoral artery, 72. 
 
 to gluteal artery, 66. 
 
 to iliac arteries, common, 62. 
 
 to iliac artery, external, 69. 
 
 to left inguinal colotomy, 372. 
 
 to left lumbar colotomy, 368. 
 
 to lingual artery, 113. 
 
 to mammary artery, internal, 95. 
 
 to palmar arch, superficial, 106. 
 
 to peroneal artery, 85. 
 
 to popliteal artery, 77. 
 
 to pudic artery, internal, 68. 
 
 to radial artery, 101. 
 
 to sciatic artery, 67. 
 
 to subclavian artery, second portion, 89. 
 
 to subclavian artery, third portion, 89. 
 
 to thyroid artery, inferior, 95. 
 
 to tibial artery, anterior, 79. 
 
 to tibial artery, posterior, 83. 
 
 to ulnar artery, 104. 
 
 to the vertebral artery, 93. 
 Lingual artery, ligature of, 113. 
 
 linear guide to, 113. 
 Lingual nerve, operations on, 145. 
 Lip, lower, Buck's operation of cheiloplasty 
 for, 322. 
 
 Celsus' method of cheiloplasty for, 321. 
 
 Malgaigne's operation of cheiloplasty for, 
 324. 
 
 Sedillot's operation of cheiloplasty for, 
 324. 
 
 Syme's operation of cheiloplasty for, 
 
 322. 
 
 Lip, upper, Buck's interno-lateral flap 
 method of cheiloplasty, 325. 
 
 Lip, Buck's semicircular-flap method of chei- 
 loplasty, 325. 
 deformities of the, 325. 
 Dieffenbach's operation of cheiloplasty 
 
 for, 326. 
 
 entire loss of the, 325. 
 Sedillot's vertical flap method of cheilo- 
 plasty, 326. 
 Lisfranc's amputation at the tarso-metatar- 
 
 sal joint, 260. 
 
 Lister's excision of the wrist- joint, 195. 
 Lister's tourniquet, abdominal, 287. 
 Litholapaxy, 432. 
 Lithotomy, 440. 
 
 bilateral operation, 450. 
 bilateral operation, Nelaton's modifica- 
 tion of, 451. 
 lateral, 441. 
 median, 447. 
 medio-bilateral, 452. 
 medio-lateral operation, Buchanan, 451. 
 supra-pubic, 452. 
 Lithotomy in the female, 454. 
 vesico-vaginal, 455. 
 urethral, 455. 
 
 Lithotrite, introduction of the, 429. 
 Lithotrity, 428. 
 
 combined crushing and evacuating, 436. 
 in the female, 440. 
 perineal, 437. 
 rapid, 432. 
 
 Littre's operation for left inguinal coloto- 
 my, 372. 
 
 Lloyd's tourniquet, abdominal, 289. 
 Lorcta's operation for divulsion of the pylo- 
 rus, 359. 
 Loreta's retrograde divulsion for stricture 
 
 of the O3sophagus, 346. 
 Lumbar plexus, branches of, 149. 
 
 Macewen's supra-condyloid osteotomy for 
 
 genu valgum, 218. 
 Mackenzie's non-subperiosteal excision of 
 
 knee-joint, 204. 
 
 Maenec's amputation at hip-joint, 290. 
 Maisonneuve's operation of excision of the 
 
 rectum, 414. 
 
 Malgaigne's amputation at hip-joint, 293. 
 Malgaigne's operation of cheiloplasty for 
 
 lower lip, 324. 
 Mammary artery, internal, ligature of, 94. 
 
 linear guide to, 95. 
 
 Maxillae, superior, excision of both, 174. 
 Maxilla, inferior, anchylosis of, 178. 
 
 Esmarch's operation for, 179. 
 Maxilla, inferior, excision of, 175. 
 
 alveolar process of, 178. 
 
 central portion of, 176. 
 
 half of, 177. ' 
 
 lateral portion of body of, 176. 
 
 whole of, 178. 
 Maxilla, superior, excision of, 170. 
 
 below floor of orbit, 173. 
 
 by median incision, with removal of whole 
 bone, 172.
 
 INDEX. 
 
 525 
 
 Maxilla, superior, excision of, subperiosteal, 
 173. 
 
 Maxillary nerve, superior, operations on, 
 142. 
 
 Maury's (F. F.) operation for extroversion 
 of the bladder, 423. 
 
 Mechanical apparatus for loss of nasal sep- 
 tum, 310. 
 
 Mechanical means employed in uranoplasty, 
 334. 
 
 Median lithotomy, 447. 
 
 Median nerve, operations on, 147. 
 
 Medio-bilateral lithotomy, 452. 
 
 Medio-lateral lithotomy, Buchanan, 451. 
 
 Medio-tarsal joint, amputation at, Chopart, 
 
 262. 
 Forbes' modification of Chopart's, 264. 
 
 Meningocele, 135. 
 
 Metacarpal bones, amputation of last four, 
 
 243. 
 
 amputation through the, 242. 
 disarticulation of the last four, 243. 
 
 Metacarpo-phalangoal articulation, amputa- 
 tions at, 239. 
 disarticulation at, 239. 
 joints, excision of, 1 97. 
 
 Metatarsal bones, amputation through all 
 the, 258. 
 
 Metatarso-phalangeal joint, disarticulation 
 at the, 258. 
 
 Metallic sutures, 43. 
 
 Mikulicz's osteoplastic amputation at the 
 ankle-joint, 273. 
 
 Moliere's amputation at ankle, 266. 
 
 Mother's mark, 132. 
 
 Mott's aneurism needle, 59. 
 
 Movable bodies in joints, 510. 
 
 Multifidus spinse, tenotomy of, 158. 
 
 Musculo-cutaneous nerve, operations on, 
 147. 
 
 Mosculo-spiral nerve, operations on, 147. 
 
 Naevus, 132. 
 
 operations for, 132. 
 Nail, toe, ingrowing, 302. 
 Nares, posterior, plugging the, 484. 
 Nasal polypi, ^removal of, 485. 
 
 Langenbeck's operation, 487. 
 
 Nelaton's operation, 488. 
 Nasal septum, mechanical apparatus for loss 
 
 of, 310. 
 
 Naso pharyngeal polypi, removal of, Cheev- 
 er's operation, 489. 
 
 Langenbeck's operation, 488. 
 Needle, aneurism, 59. 
 
 Fletcher's, 60. 
 
 Mott's, 59. 
 
 " students'," 60. 
 
 Byrne's, 59. 
 
 Needle forceps or holders, 42. 
 Ndlaton's modification of the bilateral op- 
 eration of lithotomy, 451. 
 Nelaton's operation of enterotomy, right 
 inguinal, 363. 
 
 for epispadias, 467. 
 
 Nelaton's operation for removal of nasal 
 polypi, 488. 
 
 of urethroplasty, 470. 
 
 for webbed fingers, 301. 
 Nephrectomy, 374. 
 
 abdominal, 375. 
 
 lumbar, 375. 
 Nephro-lithotomy, 376. 
 Nephrorraphy, 376. 
 
 Nerve, auricularis magnus, operations on, 
 146. 
 
 wural, anterior, operations on, 149. 
 
 dental, inferior, operations on, 144. 
 
 facial, operations on, 146. 
 
 infra-orbital, operations on, 142. 
 
 lingual, operations on, 145. 
 
 maxillary, superior, operations on, 142. 
 
 median, operations on, 146. 
 
 musculo-cutaneous, operations on, 147. 
 
 musculo-spiral, operations on, 146. 
 
 occipital, great, operations on, 145. 
 
 perineal, operations on, 149. 
 
 plantar, operations on, 149. 
 
 popliteal, external, operations on, 148. 
 
 popliteal, internal, operations on, 148. 
 
 radial, operations on, 147. 
 
 saphenous, external or short, operations 
 on, 150. 
 
 saphenous, internal or long, operations 
 on, 150. 
 
 sciatic, great, operations on, 147. 
 
 sciatic, small, operations on, 148. 
 
 spinal accessory, operations on, 146. 
 
 supra-orbital, operations on, 141. 
 
 tibial, anterior, operations on, 148. 
 
 tibial, posterior, operations on, 148. 
 
 ulnar, operations on, 147. 
 Nerves, branches of brachiat plexus of, 
 
 operations on, 146. 
 Nerves, excision of, 141. 
 Nerves of the cranium, operations on, 141. 
 Nerves, spinal, operations on, 145. 
 Nerves, stretching of, 141. 
 Nerves, suturing of, 150. 
 Nerves, transplantation of, 151, 
 Neuber's canalization, 47. 
 Neuber's decalcified drainage-tubes, 47. 
 Nitrous oxide, 7. 
 Non-subperiosteal excision of knee-joint, 
 
 Mackenzie, 204. 
 Noyes' ether inhaler, 10. 
 
 Occipital artery, ligature of, 116. 
 Occipital nerve, great, operations on, 145. 
 O'Dwyer's intubation of the larynx, 503. 
 (Esophagectomy, 346. 
 CEsophagostomy, 347. 
 (Esophagotomy, 344. 
 
 internal, for stricture, 346. . 
 (Esophagus, removal of foreign bodies from, 
 347. 
 
 stricture of the, 345. 
 
 stricture of the, retrograde divulsion for, 
 
 Loreta, 346. 
 Ogsten's osteo-arthrotomy, 220.
 
 526 
 
 INDEX. 
 
 Ogsten's operation for flat-foot, 302. 
 Ollicr's operation for osteoplastic 1 rhino- 
 
 plasty, 313. 
 Ollier's subperiosteal excision of knee-joint, 
 
 206. 
 Ollier's subperiosteal excision of scapula, 
 
 184. 
 
 Open dressing for wounds, 53. 
 Operating table, 21. 
 
 Operation, antiseptic, preparation for, 52. 
 Operations, assistants at, 40. 
 
 nursing after, 3. 
 
 place for, 3. 
 
 preparatory treatment for, 4. 
 
 requirements, essential, 4. 
 
 requirements, necessary, 4. 
 
 requirements, precautionary, 63. 
 
 season of year for, 2. 
 
 surroundings of patient after, 3. 
 
 temperature of room after, 3. 
 
 time of day for, 3. 
 Operations on bones, 162. 
 
 excision, 165. 
 
 gouging, 162. 
 
 osteotomy, 212. 
 
 sequestrotomy, 163. 
 
 sequestrotomy, direct method, 1 64. 
 
 sequestrotomy, indirect method, 165. 
 Operations on the gall-bladder, 360. 
 Operations on hollow viscera in contact with 
 
 serous surfaces, 348. 
 Operations on special ai-teries, 60. 
 Operations on the palate, 329. 
 Operations on the stomach, 352. 
 Operation wounds, treatment of, 41. 
 Operative surgery, general considerations. 1. 
 Osteo-arthrotoiny, Chiene, 220. 
 
 Ogsten, 220. 
 
 Reeves, 220. 
 Osteoplastic amputation of heel and ankle, 
 
 Mikulicz, 273. 
 Osteoplastic rhinoplasty, 313. 
 
 Ollier's method, 313. 
 
 Pancoast's method, 314. 
 
 Sabine, T. T., 314. 
 Osteotomy, 212. 
 
 for genu varum, 220. 
 
 inter-trochanteric, Sayre, 217. 
 
 inter-troehanteric, Volkmann, 217. 
 
 supra-condyloid, for bony anchylosis of 
 knee-joint, 217. 
 
 supra-condyloid, for genu valgura, Mac- 
 ewen, 218. 
 
 astragaloid, Stokes, 303. 
 
 Palate, operations upon the, 329. 
 Palmar arch, superficial, ligature of, 1 06. 
 
 linear guide to, 106. 
 Palmar fascia, 159. 
 
 Dupuytrcn's contraction of, 160. 
 
 Dupuytren's operation for contraction of, 
 
 160. 
 
 Pancoast's operation for extroversion of the 
 bladder, 424. 
 
 operation for rhinoplastic osteoplasty, 314. 
 
 Pancoast's tourniquet, abdominal, 287. 
 Paracentesis abdominis, 377. 
 Paracentesis thoracis, 483. 
 Paraphymosis, 461. 
 Parotid gland, extirpation of the, 482. 
 Patella, excision of, 207. 
 
 wiring the, 509. 
 Peat dressing, 50. 
 Pectineus, tenotomy of, 158. 
 Penis, amputation of the, old plan, 462. 
 
 Hilton's modification, 462. 
 
 Humphrey's modification, 463. 
 Penis, extirpation of the, Gouley's opera- 
 tion, 463. 
 
 Perforation of the antrum, 484. 
 Pericardium, tapping the, 479. 
 Perineal lithotrity, 437. 
 Perineal nerve, operations on, 149. 
 Perineal section, 471. 
 Perineal urcthrotomy, external, 471. 
 
 with a guide, 472. 
 
 without a guide, 473. 
 Perityphlitic abscess, 373. 
 Pcroneal artery, ligature of, 85. 
 
 linear guide to, 85. 
 Peroneus brevis, tenotomy of, 155. 
 Peroneus longus, tenotomy of, 155. 
 Peroneus tertius, tenotomy of, 156. 
 Phalangeal articulations of the hand, am- 
 putations at the, 237. 
 
 of the hand, disarticulation at, 237. 
 
 of the foot, disarticulation at, 256. 
 Phalangeal joints, excision of, 197. 
 Pharyngotomy, 506. 
 Phlebotomy, 125. 
 Pins, acupressure, 32. 
 Pirogoflf's amputation at the ankle-joint, 
 
 270. 
 
 Plantar fascia, operations on, 159. 
 Plantar nerve, operations on, 149. 
 Plaster-of-Paris jacket, Sayre's, for curva- 
 ture of the spine, 298. 
 Plastic surgery, 304. 
 
 preparation of patient, 304. 
 
 size of flap, 304. 
 Plastic surgery, methods of transfer, 306. 
 
 grafting, 307. 
 
 inversion or eversion, 306. 
 
 jumping, 306. 
 
 skin-grafting, 307. 
 
 sliding, 305. 
 
 Taliacotian operation, 306. 
 Plexus of nerves, brachial, operations on 
 branches of, 146. 
 
 lumbar, operations on branches of, 
 
 149. 
 
 Plugging the posterior nares, 484. 
 Polypi, nasal, removal of, 485. 
 
 Langenbeck's operation, 487. 
 
 Nelaton's operation, 488. 
 Polypi, naso-pharyngeal, removal of, Chcev- 
 er's operation, 489. 
 
 Langenbeck's operation, 488. 
 Popliteal artery, ligature of, 77. 
 
 linear guide to, 77.
 
 INDEX. 
 
 527 
 
 Popliteal nerve, external, operations on, 148. 
 
 internal, operations on, 148. 
 Precautionary requirements for operations, 
 
 53. 
 Preparations for an antiseptic operation, 52. 
 
 assistants, 52. 
 
 douching, 52. 
 
 instruments, 52. 
 
 operating-table, 52. 
 
 operator, 52. 
 
 patient, 52. 
 
 the wound, 52. 
 
 Pressure, digital, for controlling hemor- 
 rhage, 27. 
 
 instrumental, for controlling hemorrhage, 
 
 28. 
 
 Proctotomy, external, 412. 
 Prolapsus ani, 409. 
 Protective, antiseptic, 48. 
 
 dressings, 48. 
 Pudic artery, internal, linear guide to, 68. 
 
 ligature of, 68. 
 Puncturing the bladder, 425. 
 
 through the rectum, 426. 
 
 under the pubes, 426. 
 Pylorus, divulsion of, Loreto's operation, 
 
 359. 
 Pylorus, resection of the, 356. 
 
 Quadriceps extensor cruris, tenotomy of, 
 
 157. 
 Quilled suture, 45. 
 
 Eadial artery, ligature of, 101. 
 
 linear guide to, 101. 
 Radial nerve, operations on, 147. 
 Radius, excision of, 192. 
 Ranula, 338. 
 Rapid laryngo-tracheotomy, St. Germain, 
 
 501. 
 
 Rapid lithotrity, 432. 
 
 Receptacle, antiseptic, for instruments, 21. 
 Rectal examination, introduction of whole 
 
 hand, 409. 
 Rectotomy, 412. 
 Rectum, cancer of the, 412. 
 Rectum, excision of the, 412. 
 
 Cripp's operation, 413. 
 
 Maisonneuve's operation, 414. 
 
 Volkmann's operations, 413. 
 Rectum, imperforate, 414. 
 
 stricture of the, 414. 
 
 surgical anatomy of, 408. 
 Reef or square knot, 38. 
 Reeves' osteo-arthrotomy, 220. 
 Regnoli's excision of the tongue, 342. 
 Removal of a goitre, Watson, 508. 
 Removal of nasal polypi, 485. 
 
 Langenbeck's operation, 487. 
 
 Nelaton's operation, 488. 
 Removal of naso-pharyngeal polypi, Cheev- 
 er's operation, 489. 
 
 Langenbeck's operation, 488. 
 Requirements, precautionary, for opera- 
 tions, 53. 
 
 Resection of the pylorus, 356. 
 Respiration, artificial, 14, 54. 
 Retractors, 59. 
 Retroclusion, 32. 
 Rhinoplasty, 307. 
 
 Dieffenbach's operation, 310. 
 
 French operation, 307. 
 
 Indian operation, 311. 
 
 Italian operation, 312. 
 
 Langenbeck's operation, 308. 
 
 loss of the bony or cartilaginous septum, 
 with or without loss of nasal bones, 
 309. 
 Rhinoplasty, osteoplastic, 313. 
 
 Ollier's operation, 313. 
 
 Pancoast's operation, 314. 
 
 SabSne, T. T., 314. 
 Rib, excision of a portion of a, 180. 
 Ricord's operation for varicocele, 125. 
 Rigaud's operation of urethroplasty, 470. 
 Rod, Trendelenburg's, 31, 288. 
 Roux's amputation at ankle-joint, 269. 
 Rubber drainage-tube, 46. 
 Rupture of the bladder, 421. 
 Ruysch's amputation at the wrist-joint, 244. 
 
 Sabine, T. T., osteoplastic rhinoplasty, 314. 
 Saline solutions for transfusion, 129, 130. 
 Salivary fistula, 335. 
 
 Homer's operation, 336. 
 
 operation by a seton, 336. 
 Saphenous nerve, external or short, opera- 
 tions on, 150. 
 
 internal or long, operations on, 150. 
 Sartorius, tenotomy of, 157, 158. 
 Sayre's excision of hip-joint, 211. 
 
 intertrochanteric osteotomy, 217. 
 
 plaster-of-Paris jacket for curvature of 
 
 the spiqe, 298. 
 Saw, amputating, proper method of using 
 
 an, 233. 
 
 Saws, amputating, 232. 
 Scalpel, method of holding, 18. 
 Scapula, excision of, 182. 
 
 body of, 183. 
 
 for malignant growths, 184. 
 
 glenoid angle of, 187. 
 
 subperiosteal, Oilier, 184. 
 Schwartz's saline solution for transfusion, 
 
 130. 
 Sciatic artery, ligature of, 67. 
 
 linear guide to, 67. 
 Sciatic nerve, great, operations on, 146. 
 
 small, operations on, 147. 
 Scissors, 20. 
 
 Scrotum, excision of, 122. 
 Section, abdominal, 362. 
 
 explorative, 362. 
 Sedillot's amputation of thigh, 286. 
 
 operation for removal of the tongue, 342. 
 
 operation of cheiloplasty, for lower lip, 
 324. 
 
 vertical-flap method of cheiloplasty of 
 
 upper lip, 326. 
 Semi-membranosus, tenotomy of, 157.
 
 528 
 
 INDEX. 
 
 Semi-tendinosus, tenotomy of, 157. 
 Septum nasi, deviation of the, 491. 
 Scquestrotomy, 163. 
 
 direct method, 164. 
 
 indirect method, 165. 
 Serrefines, 33. 
 Shock, 55. 
 
 treatment of, 55. 
 
 Shoulder-joint, amputation above, 255. 
 Shoulder-joint, amputation at, 250. 
 
 by circular incision, 252. 
 
 by internal and external flaps, Dupuytren, 
 250. 
 
 oval method, Larrey, 252. 
 
 Spence's method, 253. 
 Shoulder-joint disarticulation at the, 250. 
 Silk ligatures, how prepared antiseptically, 
 
 39. 
 Skey's amputation at tarso-metatarsal joint, 
 
 262. 
 
 Skin-grafting, 307. 
 Solutions, antiseptic, 22. 
 
 saline, for transfusion, 129, 130. 
 Sound, introduction of a, into the bladder, 
 
 417. 
 
 Special emergencies, 54. 
 Spence's amputation at the shoulder-joint, 
 
 253. 
 Spinal accessory nerve, operations on, 
 
 146. 
 Spine, curvature of, 298. 
 
 Sayre's plaster-of-Paris jacket for, 298. 
 Spiral drainage, Ellis', 46. 
 Splenectomy, 377. 
 Spray apparatus, antiseptic, 48. 
 Square or reef knot, 38. 
 Squibb's ether inhaler, 10. 
 Staphyloplasty, 335. 
 Staphylorrhaphy, operation of, 330. 
 Sterno-cleido-mastoid, tenotomy of, 159. 
 Sternum, excision of, 179. 
 St. Germain's operation of rapid laryngo- 
 
 trachcotomy, 501. 
 Stimulants, 53. 
 Stokes' amputation at knee-joint, 283. 
 
 astragaloid osteotomy, 303. 
 Stomach, operations on the, 352. 
 Stomatoplasty, 327. 
 Stone in the bladder, 427. 
 Strangulated hernia, 390. 
 
 femoral, 397. 
 
 inguinal, 395. 
 
 obturator, 401. 
 
 umbilical, 400. 
 Stretching of nerves, 141. 
 
 bloodless, of the sciatic nerve, 148. 
 Stricture of the oesophagus, 345. 
 
 of the urethra, operations for, 471. 
 
 of the rectum, 414. 
 " Students' " aneurism needle, 60. 
 Styptics, 24. 
 
 Subastragaloid disarticulation, De Ligne- 
 rolles, 264. 
 
 Hancock, 266. 
 
 Tripier, 266. 
 
 Subclavian artery, ligature of first portion, 
 left side, 87. 
 
 of first portion, right side, 89. 
 
 of second portion, 92. 
 
 of third portion, 90. 
 
 Subclavian artery, second portion, linear 
 guide to, 89. 
 
 third portion, linear guide to, 89. 
 Sub-hyoid laryngotomy, 506. 
 Subperiosteal excision of ankle-joint, Lan- 
 genbeck, 199. 
 
 of elbow-joint, Langenbeck, 190. 
 
 of hip-joint, Langenbeck, 209. 
 
 of hip -joint, Say re, 211. 
 
 of humerus, head of, Langenbeck, 186. 
 
 of jaw, upper, 173. 
 
 of knee-joint, Langenbeck, 205. 
 
 of knee-joint, Oilier, 206. 
 
 of maxilla, superior, 173. 
 
 of scapula, Oilier, 184. 
 Supra-malleolar amputation of the leg, 
 
 274. 
 
 Supra-orbital nerve, operations on, 141. 
 Supra-pubic lithotomy, 452. 
 Surgical engine, 169. 
 Suture, continuous, 44, 349. 
 
 different forms of, 44. 
 
 glover's, 44. 
 
 hare-lip, 45. 
 
 horse-hair, 43. 
 
 inorganic, 43. 
 
 interrupted, 44. 
 
 intestinal, Czerny-Lembert, 351. 
 
 Gely's, 350. 
 
 Gussenbauer's, 351. 
 
 Jobert's, 350. 
 
 Lembert's, 350. 
 
 metallic, 43. 
 
 quilled, 45. 
 
 twisted, 45. 
 Sutures, 42. 
 Suturing of nerves, 150. 
 
 of tendons, 161. 
 
 Syme's amputation at ankle-joint, 267. 
 Syme's aneurism needle, 60. 
 Syme's operation of cheiloplasty for lower 
 
 lip, 322. 
 Szumann's saline solution for transfusion, 
 
 130. 
 Szymanowski's operation for hypospadias, 
 
 466. 
 
 Szymanowski's operation of urethroplasty, 
 471. 
 
 Table, operating, 21. 
 Tapping hydrocele, 455. 
 
 the pericardium, 479. 
 
 the urethra, Cock, 478. 
 Tarsal amputations, irregular, Moliere, 266. 
 Tarsectomy, 303. 
 
 Tarso-metatarsal joint, amputation at, Lis- 
 franc, 260. 
 
 Bauden's modification of, 262. 
 
 Hey's modification of, 262. 
 
 Skey's modification of, 262.
 
 INDEX. 
 
 529 
 
 Tarso-metatarsal joints, disarticulation at ! 
 
 the, 260. 
 Taxis, 391. 
 
 Teale's method of amputation, 228. 
 Temporal artery, ligature of, 116. 
 Tenacula, 33, 84, 53. 
 Tendo Achillis, tenotomy of, 155. 
 Tendon suturing, 161. 
 Tenotomy, 151. 
 
 in lower extremities, 154. 
 
 in upper extremities, 153. 
 
 of adductor longus, 158. 
 
 of biceps flexor cruris, 157. 
 
 of biceps flexor cubiti, 154. 
 
 of erector spinse, 159. 
 
 of extensor communis digitorum, 153. 
 
 of extensor longus digitorum, 156. 
 
 of extensor ossis metacarpi pollicis, 153. 
 
 of extensor primi internodii pollicis, 153. 
 
 of extensor proprius pollicis, 156. 
 
 of extensor secundi internodii pollicis, 
 153. 
 
 of flexor carpi radialis, 1 53. 
 
 of flexor carpi ulnaris, 154. 
 
 of flexor longus digitorum, 154. 
 
 of flexor longus pollicis, 155. 
 
 of flexor profundus digitorum, 153. 
 
 of flexor sublimis digitorum, 153. 
 
 of gracilis, 157. 
 
 of latissimus dorsi, 158. 
 
 of multifidus spinse, 158. 
 
 of pectineus, 158. 
 
 of peroneus brevis, 1 55. 
 
 of peroneus longas, 155. 
 
 of peroneus tertius, 156. 
 
 of quadriceps extensor cruris, 158. 
 
 of sartorius, 157, 158. 
 
 of semi-membranosus, 157. 
 
 of semi-tendinosus, 157. 
 
 of sterno-cleido-mastoid, 159. 
 
 of tendo Achillis, 155. 
 
 of tensor vaginae femoris, 158. 
 
 of tibialis anticus, 156. 
 
 of tibialis posticus, 154. 
 
 of trapezius, 159. 
 
 Tensor vaginae femoris, tenotomy of, 158. 
 Thermo-cautery, 36. 
 Thiersch's fluid, antiseptic, 51. 
 
 operation for epispadias, 468. 
 Thigh, amputation of, 283. 
 
 an t ero-posterior musculo- integumentary 
 flaps, 285. 
 
 bilateral method, 284. 
 
 circular integumentary flap, 285. 
 
 long anterior flap method, Sedillot, 286. 
 
 single circular incision method, Celsus, 
 
 285. 
 
 Thumb, amputation of, at the carpo-meta- 
 carpal articulation, lateral-flap method, 
 241. 
 
 oval method, 240. 
 Thumb-forceps, 18. 
 Thyroid artery, inferior, ligature of, 95. 
 
 linear guide to, 95. 
 
 Thyroid artery, superior, ligature of, 113. 
 34 
 
 Thyrotomy, 505. 
 
 Tibia, excision of, 202. 
 
 Tibial artery, anterior, ligature of, 79. 
 
 linear guide to, 79. 
 Tibial artery, posterior, ligature of, 82. 
 
 linear guide to, 83. 
 Tibialis anticus, tenotomy of, 155. 
 Tibialis posticus, tenotomy of, 154. 
 Tibial nerve, anterior, operations on, 148. 
 
 posterior, operations on, 148. 
 Toe, amputation of the fifth, with its meta- 
 tarsal bones, 259. 
 
 lateral-flap method, 259. 
 
 of great, by large square internal flap, 
 257. 
 
 of great, with its metatarsal bone, 259. 
 Toe-nail, ingrowing, 302. 
 Toes, amputation of all, at the metatarso- 
 phalangeal joint, 258. 
 
 in their continuity, 255. 
 
 of single, 256. 
 
 of single, lateral flap, 256. 
 
 of two adjoining, 257. 
 Toes, disarticulation of the, 256. 
 Tongue, excision of the, 339. 
 
 below or through the jaw, Regnoli's 
 peration, 34 2. 
 
 Billroth's operation, 342. 
 
 entire, 341. 
 
 Heart's operation, 342. 
 
 Knox's operation, 342. 
 
 Kocher's operation, 343. 
 
 Regnoli's operation, 342. 
 
 Sedillot's operation, 342. 
 Tongue, hypertrophy of the, 340. 
 Tongue-tie, 338. 
 Torsion, 32. 
 Torsoclusion, 32. 
 Tourniquet, abdominal, Biandis', 287. 
 
 Esmarch's, 287. 
 
 Lister's, 287. 
 
 Lloyd's, 289. 
 
 Pancoast's, 287. 
 Towels, clean, 22. 
 Trachea, surgical anatomy of, 493. 
 Tracheotomy, 499. 
 
 above the isthmus, 500. 
 
 below the isthmus, 500. 
 
 instruments, 495. 
 
 through the isthmus, 501. 
 Transfusion, 54, 126. 
 
 arterial, 131. 
 
 direct from arm to arm, 127. 
 
 injection of milk, 131. 
 
 injection of saline solution, Bull, W. T., 
 130. 
 
 injection of saline solution, Schwartz, 
 130. 
 
 injection of saline solution, Szumann, 
 
 130. 
 
 Trapezius, tenotomy of, 159. 
 Trendelenburg's rod, 31, 228. 
 Trephining the cranium, 136. 
 Treves' apparatus for enterectomy, 365. 
 Tripier's subastragaloid disarticulation, 266.
 
 530 
 
 INDEX. 
 
 Tube, drainage, rubber, 46. 
 
 tracheotomy, 53. 
 Twisted suture, 45. 
 
 Ulna, excision of, 192. 
 Ulnar artery, ligature of, 104. 
 
 linear guide to, 104. 
 Ulnar nerve, operations on, 147. 
 Uranoplasty, Ferguson's operation of, 334. 
 
 Lannelongue's operation of, 334. 
 
 mechanical means employed in, 334. 
 Urethra, tapping the, Cock, 478. 
 Urethroplasty, Delpech's operation of, 470. 
 
 Dieffenbach's operation of, 470. 
 
 Nekton's operation of, 470. 
 
 Rigaud's operation of, 470. 
 
 Szymanowski's operation of, 471. 
 Urethrotomy, internal, 475. 
 Urethrp-tomy, external perineal, 471. 
 
 with a guide, 472. 
 
 without a guide, 473. 
 Uvula, elongated, 335. 
 
 Varicocele, 121. 
 
 compression, 123. 
 
 compression by double loop of Ricord, 125. 
 
 compression by wires, 123. 
 
 Keyes' operation for, 124. 
 
 radical treatment for, 123. 
 
 subcutaneous ligaturing, 124. 
 
 Videl's operation for, 123. 
 Varicose veins, 118. 
 Veins, air in the, 55. 
 
 symptoms, 55. 
 
 treatment of, 55. 
 
 treatment of, preventive, 55. 
 Veins, ligature of, 117. 
 Veins, varicose, operations for, 118. 
 
 acupressure, 118. 
 
 injection, 118. 
 
 subcutaneous ligaturing, 118. 
 
 Venesection, 125. 
 
 Vertebral artery, ligature of, 92. 
 
 linear guide to, 93. 
 Verneuil's amputation at hip-joint, 296. 
 
 operation of rhinoplasty, 311. 
 Vesico-vaginal lithotomy in the female, 
 
 455. 
 
 Vessels, empty, 21. 
 Videl's operation for varicocelc, 123. 
 Volkmann's iutert.'ochanteric osteotomv, 
 
 217. 
 Volkmann's operations of excision of the 
 
 rectum, 413. 
 
 Watson's operation for removal of a goitre, 
 
 508. 
 Webbed fingers, 300. 
 
 Annandale's operation, 301. 
 
 Nelaton's operation, 301. 
 Whalebone guides, introduction of, 420. 
 White's excision of hip-joint, 208. 
 Wiring of bones in compound fractures, 
 512. 
 
 the patella, 509. 
 
 Wood's operation for extroversion of the 
 bladder, 424. 
 
 for radical cure of femoral hernia, 388. 
 
 for radical cure of inguinal hernia, 384. 
 
 for radical cure of inguinal hernia with 
 
 pins, 386. 
 
 Wounds, operation, treatment of, 41. 
 Wrist-joint, amputation at, 244. 
 
 circular method, 244. 
 
 double-flap method, Ruysch, 244. 
 
 radial flap, Dubrueil, 245. 
 
 single palmar flap, 245. 
 Wrist-joint, disarticulation at the, 244. 
 
 excision of, 193. 
 
 excision of, complete, Langenbcck, 194. 
 Wiitzer's operation for radical cure of in- 
 guinal hernia, 382. 
 
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